Area: 2,505,810 km²
Population: 36,080,373 inhabitants (2001 estimation)
Official Language: Arabic
Currency: Soudanese Dinar
Bordering Countries: Egypt, Libya, Chad, C.A.R, .D.R. of Congo, Uganda, Kenya, Ethiopia, Eritrea

Sudan is the largest country in Africa and because of this there are huge variations in the climate. Going from the driest to most humid regions one notes a gradient of north-south and west-east. The climate is tropical in the south and arid desert in the north. 

Very few epidemiological studies have been conducted in Sudan.  
The majority of those available were carried out in the centre of the country, to the east in the Blue Nile region, and in Karthoum.   
This is largely due to the turmoil that has shook the country for the last 30 years, rendering virtually impossible any study in the south, despite the fact that this remains the region most affected by malaria.

With regard to the epidemiology of malaria in Sudan, the country can be split into four zones:
.    The North and north-west are arid desert regions with no malaria.
.   The central eastern region in the Blue Nile zone has a short rainy season from June to August. Malaria thrives mainly from September to November, and is unstable, without acquisition of relative immunity. Malaria attacks therefore occur essentially between September and November (19, 62, 66)
.   The White Nile zone in the southern part of the country has a longer rainy season from March to October, with maximum rainfall from May to October   (during which rainfall does not however surpass the 150 mm mark) Malaria here is also unstable with high seasonal outbreaks from September to December (15). During the rainy season, parasites are found in 62.5% of children in school and 58% of children with fevers (15). Relative immunity occurs at the age of about 10 years old.
.   Karthoum, between the White Nile and the Blue Nile, suffers from an urban   hypo-endemic malaria. The rainy season lasts from August to October and no relative immunity is developed. During the rainy season, parasites are found in 1.08% of school children, 43.8% of children with fevers (15), 0.8% of refuges (45) and 1% of hospitalized patients in Omdurman (50).

A study conducted by G. and W. Wernsdorfer in 1959 was based upon the climatology of 6 places in Sudan:- Wadi Haifa, Port Sudan, Wad Madani, El Obeid, Wau and Juba (01):

Parasites 
Sudan is one of the rare regions in Africa where the four plasmodium species are found. The relative frequency of the species varies according to different studies:

In Karthoum: 
Plasmodium falciparum: from 84.9% to 100% (02, 15, 67)  
Plasmodium vivax: from 4.5% to 6.9% (02, 67) 
Plasmodium ovale: from 0 to 8.2% (02, 67) 
Plasmodium malariae: from 0 to 4.1% (02, 69) 

In the centre and East:
Plasmodium falciparum: from 90 to 95% (57, 59) 
Plasmodium vivax: 5% (57) 
Plasmodium ovale: not stated 
Plasmodium malariae: not stated 

In the south:
Plasmodium falciparum: from 83.9% to 7% (02, 15, 17) 
Plasmodium vivax: from 0 to 6.8% (02, 15, 17)  
Plasmodium ovale: from 0 to 1.2% (02, 15, 17 
Plasmodium malariae: from 1.6% to 7.7% (02, 15, 17) 

Plasmodium ovale is documented for the first time in Karthoum in 2000 (67).

Chemoresistance 

This is a badly documented domain.

Chloroquine resistance:

In 1978 at Sennar, in the east of Sudan, RL Kouznetsov et al. suspected as much: they achieved 100% good results in vivo, but had doubts on those in vitro (04). In the same year in Al Jazirah, Abdel Hamid Sayed Omer recorded 0.4% of type RI resistance and 0.2% of type RII (03). 
In 1981 in Karthoum, on 16 patients treated with chloroquine, there were 9 occurrences of   type RI resistance and 7 of type RII (06).
In 1984 in the Blue Nile Province, no in vitro resistance was proved (10)
In 1987 in Gedaref, 30 cases of drug failure were noted out of 63 (47.6%)(31).
In Asar (East) in 1991, 8 strains of Plasmodium falciparum out of 26, were resistant in vitro (30.8%)(33).
In 1992 in Wad Medani, out of 140 children aged between 6 months and 16 years old, suffering from fever, 19% were recorded as being RI and RII resistant (37).
In 1996 in Daraweesh, (east) 20 patients were treated with chloroquine: no resistance was recorded (63). In Waat, the Upper Nile Province, 4% of RI and 6% of RII resistances were noted in the case of 56 children treated with chloroquine (52).

So we can say that although chloroquine resistance exists, there have been no cases of the type RIII, and with the exception of the Gedaref study in 1988 the levels of resistance are low.

Resistance to other antimalarial drugs:

Very few studies have been published on this area.
.   amodiaquine: no publications
.   quinine: in 1993, out of 18 patients treated, clinical and parasitic clearance was achieved in under   48 hours, but 1 patient still had parasites on day 14, one on day 21 and   1 on day 28 (39).
.   mefloquine: in 1984, in the Blue Nile Province, not one of the 66 strains of plasmodium falciparum tested were resistant to mefloquine (10), the same results were achieved in 1991 in Asar   where not one of the   26 strains of Plasmodium falciparum showed resistance (30.8%)(33).
.   pyrimethamine: in Asar in 1991, 3 strains of Plasmodium falciparum out of   26 were resistant in vitro (11.5%)(33).
.   Sulfadoxine-pyrimethamine combination: in a 1997 in Daraweesh, 17 patients were successfully treated (63).
.   clindamycine: in 1985, out 20 patients treated, 3 were still parasite carriers on day 17 and 2   on day 28 (14).
.   Artemether: 100% success rate in a 1993 study(39). 

In this domain too, there is very little published material.
Vectors 
In 1983 in the Blue Nile Province, Anopheles funestus was predominant during the dry season, and Anopheles arabiensis during the rainy season (05).
In Daraweesh, the exclusive vector is Anopheles arabiensis. It proliferates during the rainy season (July to September) and survives in wells during the dry season (October to May) (59).
Still in the east of the country, a year 2000 study conducted in 40 villages allowed the capture of 2,162 female mosquitoes: 93% were Anopheles arabiensis and 7% Anopheles gambiae s.s. (64).

Vector control 
Only a 1983 study showed the effectiveness of malathion (07).

In the “recommandations sanitaires pour les voyageurs 2005” (sanitary recommendations for travellers 2005) : B.E.H.  n°24-25 of 14th june 2005, Sudan is classified under chemoresistance group III ; that is to say, it is considered as being a country with “Widespread high chloroquine-resistance”, which would indicate a chemoprophylaxis with Mefloquine or with Atovaquone-Proguanil combined treatment.
In practice many things must be taken into consideration before deciding upon a treatment: the length of the dry season, the fact that there is little malaria in the capital and the relatively low chloroquine-resistance in the country. For most cases, individual measures of protection against mosquito bites (skin creams, mosquito bed nets treated with a long lasting insecticide) should be more than sufficient.

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