The Distribution and Determinants of COVID-19 in Sudan, 2020/2021: Analysis of Surveillance Data
Authors: Abdullah Ahmad Izzoddeen , Mohammed Sabir Ali , Ibrahim Alaa Khalil , Hashim Mohamed , Elzain Muaaza Abasher , Mohamed Omer Abadri , Abuelgasim Hafsa , Ismaiel Ismaiel Mohamed , Abdalla Abdalla Mohamed , Dafalla Alla Hamed , Elgurashi Suliman Gamal , Osman Muntasir M. , Mahmoud Tehani Amin , Alkhidir Mohamed Abdalhafiz , Mahmoud Elfadil Mohammed , Magboul Babiker Ahmed Ali , Osman Abdalla Siedahmed , Saeed Mohamed Elfatih Mohamed , Kuete Victor , Efferth Thomas , Elhassen Ibrahim Abdalla , Lane Chris , AbdElGawad Basma , Habibi Muzhgan , Sadek Mahmoud , Bashier Haitham , Malik Elfatih M. 
Published: March 2022

Background
Since the first case of COVID-19 in Sudan was reported in March 2020, the Federal Ministry of Health adopted an active surveillance system to collect and analyze information from the isolation centers and public and private laboratories about all suspected and confirmed COVID-19 cases. This study used the surveillance data to better understand the distribution and determinants of COVID-19 in Sudan and to construct a threshold level beyond which the dramatic surge may occur.
Methods
Data of suspected and confirmed COVID-19 cases were extracted from the line list prepared by the Surveillance and Information Department at the Federal Ministry of Health after obtaining ethical approval from the National Ethics Committee. Data were cleaned, coded, and analyzed using SPSS version 21. Frequencies and proportions were used to describe data. A univariate logistic regression analysis was used to determine the association of variables with the positivity of COVID-19. Variables with p-values < 0.05 in the univariate logistic analyses were included in multivariable logistic regression to determine the adjusted odds ratios (ORs) and their 95% confidence interval (CI). A two-sided α of less than 0.05 (p < 0.05) was considered statistically significant.
Results
Out of 48,545 suspected cases, 27,453 were positive. Four waves were seen, with a distinct explosion point of around 200 cases observed nationwide. Khartoum reported the highest number of cases. Of those tested positive, 16,444 (59.9%) were male and 11,009 (40.1%) were female. The mean (SD) age of cases was 41.1 (19.0) years with 21.6% of cases above 60 years. 14,780 (53.8%) of cases were asymptomatic. Fever, cough, shortness of breath, and loss of smell and taste were reported in 32.7%, 26.4%, 19.1 and 4.5% of confirmed cases, respectively. A total of 1,793 confirmed cases died; the case fatality rate was 6.5%. A considerable proportion of infection was reported among health workers. A univariate logistic regression analysis revealed that being symptomatic is significantly associated with testing negative for COVID-19 (odds ratio < 1).
Conclusions
COVID-19 was widely spread in Sudan with more cases in Khartoum, the capital of Sudan. The country experienced four waves with an observable epidemic explosion point of around 200 positive cases per week nationwide. Around half of the patients were asymptomatic; however, fever, cough, and shortness of breath were the commonest symptoms. The CFR all through was 6.5%, with death having a strong association with age. Further studies are recommended to clarify the image, especially among health workers. The study also highlighted the need to improve the quality of surveillance data.