Epidemic Keratoconjunctivitis in Conflict-Affected Kassala, Sudan (2024–2025): A Qualitative Exploration of Community Experiences and Health System Response

Technical Summary: Epidemic Keratoconjunctivitis in Conflict-Affected Kassala, Sudan (2024–2025)

Problem Statement
Epidemic Keratoconjunctivitis (EKC), a highly contagious adenoviral infection, presents a critical public health challenge in conflict-affected regions characterized by overcrowding, displacement, and fragile health systems. In eastern Sudan, specifically Kassala State, the convergence of ongoing war, population displacement, and underfunded infrastructure has created conditions conducive to rapid disease transmission. While EKC outbreaks are documented in high-income settings, their dynamics in low-resource, war-torn environments often remain undetected until severe. The situation in Kassala escalated dramatically in 2024, with reported cases surging from approximately 195 in 2023 to over 14,000 in 2024—a more than 90-fold increase. This study addresses the urgent need to understand the community experiences, health system responses, and socio-cultural barriers associated with this outbreak, moving beyond clinical metrics to explore the qualitative realities of the epidemic.

Methodology
The research employed a qualitative descriptive design conducted between September 2024 and January 2025 in Kassala State. The study utilized purposive sampling to recruit three distinct stakeholder groups:

1. Healthcare Managers and Physicians: 20 in-depth interviews (IDIs) with staff from public hospitals, police hospitals, eye hospitals, and rural health centers.
2. Patients and Caregivers: 5 focus group discussions (FGDs) involving affected individuals and their families.
3. Community Leaders: 5 FGDs with elders, religious leaders, women leaders, and representatives from displaced communities.

Data collection was conducted by a trained, Arabic-fluent team using audio-recorded IDIs (30–45 minutes) and FGDs (60–90 minutes) in neutral, private venues. Transcripts were translated from Arabic to English and analyzed thematically using NVivo 14 following Braun and Clarke's six-step approach. Rigor was ensured through triangulation across participant groups, reflexive memoing, member checking, and an audit trail. Ethical approval was granted by the Kassala State Ministry of Health's Directorate of Planning and Research.

Key Results
The analysis revealed that the EKC outbreak in Kassala is not merely a clinical event but a symptom of broader health-system fragility and conflict-induced disruption. The findings are organized around several cross-cutting themes:

• Uneven Awareness and Informal Information Channels: Awareness of the outbreak varied significantly by education level and location. While urban and educated participants utilized social media and radio, rural and displaced populations relied heavily on word-of-mouth, direct observation, and informal networks (mosques, neighbors). Official health messaging often arrived late or was perceived as ineffective.
• Barriers to Care and Reliance on Traditional Remedies: Significant financial, geographic, and structural barriers delayed formal care-seeking. Patients frequently resorted to home remedies (e.g., tea washes, sugar water, herbal infusions) or shared medications within families due to cost and scarcity. Traditional healers were often consulted before biomedical facilities.
• Gendered and Cultural Constraints: Female participants faced specific mobility restrictions due to social norms and tribal customs, limiting their access to male-dominated clinics. Stigma associated with visible eye symptoms led to social isolation and further delayed treatment, particularly for women and children.
• Health System Strain and Fragmentation: Health managers reported overwhelmed facilities, staff shortages, inconsistent supply chains (particularly for eye drops and steroids), and a lack of isolation capacity. While some facilities implemented emergency protocols, coordination with the Ministry of Health (MOH) and community actors was often fragmented.
• Socio-Economic Disruption: The outbreak caused widespread absenteeism in schools and workplaces, economic loss for manual laborers, and psychological distress. Community leaders noted that the epidemic exacerbated existing vulnerabilities, with some attributing the spread to environmental factors like poor sanitation and standing water, reflecting "epidemic ambiguity" regarding disease etiology.

Key Contributions
This study provides a granular, qualitative understanding of EKC dynamics in a conflict zone, offering insights that quantitative surveillance alone cannot capture.

• Contextualizing the Outbreak: It frames EKC not just as a viral transmission event but as a "biosocial" crisis where poverty, gender norms, mistrust, and infrastructure collapse interact to fuel the epidemic.
• Identifying Decision Pathways: The research maps the complex, non-linear decision-making processes of patients, illustrating how cultural beliefs and misinformation often divert individuals away from formal care, even when services are technically available.
• Triangulating Perspectives: By integrating the views of patients, community leaders, and health managers, the study highlights critical disconnects between community needs and institutional responses, such as the gap between official protocols and the reality of supply shortages or cultural resistance.
• Visualizing Systemic Barriers: The authors introduce conceptual frameworks (e.g., Social-Epidemiological Feedback Loops, Multilevel Barriers to Containment) to illustrate how structural vulnerabilities and cultural practices mutually reinforce epidemic spread.

Significance and Claims
The paper claims that effective EKC response in conflict-affected settings requires a shift from purely biomedical interventions to decentralized, culturally grounded, and multisectoral strategies. The authors argue that:

1. Standard protocols are insufficient: In fragile settings, top-down health messaging often fails; instead, responses must leverage trusted local networks (religious leaders, community elders) and mobile, decentralized services.
2. Gender sensitivity is critical: Interventions must specifically address mobility barriers and cultural norms restricting women's access to care.
3. Supply chain and infection control are paramount: Without reliable access to affordable medications and functional isolation protocols, outbreaks will persist regardless of awareness campaigns.
4. "Nonlethal" epidemics matter: The study emphasizes that outbreaks like EKC, while not immediately fatal like cholera, cause significant social disruption, economic loss, and long-term visual impairment, warranting serious inclusion in public health preparedness planning.

Ultimately, the paper concludes that rebuilding resilience against such epidemics in Sudan requires coordinated action among health authorities, humanitarian actors, and community leaders to create affordable, accessible, and trusted eye care systems.