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, poses a severe public health threat in low-resource and conflict-affected environments. In eastern Sudan, specifically Kassala State, the convergence of active conflict, population displacement, overcrowding, and fragile infection-control systems has created conditions conducive to rapid viral transmission. While EKC is well-documented in high-income settings, its trajectory in war-torn regions is often characterized by delayed detection and overwhelmed health systems.

The study highlights a critical epidemiological shift in Kassala: reported cases surged from approximately 195 in 2023 to over 14,000 in 2024, representing a more than 90-fold increase during the epidemic period (August–December 2024). This surge occurred amidst a collapse of routine disease surveillance and healthcare access, complicating clinical management and increasing the risk of misdiagnosis due to overlapping epidemic threats (e.g., influenza, dengue). The paper posits that without qualitative insights into community experiences and health system responses, outbreak control measures remain insufficient.

Methodology
The authors employed a qualitative descriptive design to explore the perceptions, experiences, and responses to the EKC outbreak among diverse stakeholders in Kassala State.

• Study Period: September 2024 to January 2025.
• Participants: A purposively sampled cohort of 30 individuals across three groups:
  1. Healthcare Managers and Physicians: 20 in-depth interviews (IDIs) conducted with staff from public hospitals, police hospitals, eye hospitals, and rural health centers.
  2. Patients and Caregivers: 5 Focus Group Discussions (FGDs).
  3. Community Leaders: 5 FGDs involving elders, religious leaders, women leaders, and representatives from displaced communities.
• Data Collection: Audio-recorded IDIs (30–45 minutes) and FGDs (60–90 minutes) were conducted in Arabic by a trained team fluent in the local context. Field notes captured non-verbal cues and group dynamics.
• Analysis: Transcripts were translated into English and analyzed thematically using NVivo 14 following Braun and Clarke's six-step approach (familiarization, coding, theme development, review, definition, and reporting).
• Trustworthiness: Rigor was ensured through triangulation across participant groups, reflexive memoing, member checking, peer debriefing, and an audit trail. Ethical approval was granted by the Kassala State Ministry of Health.

Key Contributions and Results
The study identifies EKC not merely as a clinical outbreak but as a symptom of broader health-system fragility exacerbated by conflict. The analysis yielded several cross-cutting themes:

1. Uneven Awareness and Information Channels:

   • Awareness was highly stratified. Younger, educated individuals accessed information via social media and radio, while older adults, displaced families, and less-educated populations relied on word-of-mouth and direct observation of symptoms.
   • Official health messages often arrived late or were inconsistent, leading to reliance on informal networks and rumors.

2. Barriers to Care and Reliance on Traditional Remedies:

   • Structural Barriers: Patients faced significant hurdles including financial constraints, lack of transport, geographic distance to facilities, and staff shortages.
   • Behavioral Patterns: There was a strong tendency to utilize home remedies (e.g., tea washes, sugar water, herbal applications) and informal advice before seeking biomedical care. This was driven by cost, availability, and cultural norms.
   • Gendered Constraints: Women faced specific barriers related to mobility, family responsibilities, and social norms restricting their movement to hospitals without male accompaniment.

3. Health System Strain and Response Limitations:

   • Health managers reported limited capacity for patient isolation, inconsistent infection-control infrastructure, and fragmented supply chains for medications.
   • While some facilities implemented internal education and WhatsApp alerts, these efforts were constrained by the wider conflict environment and resource scarcity.
   • The outbreak caused significant absenteeism in schools and workplaces, alongside psychological stress and stigma for affected individuals.

4. Community Disruption:

   • The epidemic disrupted daily routines, including worship and education. Stigma led to social isolation for some patients, while economic hardship forced manual workers to miss wages and students to miss exams.

Significance and Claims
The paper claims that an effective response to EKC in conflict-affected settings requires a shift from purely clinical interventions to a holistic, community-integrated approach. The authors argue that viral transmission dynamics are inextricably linked to social determinants, including:

• Affordability and Access: The need for free or affordable treatment and decentralized, mobile eye care services to reach displaced and rural populations.
• Communication: The necessity of trusted, local risk communication that bridges the gap between official health messages and community realities.
• Coordination: Stronger collaboration among health authorities, humanitarian actors, and community leaders to manage supply chains and infection control.

The study concludes that the EKC outbreak in Kassala serves as a "systems test," revealing that without addressing underlying structural fragilities—such as staff shortages, supply chain failures, and gendered access barriers—epidemic control measures will remain ineffective. The paper does not propose new therapeutic agents but emphasizes the urgent need for operational improvements in surveillance, mobile service delivery, and community engagement to mitigate future outbreaks in similar conflict zones.