Introduction

Cystic Echinococcosis (CE) is a parasitic disease caused by tapeworm (Echinococcus granulosus) which principally affect herbivorous and carnivous animal, human get accidentally affected by disease and it is not part of life cycle. According to World Health Organization (WHO) echinococcosis is a neglected disease. affected cases of Cystic echinococcosis in the world is estimated to be more than one million, causing one billion dollars per annum[1]. Pathology is known to cause unilocular or multilocular cysts, with different sizes small like an orange to larger sizes like small football [2].They are four different types E. granulosus, multilocularis, olgaris and oligarsus. According to molecular classification, their geographical distribution, and according to their host relationship they are many types like E. Ortleppi and E. equinus [3]. DNA extraction has led to taxonomic divisions , G1-G3 grouped as E. Granulosus sensu stricto, G4 known as E.equinus, G5 E.ortelepi, G6-G10 E. canadensis and E. felidis which is loin strain [4].

E.granulosus definitive host are carnivorous ,mainly dogs were it get harboured in their intestine, eggs hatched through the excreta get access to the environment ,picked up by herbivores in their feed or drinking water. Echinococcosis is cause of morbidity for animals and humans[5].The life cycle of Cystic granulosus start by carnivores like dogs eat infected meat with echinococcuscysts of the intermediate hosts, sheep, goat, cattle, camels, etc. in the intestine of the carnivores which is the dog tape worm with the size of 3-6 mm will develop. hatched eggs from the intestine of the dog will soil the nearby environment with multiple of eggs which get access to grass, unclean water and infect animals and human, where in their intestine and through portal and systemic circulation get access to liver and lungs and other organs in the body of infected animal or human. Once get impeded at the infected animal or human organsthey change to different sizes of cysts, within which they reproduce asexually into protoscolices. A single cyst can have thousands of protoscolices, and each protoscolex is capable of developing into an adult worm if ingested by the definitive host[6]. There are many social reasons favoring the life cycle of E. granulosus and prevalence of CE in various parts of the world. Many families in rural have small plots of land and live in close proximity with their flocks and dogs. Grouping of animals together specifically with dogs as guards will help spreading of the disease, including CE. Slaughtering of animals in or near homes will help spread of the disease [7]. Poor equipped with unacceptable sanitation will spread the disease easily. Carnivorous like dogs, wolves, foxes who can feed on infected offal's will complete echinococcosis cycle. Close proximity of grazing animals dogs and human will help spread of the disease. humans incidentally get infected by ingestion of hatched egg which soil unclean water or feed. However, they are not part of the cycle[8]. Dogs are particularly important in zoonotic transmission due to their close relationships with humans. Cystic echinococcosis is a cosmopolitan disease, which found all the world including Sudan. Echinococcosis in Sudan is common and it is a cause of financial loss for both human and animals.

Prevalence of the disease is different in different area, which need different measures [9].It is essential to have adequate knowledge of the disease before contemplating control programs[10]. In case of control of disease needs better understanding of knowledge attitude (KAP) and practice in the community. Three areas have been assigned in Khartoum state to study KAP using structured well designed questionnaires [10].

Materials and Methods

Study design: This is descriptive cross sectional study was conducted over a period from December 2017 and April 2018 to determine up on the knowledge, awareness, attitudes and practice regarding cystic echinococcosis among human in Khartoum state, Sudan[10].

Study area: This study conducted in three townships in Khartoum state (Khartoum, Omdurman and Bahry), apart of central Sudan (Figure 1).

Khartoum State is between the Blue Nile and White Nile were the meet to form river Nile and the around area on the starts of River Nile. The main area of Khartoum State 20,736 Km². wit elevation up to 400m.a.s, it’s climate arid and semiarid. The rains in Khartoum state is scarse few months in summer. Winter is dry and cold. Rain ranges between 10-300 in Sudan, all this in summer. Temperature in whole year range between 20-40°C. Temperature degrees continue to fall during the winter period between November-March to the level of 15-25 CO. Khartoum State is divided into three clusters (cities), built at the convergence of the Blue and White Niles: Omdurman to the northwest across the White Nile, North Khartoum, and Khartoum itself on the southern bank of the Blue Nile.

Data collection

Clinical data is collected by the facility medical staff via study structured questionnaire.

Questionnaires

Participants involved in KAP study were above the age of 18 years. The consent according to ethical committee approval is verbal from the participant.a questionnaire was administered to obtain basic epidemiological and individual information regarding known CE risk factors. Important information were addressed by the structured questionnaire which include age, sex, educational level, residence, occupation, hygiene, dog information and other domestic animals records. The questionnaire was well structured which minimize interrogators differences.

Study variables: The following are the variables utilized by this study.

• Demographic data

• Dog ownership

• Dog contacts

• Treatment of owned dog

• Home slaughtering and raw offal disposal

• Education level

• Knowledge of disease

Study population: Five hundred and twelve individuals were enrolled in this study, 198 males and 314 females, their place of resident is in Khartoum state and their age range from ≥18 years.

Statistical Analysis: Statistical Package for Social Science (SPSS) has been used of version 21.0. Data was analyzed descriptively using the frequency table and cross tabulation.

Ethical approval

This study was approved by the Institutional Review Board Committee of Alneelain University, Khartoum, Sudan. Then study participants were first asked whether they accept to take part in the survey.

Results

Socio-Demographic Characteristics of the Study Population

We interviewed 512 individuals, 314(61%) female and 198(39%) male; all of them were originated from Khartoum state. Their ages range from 18 -90 years with age mean (41.3 ± 18.08 SD) (Table 1). Regarding the populations’ level of education, 24% of the population had completed primary school, 25% for secondary school, 35% at university level, and 16% of them were unable to read and write (Table 1). Sheep and goat was the main livestock species owned by the population interviewed in this study (Table 1).

Practices towards CE Prevention

Of all the participants interviewed, 9% (44/512) indicated owning dogs on their houses (Table 2).the result showed substantial negligence for owned dogs. For instance, among participants owning dogs, 13% (6/44) dewormed their dogs. Added to that, approximately all 91% (468/512) of the participants reported slaughtering livestock at home for their families’ consumption, of whom, 23.5% (110/512) they provide raw infected organ and uneatable offal like lung, intestine, etc. for their dog and cats.94%of the participants (479/512) has been noted they don

Knowledge and Awareness about CE Infection

83% of the participants (427/512) they didn’t know about diseases affects human and animals (zoonosis). Small proportions 17% (85/512) of study participants had heard of echinococcus disease prior, but 4.7%from them had wrong knowledge about this disease as some of them think that the hydatid cyst is a sebaceous cyst (Table 3).

Discussion

The objective of this study to know the awareness, family practices, attitudes of Khartoum State inhabitants, this to enable to set guidelines and preventive measures for future practice regarding the disease. Chronic parasitic diseases such as echinococcosis can be serious and lead to deleterious complications [11]. Sudan being a hot climate country this is a good whether for many parasitic diseases.

Uncontrolled well looked after dogs almost none existing according to our questionnaire results. Because the KAP study in human questioners are structured unlike KAP for animal studies [10,12]. Forty-four (9%) of the surveyed person owned one or more dogs. Of these, six reported to deworm their dogs. His finding correlate with poor awareness of participants about the role of dogs in Cystic echinococcosis disease. Most of the participants they aren’t aware of dogs role in this disease, usually they feed dogs with lungs and some infected viscera of slaughtered animals. Such practices are direct causes of the owned dogs to be infected with the disease by feeding them with infected meals[13]. Similar practices has been noted in similar settings. In Sardinia Italy dogs get access to slaughtered animals offal [14]. A study in Tibet demonstrated that uncooked viscera fed to dogs were the likely case of spread of the disease [15]. Contaminated water or food can be a source of direct infection at endemic areas [16]. Our results show that almost 94% of the respondents drink water directly without boiling. Unclean water is well known to be a cause of getting the infection of the disease [16,17]. Studies in Jordon[18] and Kenya[19] had showed contaminated water is an important cause of spread of the disease. Water disinfection at endemic area is very important to prevent spreading of the disease. Personal hygiene is paramount important in endemic areas.

In Sudan recently increase in stray as well as poorly looked after owned dogs had been notice is a source of spreading the infection. In Sudan, bad set up as well as open access slaughter house were direct cause of spread of the disease [10]. The practice of house slaughtering increase the chance of dogs to get access to infected unwanted viscera of animals.

Awareness level of the disease has to be improved to get better control of the disease. Many KAP studies has been published with similar finding of our study [20-23].

Participant in our KAP study were found to have insufficient knowledge for Cystic echinococcosis [10]. It has been concluded that Public understanding of the disease as well as collaboration between health works in human and animal with water and food safety for both human and animals will help future control of echinococcosis. Provision of clean water is important for control of CE disease [10,24].

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