Awareness Survey on Knowledge of Microbial Infectious Causes of Cancer in Northern State of Sudan

Infections with certain viruses, bacteria, and parasites are one of the biggest and preventable causes of cancer worldwide. Approximately 20% of cancers worldwide are induced by infectious agents (Zur, 2006; Bouvard et al., 2009). Cancers caused by infections generally have a higher mortality rates than other cancers. Out of the 12.7 million new cancer cases that occurred in 2008, the population attributable fraction (PAF) for infectious agents was 16.1%, meaning that around 2 million new cancer cases were attributable to infections. This fraction was higher in less developed countries (22.9%) than in more developed countries (7.4%), and varied from 3.3% in Australia and New Zealand to 32.7% in sub-Saharan Africa (IARC, 2008; Catherine et al., 2010) Cancer prevention and early detection through primary prevention and screening are among the key components of cancer control which, in turn, can lead to a decrease in cancer incidence and mortality in the population. This goes along with the development and implementation of sustainable awareness and education programs (IARC, 2012). Therefore, the role of the current study was to evaluate impact of ongoing cancer awareness, through measuring acquired knowledge after delivering seminars about the etiology of cancer in general. Section of Early Detection and Prevention.


Introduction
Infections with certain viruses, bacteria, and parasites are one of the biggest and preventable causes of cancer worldwide. Approximately 20% of cancers worldwide are induced by infectious agents (Zur, 2006;Bouvard et al., 2009). Cancers caused by infections generally have a higher mortality rates than other cancers. Out of the 12.7 million new cancer cases that occurred in 2008, the population attributable fraction (PAF) for infectious agents was 16.1%, meaning that around 2 million new cancer cases were attributable to infections. This fraction was higher in less developed countries (22.9%) than in more developed countries (7.4%), and varied from 3.3% in Australia and New Zealand to 32.7% in sub-Saharan Africa (IARC, 2008;Catherine et al., 2010) Cancer prevention and early detection through primary prevention and screening are among the key components of cancer control which, in turn, can lead to a decrease in cancer incidence and mortality in the population. This goes along with the development and implementation of sustainable awareness and education programs (IARC, 2012). Therefore, the role of the current study was to evaluate impact of ongoing cancer awareness, through measuring acquired knowledge after delivering seminars about the etiology of cancer in general. Section of Early Detection and Prevention.

Results
This survey included 200 participants their ages ranging from 10-78 years with a mean age of 35 years old. Most of the participants their ages ranging between 18-29 years followed by 30-39, more than 50, 40-49, and 17 years old or less constituting, 41.  Figure 1.
In regard to knowledge, whether infectious agents can cause cancer, among different age groups, 33% of individuals in age range >17 years have supposed that, bacteria, parasites and fungi don't cause cancer. Also 30% in range 30-39 years have believed that parasites and fungi don't cause cancer, hence, the scores (No) for viruses and bacteria were 28% and 16%, respectively. Furthermore, 30%, 25% and 15% of participants among age group 40-49 years have stated the negative role of fungi, bacteria and parasite, in this order, in the etiology of cancer, as shown in Figure 2.
The relation between level of awareness and was indicated in Figure 3. High frequencies of answers (No) were identified among engineers, labors and housewife as shown in Figure 3.
When look upon the correlation between education level and knowledge of infectious agents as some can cause cancer, high frequencies of answer (No) were observed among secondary education level, followed by graduate and basic for all microbial infectious agents, but none of post-graduate have such suppose, as indicated in Figure 4.

Discussion
Cancer often creates fear which comes out of ignorance and misconception. More than 30% of cancer cases could be prevented by modifying lifestyle or avoiding key risk factors. About 1/3rd of cancer cases could be reduced if cases are treated and detected at an early stage. Many infection-related cancers are preventable (IARC, 2008). Helicobacter pylori, hepatitis B and C viruses, and HPV were responsible for 1.9 million cases, mainly gastric, liver, and cervix uteri cancers. Around 30% of infectionattributable cases occur in people younger than 50 years (Catherine et al., 2010).
It has been shown that Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the major causative agent for hepatocellular carcinoma (Zemel et al., 2011;Yanming et al., 2012). HPV infection has been etiologically linked to cervical cancer (Elasbali et al., 2012), oropharyngeal squamous cell carcinoma (Rietbergen et al., 2012) and other cancers.
A high level of evidence exists for the association of Helicobacter pylori with carcinoma of the stomach (Lin, 2012), Salmonella Typhi with gallbladder and hepatobiliary carcinoma (Samaras, et al., 2010). Opisthorchis viverrini and Clonorchis sinensis with cholangiocarcinoma (Sripa et al., 2012) and Schistosoma hematobium with bladder cancer (Aly et al., 2012).
Aspergillus flavus is saprophytic soil fungus that infects and contaminates pre-harvest and post-harvest seed crops with the carcinogenic secondary metabolite aflatoxin (Amaike and Keller, 2011). Dietary exposure to aflatoxin B1 (AFB1) is associated with an increased incidence of hepatocellular carcinoma (Hui-Chen et al., 2009;Maryann et al., 2001).
The application of accessible public-health programs for infection prevention, including awareness to motivate people to seek suitable actions at time such as vaccination, safer injection practice, or antimicrobial treatments, could have a significant outcome on future burden of cancer worldwide. Therefore, this study highlights the need for cancer awareness program to be set on a national basis in light of the burden of infection-related cancers, particularly in a country like Sudan (a very lowincome country). Although, this survey was preceded by educational program including public awareness seminars    and pamphlets, but still there is a lack of knowledge regarding the relation between microbial infectious agents and cancer development. However, a reasonable number of individuals ignore the role of fungi in the etiology of liver cancer, though, Sudanese are commonly using groundnuts crop, in preparation of different types of meals. This groundnut in most instances exposure to aspergillous flavus, which produces aflatoxin. Aflatoxin produces a tart test which is unfavorable, but because the crop is locally prepared by honing known as "Dacow", the aflatoxin will be distributed all over; the material and the tart test no longer exist.

Figure 4. Description of the Study Subjects Answered (No) Infectious Agents Don't Cause Cancer by Education
For parasitic infection, many people think that the parasites have no role in the etiology of cancer, although, Sudan is one of endemic area for Schistosomiasis, particularly Schistosoma Hematobium 9 (Deribe et al., 2011). In a study investigated the prevalence of Helicobacter pylori in Sudanese subjects with gastroduodenal inflammation. Helicobacter pylori was found in 80% of patients with gastritis, 56% of patients with duodenal ulcer, 60% of patients with duodenitis and 16% of normal control subjects (Azim et al., 1994). The role of HPV, herpes simplex virus and Epstein-Barr virus in the etiology of oral cancers (Ahmed and Eltom, 2010;Jalouli et al., 2010), as well as the role of HPV in the development of cervical cancers cancer (Salih et al., 2010;Elasbali, et al., 2012;Ginawi et al., 2012) in different parts of Sudan was well established.
However, in comparison of the findings of this study with other findings in developed world, levels of awareness seemed to be higher among Sudanese and this might be attributed to the influence of the educational program that preceded the collection of data. Most available data regarding cancer awareness in relation to infectious agents are about HPV. In 1992 about 13% of women attending a southeastern university had ever heard of HPV and only 8% of them knew that it was associated with cervical cancer (Vail-Smith et al., 1992). In 2000, a population-based survey of women ages 18 to 65 living in the United States (US) found that only 28% had ever heard of HPV and only 41% of those knew that it was sometimes associated with cervical cancer (Lambert, 2001). In a national sample of women ages 18 to 75 years old, found that ~40% of women had heard of HPV, but less than half of those also knew that it caused cervical cancer. These low levels of knowledge are consistent with findings from other studies of US adult women (Mays et al., 2000;Holcomb et al., 2004;The Kaiser Family Foundation, 2006). In 39 studies published between 1992 and 2006 covering a total of 19,986 participants, the proportion of participants who had heard of HPV varied from 13% to 93%. Understanding that HPV is a risk factor for cervical cancer depended on whether the question was closed (8-68%) or open (0.6-11%). Between 5% and 83% knew about the association of HPV and (genital) warts. HPV was often mistaken with other sexually transmitted viruses. Health professionals and women had better knowledge about HPV than other participants (Klug et al., 2008).
In regard to occupation, most of those with low level of knowledge about the relationship between infectious agents and cancer were among engineers and housewives, particularly for fungal infection. Notably, all medicals were found with full knowledge. Moreover, many participant at secondary education level lack the knowledge, particularly for viral and fungal infections, hence, all participant at post-graduate level were fully knowledgeable.
In conclusion, the level of cancer awareness has relatively increased amongst Sudanese northern state inhabitants after delivering an educational program. Cancer awareness can reduce the suffering due to cancer by educating patient choices and supporting cancer prevention.