Early Warning and Disease Surveillance System

Republic of South Sudan

EARLY WARNING AND DISEASE SURVEILLANCE BULLETIN (IDP CAMPS AND COMMUNITIES)

Week 48 24 – 30 November 2014

General Overview

Completeness for weekly reporting decreased from 98% to 92% while timeliness decreased from 72% to 50% in week 48 when compared to week 47. Malaria remains the top cause of morbidity in week 48 with Malakal PoC having the highest incidence followed by Tongping, Bentiu, Bor and Lankien. During week 48, Malakal PoC had the highest incidence for malaria and ABD, while Bentiu PoC had the highest incidence for ARI and AWD. A total of three suspect measles cases were reported from Melut (1 case) and Lankien (2 cases) during week 48. There are no new HEV cases reported since week 47. The cumulative for HEV in Mingkaman remains at 124 cases including four deaths (CFR 3.23%). There are no new cholera cases reported since week 47. The cumulative remains at 6,421 cholera cases including 167 deaths (CFR 2.60%) from 16 counties in South Sudan. The under-five and crude mortality rates in all IDP sites were below the emergency threshold in week 48. Seven suspect meningitis deaths have been reported from Chotbora PHCC in Longechuk County. The preliminary verification report indicates no new suspect cases since 18 November 2014.

Completeness and Timeliness of Reporting

Completeness for weekly reporting decreased from 48 (98%) in week 47, to 46 (92%) in week 48. Timeliness for weekly reporting decreased from 35 (72%) in week 47 to 25 (50%) in week 48.

Figure 1 Number of sites (clinics) reporting per week (n=50)

60 4648474846 50 41 42 42 38 38 36 35 37 40 32 33 34 34 343334 29 2931 29 2626 26282726 28 30 24 24 21 21 23

Number of sites of Number 20 17 171718 1819 20 1315 6 8 10 5

0 010203040506070809101112131415161718192021222324252627282930313233343536373839404142434445464748 Epidemiologic Week 2014 Early Warning and Disease Surveillance System

In week 48, we did not receive reports from four facilities (Table1). Health facilities are requested to kindly submit their IDP reports for the preceding week, by 17:00 hrs on Monday.

Table 1: List of silent health facilities during week 48, 2014 No. IDP site Health Facility/Partner 1 Nyirol Chuil PHCU 2 Twic Man Awan GOAL 3 Bor PoC Bor IRC 4 Renk IOM Prayer

Consultations (All patients seen at Outpatient and Inpatient facilities) The total number of consultations increased from 18,545 in week 47 to 19,704 in week 48. During week 48, most of the consultations were reported from Bentiu, Awerial, Malakal, and Renk (Figure 2).

Figure 2 Consultations by IDP Camp & Partner, week 48, 2014

5000 4500 4000 3500 2021 3000 435 2500 408 2000 572 364

Number of consultationsof Number 1500 1201 643 1000 1401 849 1344 1168 526 1231 798 811 846 500 460 678 386 400 469 312 504 337 341 232 Lul 283 240 214 Bor 87 143 Yuai 0 DUK Renk Ayod Ogod Melut Akoka Akobo Kodok Bentiu Awerial Malakal Lankien Tongping Twic East Twic UN HOUSE UN Wau Shilluk Wau Man-Anguei

CCM IMC IOM IRC MSF-E MSF-OCA CARE Medair HealthLink GOAL IMA SMC Since the onset of the crisis, 718,746 consultations have been registered from all IDP sites with an overall annualised outpatients department (OPD) utilisation rate of 1.2 consultations per person per year (Figure 2.1). The IDP site-specific annualised OPD utilisation rates are shown in Figure 2.1.

Figure 2.1 Annualised OPD Utilization Rates by IPD site, week 1-48, 2014

6.0

5.0

4.0

3.0 5.6

3.9 2.0 3.1 2.5 2.7 2.0 1.7 2.0 1.0 1.6 1.3 1.6 0.3 0.3 0.6 1.2 0.5 0.6 0.4 0.2 0.5 0.2 0.1 0.2 0.04 1.2 Consultations per person per year per personper Consultations -

Annualised Utilization rate Threshold [1-1.5] Early Warning and Disease Surveillance System

Overall Trends of Priority Epidemic-prone Diseases

Figures 3 and 4 show the proportionate and incidence morbidity trends for Acute Respiratory Infection (ARI), Malaria, Acute Watery Diarrhoea (AWD), suspected measles and Acute Bloody Diarrhoea (ABD).

Figure 3 Priority Disease Proportionate Morbidity - Week 1 - 48, 2014

45.0% 100% 40.0% 90% 35.0% 80% 30.0% 70% 60% 25.0% 50% Completeness 20.0% 40% 15.0% Percent of allconsultations of Percent 30% 10.0% 20% 5.0% 10% 0.0% 0% 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic Week Completeness ARI Bloody Diarrhea Malaria Suspected Measles Watery Diarrhoea Malaria, ARI and AWD were the top three causes of morbidity among IDPs in week 48 (Figure 3 and 4). During week 48, malaria had the highest proportionate morbidity and incidence (Figure 3 and 4). The overall incidence for malaria, ABD and suspect measles decreased, while the ARI and AWD incidence increased in week 48 when compared to week 47 (Figure 4). The weekly number of cases for the current and preceding week, and the cumulative number of cases for the top five causes of morbidity are presented in Table 2.

Table 2 New cases for weeks Cumulative cases since week No. Disease 47 48 51 of 2013 1 Malaria 3,928 3,911 140,792 2 AWD 1,488 1,586 62,524 3 ARI 2,521 3,006 108,209 4 ABD 264 184 10,338 5 Measles 12 3 1,516

Figure 4 Incidence for Priority Diseases, week 1 - 48, 2014

140

120

100

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60 Cases per 10,000per Cases 40

20

- Epidemiological Week 2014 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

ARI Bloody Diarrhea Malaria Suspected Measles Watery Diarrhoea Early Warning and Disease Surveillance System

Specific Priority Epidemic-Prone Diseases

Acute Respiratory Infection

ARI remains a leading cause of morbidity among IDPs and has registered an increasing trend since the beginning of the year (Figures 3 and 5).

Figure 5 ARI Adjusted Proportionate Morbidity , for week 1 - 48 2014

40% 100% 37.7% 90% 35% 33.3% 31.9% 30.7% 30.6% 80% 30% 27.1% 70% 26.4% 25.7% 25% 23.7% 24.2% 23.3% 22.9% 22.5% 60% 21.0% 20% 20.0% 19.6% 20.3% 20.1% 50% 18.0% 17.3% 16.0%14.9% 15.2% 15.3% 40% [%] Completeness 15% 14.0% 14.3% 13.8% 13.9% 12.7% 13.4% 30% 10%

Percent of total consultations total of Percent 20% 6.0% 6.8%6.3% 5% 4.4% 2.5% 10% 0.9% 0% 0% 01 03 05 07 09 11 13 15 17 19 21 Epidemiologic23 25 27 29 Week31 33 35 37 39 41 43 45 47

ARI registered the second highest proportionate morbidity of 15.3% and incidence of 53 cases per 10,000 population) in week 48 (Figure 5). During week 48, a total of 3,006 cases of ARI were reported with the highest ARI incidence (cases per 10,000) being reported in Bentiu (219) followed by Malakal (186), UN House (147), Melut (61) and Wau Shilluk (56).

Acute Watery Diarrhoea

As seen from Figure 6, the AWD proportionate morbidity increased from 8.02% to 8.05%, while the overall AWD incidence (cases per 10,000) increased from 26.1 to 28.8 in week 48 when compared to week 47 (Figure 4). Overall, the AWD trend has been on the decline since the beginning of the year.

Figure 6 AWD Adjusted Proportionate Morbidity, for week 1 - week 48, 2014

28% 30% 27% 26% 100% 90% 80% 70% 20% 16% 16% 60% 14% 14% 14% 14% 13% 12% 12.3% 12% 11% 11.4% 50% 11% 11% 10% 9% 9% 8% 8.0% 40%

7.7% Completeness 10% 7.1% 7.2% 6.9% 7.7% 6.1% 6.8% 30% Percent of total consultationstotalof Percent 5.2% 20% 10% 0% 0% 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic week During week 48, a total of 1,586 AWD cases were reported with the highest AWD incidence (cases per 10,000) being reported in Bentiu (99), Tongping (86), Malakal (85), Bor (35) and Melut (35) as illustrated in Figure 7. Early Warning and Disease Surveillance System

Figure 7 AWD Incidence, by IDP site, for week 1 - 48, 2014

700

600

500

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Cases per 10,000 per Cases 300

200

100

- 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiological week 2014 Bentiu Malakal Melut Bor Tongping Figure 7.1 shows the AWD trends by age-group. The incidence (cases per 10,000) of AWD is higher in children under five years of age. These trends indicate that the background risk for acute watery diarrhoea is high, especially in children under-five.

Figure 7.1

AWD incidence by age group, for week 1 to 48, 2014

200 100% 180 90% 160 80% 140 70% 120 60% 100 50% Completeness Cases per 10,000 per Cases 80 40% 60 30% 40 20% 20 10% 0 0% 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiological week 2014 Completenes ≥5 yrs <5 yrs Dysentery / Acute Bloody Diarrhoea

Figure 8 ABD Proportionate Morbidity, for week 1 - 48, 2014

8.0% 100% 6.7% 7.0% 90% 80% 6.0% 70% 5.0% 60%

4.0% 3.4% 3.4% 50% Completeness 2.6% 2.4% 2.4% 40% 3.0% 2.2% 2.2% 2.3%

Percent of total consultationstotalof Percent 1.8% 1.9% 1.6% 1.6% 1.7% 1.6% 1.6% 1.7% 1.6% 1.7% 1.6% 30% 1.3% 1.5%1.4% 1.3% 1.4%1.3% 1.4%1.4% 2.0% 1.2% 1.2% 1.0% 1.1% 0.8% 1.0% 0.9% 0.9% 20% 1.0% 10% 0.0% 0% 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic Week Early Warning and Disease Surveillance System

The overall ABD trend has been on the decline since the beginning of the crisis with successively shorter peaks in weeks 2, 21, and 37 (Figure 8). The incidence (cases per 10,000) of ABD decreased from 5 to 3 while the proportionate morbidity (%) decreased from 1.4 to 0.9 in week 48 when compared to week 47. During week 48, 184 ABD cases were reported with the highest ABD incidence (cases per 10,000) being reported in Malakal (7.6), followed by Melut (7.2), Bentiu (6.7), Ogod (5) and Lul (4), see Figure 9. This trend highlights the need for continued hygiene and sanitation promotion in all IDP camps.

Figure 9 ABD Incidence, by IDP site, for week 1 - 48, 2014

200 180 160 140 120 100

Cases per 10,000 per Cases 80 60 40 20 - 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiological week 2014

Malakal Renk Bentiu Melut UN House Akoka Measles

The measles trend peaked at the beginning of the crisis with the highest peak occurring in week 3, followed by a decline with subsequent shorter peaks in week 5 and 13 (Figure 10).

Figure 10 Suspected Measles Proportionate Morbidity, for week 1 - 48, 2014

3.5% 100% 90% 3.0% 80% 2.5% 70% 2.0% 60% 50% Completeness 1.5% 40% 1.0% 30% Percent of total consultationstotalof Percent 20% 0.5% 10% 0.0% 0% 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic week Completeness Suspected Measles Adj. Linear (Suspected Measles Adj.) This trend is attributed to a series of reactive measles vaccination campaigns conducted to contain the outbreaks in UN House, Tongping IDP camp, Bor, Yuai, Lankien, Cueibet and Thol Payam, Nyirol County in Jonglei State. During week 48, three suspect measles cases were reported from Melut (1 case) and Lankien (2 cases). Three measles samples from Melut were confirmed as measles in September 2014, while in Lankien seven samples were confirmed as measles in October 2014. Integrated measles campaigns are planned for the two locations. Early Warning and Disease Surveillance System

Malaria

As seen from Figure 11, since the beginning of the year, three peaks of malaria transmission have been registered with the highest occurring at the beginning of the crisis (weeks 1-3), while the other peaks were registered in weeks 20, 25, 31 and 37. The malaria trend has been on the decline since week 37. During week 48, malaria recorded the highest proportionate morbidity of 19.8%. The malaria incidence (cases per 10,000) decreased from 68.82 in week 47, to 68.52 in week 48.

Figure 11 Suspected Malaria Adjusted Proportionate Morbidity , week 1 - 48, 2014

45% 40.5% 100% 38.4% 90% 40% 35.3% 34.6% 34.4% 32.9% 35% 31.3% 30.5% 80% 27.9% 28.9% 28.0% 26.7% 70% 30% 24.2% 24.6% 24.6% 24.3% 25.0% 22.4% 21.3% 22.5% 22.3% 60% 25% 20.0% 20.5% 21.2% 20.3% 18.2% 18.8% 19.0% 50% 16.8% Completeness 20% 15.7% 15.2% 13.6% 14.7% 14.4% 40% 15% 11.4% 30% Percent of total consultationstotalof Percent 10% 20% 5% 10% 0% 0% 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic week Completeness Malaria Adj. Linear (Malaria Adj.) During week 48, a total of 3,911 malaria cases were reported with the highest malaria incidence (cases per 10,000) being reported in Malakal (273), followed by Tongping (153), Bentiu (125), Bor (123) and Lankien (106) as seen in Figure 12.

Figure 12

Malaria Incidence, by IDP site, for week 1 - 48, 2014

1,800 1,600 1,400 1,200 1,000 Cases per 10,000 per Cases 800 600 400 200 - 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiological week 2014

Bor Bentiu Tongping Malakal Awerial Lankien Hepatitis E Virus (HEV)

As seen in Figure 14, Acute Jaundice Syndrome (AJS) cases were first reported in week 10 in Mingkaman and after reaching the highest peak in week 35, the cases have been declining steadily. At least eight cases were confirmed through laboratory testing (ELISA/PCR). No new HEV cases were reported from Mingkaman during week 47 and 48, hence the cumulative remains 124 cases including four deaths (CFR 3.23%). Three (75%) deaths occurred among pregnant women (Figure 13). Overall, 142 AJS cases have been reported from various camps as shown in Figure 14. Early Warning and Disease Surveillance System

Figure 13

Hepatitis E Virus trends in Mingkaman, week 10-48, 2014

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12

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8 11 11 No. casesNo. 9 6 8 7 7 7 6 5 5 5 5 4 4 4 3 3 3 3 3 2 2 2 2 1 1 1 1 1 2 0 0 0 0 0 0 0 0 0

0 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiological week 2014

Cases Deaths Several interventions including supportive case management, targeted preventive interventions during antenatal visits, soap distribution, shock chlorination of boreholes, as well as house-to-house hygiene and sanitation promotion visits are being conducted by partners in response to the HEV trends.

Figure 14 Acute Jaundice Syndrome cases by Camp, week 3-48, 2014

18 16 14 12 10 No. casesNo. 8 6 4 2 0 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiological week 2014 Awerial Bor Malakal Lul Juba 3 Lankien Bentiu Tongping Cholera

The Ministry of Health, working in collaboration with partners, rolled out a comprehensive response to the cholera outbreak that started in Juba in week 17 of 2014. The national cholera taskforce is coordinating the implementation of comprehensive interventions for cholera prevention and control. There were no new cases of cholera reported within the IDP sites in week 48. Table 3 shows the cholera cases reported in the displaced and host populations. The cumulative for cholera in South Sudan is 6,421 cases including 167 deaths (CFR 2.60%) from five states and 16 counties (Table 3). There are no new cholera cases reported since week 47.

Table 3: Cholera cases and deaths by county week 17 – 48, 2014 No. State County New cases by Epidemiological week Total cases Total CFR 2014 deaths [%] 37 38 39 40 41 42 43 44 45 46 47 48 1 CES Tongping PoC 0 0 0 0 0 0 0 0 0 0 0 0 72 3 4.2 (IDP) 2 Juba 3 PoC 0 0 0 0 0 0 0 0 0 0 0 0 97 0 0 3 CES Juba 9 4 3 0 8 3 2 0 0 0 0 0 2,091 43 2.1 4 Kajo-Keji 2 0 0 0 0 0 0 0 0 0 0 0 93 7 7.5 Early Warning and Disease Surveillance System

No. State County New cases by Epidemiological week Total cases Total CFR 2014 deaths [%] 37 38 39 40 41 42 43 44 45 46 47 48 5 Yei River 0 0 0 0 0 0 0 0 0 0 0 0 47 2 4.3 6 JS Bor 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 7 EES Torit 0 3 0 0 0 0 0 0 0 0 0 0 2,032 36 1.8 8 Lopa-Lafon 0 0 0 0 0 53 3 4 0 0 0 0 264 16 6 9 Kapoeta North 1 3 7 1 0 0 0 0 0 0 0 0 83 1 1.2 10 Kapoeta South 0 0 0 0 0 0 0 12 2 0 0 0 14 0 0 11 Ikotos 5 25 19 19 5 41 30 31 4 10 0 0 297 27 9 12 Magwi 3 2 0 0 0 0 0 0 0 0 0 0 301 11 3.7 13 Budi 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 14 UNS Manyo 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 15 Malakal 0 0 0 0 0 0 0 0 0 0 0 0 1,024 21 2.1 16 WES Mundri East 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 Total South Sudan 20 37 29 20 13 97 35 47 6 10 0 0 6,421 167 2.60

Acute Flaccid Paralysis (AFP)

During week 48, seven new AFP cases were reported making cumulative of 287 cases since the beginning of 2014 (Table 4). The annualized non-Polio AFP (NPAFP) rate is 3.78 cases per 100,000 population children 0- 14 years (target ≥2 per 100,000 children 0-14 years). All states with the exception of three (30%), (Jonglei, Upper Nile, and Unity), have attained the targeted NPAFP rate of ≥2 per 100,000 children 0-14 years (Table 4). The non-Polio Enterovirus (NPEV) isolation rate (a measure of the quality of the specimen cold chain) is 17%, which is above the global threshold of ≥10%. Stool adequacy is 93%, a rate that is higher than the global target of ≥80% (Table 4). However, active surveillance continues to be hampered by insecurity in the three states that are directly affected by the current crisis.

Table 4: Summary of AFP indicators by state as of week 48, 2014

Other diseases of public health importance

Guinea worm (Dracunculiasis)

There are no new cases of suspect Guinea worm reported from the IDP sites during week 48. Early Warning and Disease Surveillance System

Viral Haemorrhagic Fever

The Republic of South Sudan continues to enhance its readiness capacities for Ebola/Marburg virus disease. The national Ebola/Marburg taskforce is coordinating the implementation of interventions guided by a national Ebola/Marburg contingency plan. No Ebola/Marburg cases have been confirmed in South Sudan but five alerts have been investigated in Ezo, Nzara, Terekeka (Tali), and Juba (Hai Jalaba and Gudele). Community sensitization on Ebola prevention and control is ongoing through radio messages, talk shows on radio and television as well as the distribution of IEC materials (posters and brochures).

Visceral Leishmaniasis (Kala azar)

Kala-azar cases have been on the decline in recent weeks. Given the high number of cases reported this year when compared to last year, the decline in Kala-azar cases in the recent weeks is largely attributed to under reporting and poor access to endemic areas due to floods and insecurity. Since the beginning of the year 6,936 Visceral Leishmaniasis (Kala-azar) cases and 196 deaths (CFR 2.8%) have been reported from 17 treatment centres. Of these 6,490 were new cases and 446 relapses or Post Kala-azar Dermal Leishmaniasis (PKDL), while 227 were defaulters. In comparison 2,828 cases and 88 deaths were reported during the same period in 2013, of which 2,616 were new cases, 212 relapses/PKDL and 40 defaulters. Lankien, Chuil and Walgak are worst affected, with Lankien accounting for 4,156 of the cases, while Chuil and Walgak account for 1,194 and Walgak 622 respectively. The higher number of cases this year in comparison to last year is attributed to several factors including displacement of non-immune populations to endemic areas, malnutrition, poor housing and reduced access to treatment centres, leading to late detection and diagnosis of cases. WHO is supporting implementing partners with case management supplies and adequate stockpiles have been assembled in endemic states. Training of health workers in Visceral Leishmaniasis case management, prevention and control is ongoing.

Meningitis

On 26 November 2014, Chotbora PHCC in Longechuk county, Upper Nile state reported seven suspect meningitis deaths, all occurring among children. The presenting symptoms included neck stiffness, headache and diarrhoea. A verification team led by MedAir with support from WHO showed that seven deaths occurred from 7 October to 18 November 2014. No new deaths have been reported since then. The investigation report will be shared in due course. Melut reported one case of bacterial meningitis secondary to otitis media. The patient improved on treatment and no additional cases have been linked to the case. Samples were not obtained for laboratory testing.

All-Causes Mortality Data

During week 48, mortality lists were received from Bentiu, Mingkaman, Malakal, Melut and Juba 3 IDP sites. A total of 12 deaths were reported this week, with the majority being reported from Juba 3 Poc 4 (33%) and Malakal PoC 4 (33%) see Table 5. Two (14%) deaths occurred in children under five years; these were all due to perinatal deaths in Juba 3 PoC. The causes of death during week 48 are listed in Table 5. Early Warning and Disease Surveillance System

Table 5: Causes of death by IDP camp during week 48 of 2014 Deaths by age-group Cause of death by site <5yrs ≥5yrs Total deaths Bentiu 3 3 Cancer 1 1 Chronic diarrhoea 1 1 Chronic illness 1 1 Juba 3 2 2 4 Cancer 1 1 Perinatal death 2 2 TB/HIV/AIDS 1 1 Malakal 4 4 Unknown disease 1 1 Encephalitis 1 1 TB/HIV/AIDS 2 2 Mingkaman 1 1 Malaria 1 1 Total deaths 2 10 12

Under-five Mortality Rate The under-five mortality rates (U5MR) per 10,000 per day from week 51 of 2013 to week 48 of 2014 are shown in Figure 15. The under-five mortality rates for all sites that reported in week 48 were lower than the emergency threshold of 2 deaths per 10,000 per day.

Figure 15

Under-5 Mortality Rate per 10,000 per day by Site - week 51 of 2013 to week 48 of 2014

18 16 14 12 10 8

Rate per 10,000 per Rate 6 4 2 0 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic Week Bentiu Bor Juba 3 Malakal Mingkaman Tongping Melut Threshold Crude Mortality Rate

The crude mortality rates (CMR) for week 48 are shown in Figure 16. During this week the CMRs were below the emergency threshold for the four camps that submitted mortality data. During week 48, the most frequent cause of death was TB/HIV/AIDS 3 (25%). This trend highlights the urgent need to integrate TB/HIV/AIDS prevention and control into the routine healthcare services in all the IDP sites. Early Warning and Disease Surveillance System

Figure 16

Crude Mortality Rate per 10,000 persons per day, week 51 of 2013 to week 48 of 2014

8 7 6 5 4

Rate per 10,000 per Rate 3 2 1 0 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 Epidemiologic week Bentiu Bor Juba 3 Malakal Mingkaman Tongping Melut Threshold Disease specific mortality

Acute watery diarrhoea related deaths

Figure 17 shows mortality due to AWD from week 52 in 2013 to week 48 in 2014. AWD has caused the highest number of deaths with a cumulative of 150 deaths since the onset of the crisis. The majority of AWD related deaths have been reported from Bentiu, Malakal, Mingkaman and Tongping (Figure 17).

Figure 17

25 Mortality due to AWD by camp, week 51 of 2013 to week 48 of 2014

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Number of deathsof Number 5

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51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 19 20 21 22 23 24 25 26 27 28 35 37 43 45 46 2013 2014

Epidemiological week

Bentiu Bor Juba 3 Malakal Mingkaman Tomping Overall Mortality

Since the onset of the crisis, at least 1,283 deaths have been reported from the IDP sites. Children under five years of age have accounted for 613 (47.8%) of the deaths. The majority of the deaths occurred in Bentiu, Bor, Malakal, Mingkaman and Tongping. The top causes of mortality during the period include AWD, severe pnuemonia, measles and malnutrition (Table 6). Early Warning and Disease Surveillance System

Table 6: Overall mortality by settlement, week 51 of 2013 to week 48 of 2014 Azar -

IDP site Jaundice Acute Syndrome watery Acute diarrhoea Bloody diarrhoea Cancer wound Gunshot disease Heart Hypertension Kala Malaria death Maternal Measles death Perinatal Pneumonia SAM Septicemia Stroke TB/HIV/AIDS Trauma Others Grand Total Agok 1 2 3 Bentiu 47 2 1 9 1 2 14 8 2 46 47 12 1 25 6 112 335 Bor 2 1 1 1 42 2 10 3 2 57 121 Juba 3 1 8 4 1 2 8 1 1 30 8 5 1 2 15 16 103 Kodok 1 0 1 Malakal 1 29 38 12 1 13 11 12 3 15 5 1 18 6 86 251 Melut 1 10 7 2 2 5 5 3 19 54 Mingkaman 6 30 4 2 1 1 16 1 4 8 9 3 8 1 4 2 45 145 Tomping 33 2 4 6 11 1 10 37 15 24 16 1 3 4 1 98 266 (missing) 1 1 2 4 Grand Total 8 150 8 11 54 29 7 23 67 4 92 71 106 94 28 8 71 15 437 1283

General recommendations

Since malaria remains the top case of morbidity in IDP settlements, malaria preventive interventions including the use of Long Lasting Insecticide Treated Nets (LLITN), indoor residual spraying (IRS) and prompt case management should be sustained. Integrate TB/HIV/AIDS prevention and control into the routine healthcare services in all the IDP sites. Biological samples should be obtained and shipped to Juba to allow laboratory confirmation of emerging outbreaks of measles, acute jaundice syndrome, bloody diarrhea and cholera. Cholera surveillance and response should be enhanced in Ikotos, Kapoeta South and Lopa-Lafon counties by supporting the County Health Departments and implementing partners to report cases promptly, conduct case management at designated oral rehydration points and health facilities while observing the recommended infection prevention and control standards, and promote household sanitation and hygiene. Lankien, Melut and Renk should be prioritized for integrated measles campaigns so as to reverse measles resurgence in these IDP sites. In response to the HEV cases in Mingkaman and AJS cases in the other IDP sites, the following interventions should be prioritized: household sanitation and hygiene promotion; improve access to safe water; and targeted interventions to prevent new infections in pregnant women. To address the escalating Kala-azar trends in endemic areas in Jonglei, Unity and Upper Nile states: a. Surveillance should be enhanced to allow timely diagnosis and initiation of treatment; b. Treatment centers should be opened up to improve access to medical care endemic areas; c. Conduct refresher trainings for health workers in endemic areas on Visceral Leishmaniasis case management, surveillance and control; d. Stockpiles for diagnostic kits and case management supplies should be enhanced in endemic states; e. Communication on kala-azar prevention and control should be initiated. Support the implementation of the Ebola preparedness and response so as to enhance capacities for case detection, investigation, response and community awareness on Ebola prevention and control. Please send all disease surveillance information and any outbreak rumours to [email protected]. IDSR reports and mortality line lists should be submitted by COB Monday after the close of each epidemiologic week.

For comments or questions, please contact Department of Epidemics, Preparedness and Response, MoH-RSS E-mail: [email protected], HF radio frequency: 8015 USP; Selcall: 7002