INTRODUCTION

Diphtheria is a potentially acute disease caused by exotoxin-producing Corynebacterium diphtheriae. Morbidity and mortality result from the bacterial toxin that may cause obstructive pseudo-membranes in the upper respiratory tract (croup) or damage to myocardium and other tissues. Although most infections with C. diphtheriae are asymptomatic or run a relatively mild clinical course, high case- fatality rates (>10%) have been reported even in recent outbreaks.

The disease still endemic in due to very low DPT3 coverages across all the states in general, especially in Greater Region, followed by the Bahr el Ghazal, from where diphtheria cases are still being reported sporadically or in small outbreaks.

Since October 2015, MSF-F medical Team has been reporting the surge of probable diphtheria cases. Therefore, an investigation was conducted by a joint WHO and UNICEF team in Old from 13th to 20th January 2016.

Fangak County is located between Guit County in State to the west, County to the south, Canal County to the east, Panyikang County of Upper Nile State and Pariang County in the north.

Fig #1: The hard reach communities in Sudd Swamp

The County is part of the Sudd swamp, one of the world's largest wetlands in the Nile basin which is considered to be nearly impassable either overland or by watercraft, making the logistics of operations in the region one of the most costly to afford

This report describes the methodology used, and provides details of findings, conclusions, challenges, SWOT analysis, recommendations and actions plan.

Methodology and activities carried out consisted in:

1. Interview with Key informants (PHOM Governor, ROSS County Director, County Health Director, MSF Program Coordinator, MSF Doctor Staff, mother caretakers 2. Clinical re-examination of 4 probable cases present in isolation at Old Fangak Hospital, out of the 9 cases admitted since October 2015 3. Attendance of the Humanitarian Coordination meeting on Friday 15th January 2016 4. Field visit to Toch Payam (Saturday 16th January 2016) and New Fangak town (Monday 18th January 2016)

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5. Retrospective case search through review of IPD and OPD registers (Old Fangak Hospital and Toch PHCU) 6. Assessment of susceptibility to VPDs through a quick historical OPV Coverage Survey referring to the last 2 SIAs plus EPI doses among 76 under 5 years’ children from 76 households randomly selected in Toch village. 7. Review of coverage data in the last 6 year of Fangak County

Observations and findings were:

1. On clinical point of view on the 4 Diphtheria probable cases in isolation and from review 7 files: - Poor, since all patients were at advanced stage of anti-biotherapy - Fig #3: Probable diphtheria case, 11 year old patient from Wang Chok Village / Old Fangak Payam – Photo MSF-F - Signs like fever, edema of submandibular areas and neck, cervical lymphadenopathies (bull neck) and pharyngitis consistently present.

- Presence of laryngopharyngeal membrane described from one of the who died (at 5 and 4 years of age respectively) - No sample collected.

2. No probable diphtheria cases missed or detected during the retroactive case search, however one AFP case were detected in Torch Payams.

Fig #4: Assessment team reviewing OPD register at Toch PHCU and detected AFP case during the quick OPV coverage survey/ Toch Payam – Proto December 16th, 2016

3. Epidemiologically: Fig #5: Epi curve (by week of onset) & Pie chart of Distribution by Age Group

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With an epidemic curve in slight propagated mode, the first case with onset of disease in Week 42 (11/10/2015) was from Pathiech Village in Toch Payam and spreaded to Old Fangak Payam and Paguir affecting mainly young children (44% between 1-4 years) and adolescent (56% between 5-14 years of age). So far no case below 1 year affected – Fig #1.

Fig #6: Pie chart of Distribution by Payam of residence By Payam; most of reported probable diphtheria cases seem1 to be residents of Old Fangak Payam (56%), following by Toch (22%) – Fig #2

Among 9 index cases, 2 reported to have been vaccinated, 3 unvaccinated and 4 unknown

21 Contact cases out of 35 are (11 under 5 years and 10, 5-14 years of age) are adolescent and only 1 were vaccinated

4. County Health system suboptimal - The County Health Department structure in place, but under staffed currently ill functioning with only 3 staff (CHD Director, M&E and Surveillance officer and Pharmaceutical officer) in displacement from New Fangak Town (County Head Quarter) to Old Fangak in an obsolete building lacking minimum conditions for better work environment.

- The county has 20 health facilities: 2 hospitals (one completely destroyed in New Fangak – Fig #3), 5 PHCC and 13 PHCUs and in addition there is 1 outreach unit in Pulita Boma.

Fig #7: Destroyed County Civil Hospital (New Fangak) and MSF-F Mobile Clinic site (Tent) – Photo of December 18th, 2016

1 Not reliable information since mother caretaker can refer to one village or another according to circumstances

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- Due to high number of IDPs (39,900) in New Fangak Town and surrounding Bomas, MSF-F is currently running mobile clinic service twice a week, this frequency is planned to be increased in the nearest future. - 6 Health facility cold chain systems in place ( 4 functional and 2 non-functional) - The County cold chain facility destroyed along with the County Civil Hospital in New Fangak - Inadequately staffed health care units - NGO Health County lead currently not operating from the temporary County head quarter - Most of the health facilities have been running without drugs for long

5. On Immunization service With exception of 2011, DPT3/Penta3 routine immunization coverages in the County have remained far below protective index and the performance worsened during the last 2 years due to the conflict since December 2013 (Fig #4)2

Fig #9: DPT3/Penta3 Routine Immunization in Fangak County – 2010 to 2015

The historical quick OPV coverage evaluation shown poor accessibility to immunization services for routine EPI and National and Subnational immunizations days (Table # 1 & Fig #10)

2 Source: MoH/EPI section

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a) Table #1: Summary description of the sample and findings: 32 household randomly selected to reach 76 under 5 years old children, out of which 35 were 6 to 24 months old.

Under five years children vaccinated Reason for failure in with OPV (out of 76) the last round of NIDs

or

The 2 last NIDs campaigns

ldren with with ldren

i

)

doses of RI

Round Round Round

Total number of Total number surveyed households five years Under children 6to24M Children

came . Team never

out of 35 of out

6to24M Ch 3 at list ( 1. November NIDs 2. December NIDs was absent 1. Child informed not mother 2 2 29 23 11 44 Total 32 76 35 5.71% 38.16% 30.26% 20.00% 80.00%

Table #1 indicates that only: - 2 children of 6 to 24 months of age (5.7%) out 35 of the same age assessed have received at least 3 OPV doses during routine EPI - 29 children under 5 years of age (38.6%) out of a total 76 assessed in the 32 households received OPV during November 2015 - 23 children under 5 years of age (30.3%) out of a total 76 assessed in the 32 households received OPV during December 2015

Table #1 indicates as well that 55 under 5 years of age were missed either in November or in December or in both NIDs rounds, mainly (44 or 80%) because team never came to their village; those once the area of residence where beyond at least 1 hour of walk from the main Toch village, or secondly (11 or 20%) child not at home or mother caretaker not informed

Fig #10: Distribution of Total OPV doses among Under 5 years children / Fangak County – 2015 The Distribution of total OPV doses (NIDs plus routine EPI) among under 5 year’s children (out of 76 assessed) revealed that (Fig #8): - 31 children under 5 years of age (41%) out of a total 76 assessed in the 32 households were Zero doses, in other words completely unprotected against wild poliovirus - Only 10 children under 5 years of age (13%) out of a total 76 assessed in the 32 households had 4 to 6 OPV doses, in other words fully protected against wild poliovirus.

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6. Week HMIS and Surveillance system, despite the presence of Diphtheria case management protocol and case definition in Old Fangak Hospital

- Use old version of MoH registers in one visited health facilities - Timeliness and completeness of Weekly zero reporting were among other issues: Data in the DHMIS were available only from week 22 to 49, 2015 these only these from 8 Health facilities out of the 20 registered in County. - No IDSR case definition posters found in visited health facilities

7. Social Mobilization and Facts from community profiling: - Diphtheria is well known by Fangak local communities, and called in Nuer “Ng’orkoda”. - Low community awareness & demand

CONCLUSIONS

Despite absence of Lab confirmation, the surge of diphtheria case in Olg Fangak community is the result of an cumulated proportion of susceptible persons to VPDs; this compounded by the ill functioning County Health System.

CHALLENGES

1. Mobility is very difficult, since the place is covered with swamps and surrounded by 3 rivers. Air transport, local canoes are the means of transport and boats though it is expensive.

2. Un number of Health facilities along with their catchment areas landlocked by swamps as such they can’t be reached neither by boat or by road rather by air

3. Before the full implementation of peace agreement, the blockage of the main canal of supplies from Malakal through Nile and Phom Rivers will continue to have negative impact of the local market, including scarcity of fuel and high increasing pecuniary pressure on the local food basket.

4. High staff turnover of CHD staff due to no salary ever since the crisis started.

5. Humanitarian safety and security framework is among challenge to operate in warlike tension such the windows of direct supervisory and monitoring are stretched to the extent that possible intervention are carried out relaying on local staff with less control about what is really happening

FANGAK ASSESSMENT SWOT ANALYSIS

Strengths Weakness  There is functioning CHD  Poor infrastructures and HF ill equipped  There is 20 functioning HF and at least staffed  Irregular drug supply  4 Functioning Cold chain equipment exit  County Health partner lead absent at the  High level collaboration County Headquarter Internal factors  Low community awareness & demand

E x Opportunitiest e r n a l f a c t o r s Threats

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 Humanitarian presence on ground (MSF-F,  Fluid security situation NPA, SSMR, ICRC …)  Suspension of Government salaries to conflict  The rivers as main road for transport and affected states exchange  Swamps  Current period of tranquility as result of the  Land locked geographic entity ongoing negotiations  Communication network absent  Interrupted fluvial navigation to Malakal

RECOMMENDATION

1. Sustain the ongoing active and passive case search 1. Follow on the procurement of the Medium for transportation of sample 2. The M&E to avail new OPD registers and IDSR reporting Tools to the Health Facility 3. Continue the case management for Index cases and Contacts according to protocol 4. Scaling routine immunization service in the County 5. MoH to assess support provided by the Fund Manager in County 6. Plans for Old Fangak should consider specificities related to logistical bottle necks in the areas 7. Plan for a Humanitarian Inter agency Assessment in the County

ACTION POINTS

1. Case Management ongoing under the lead of MSF-F - Antitoxin plus antibiotherapie - Contact tracing + preventive antibiotherapie 2. Epidemiological surveillance to continue ensuring early case detection is ongoing: the tenth case were detected last week 3. Immunization Response: - Booster dose of with TD to close contacts ongoing (MSF-F) - Routine immunization acceleration activities (in planning phase – MoH/WHO/UNICEF)

ASSISSENT TEAM

Name Function Institution Dr. Bimpa L. Dieu-Donné Medical Officer WHO Charles Ngemani Health Information Officer UNICEF George Worri Public Health Officer WHO Misuk Moses Enoka Communication for Development Office UNICEF

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