Emergency preparedness and Humanitarian Action (EHA) Week 39 (24 TH -30th) 2012

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Highlights 1. Humanitarian situation

 The overall Security situation remained stable in the country although some rumors of the Lord’s Resistance Army (LRA) movement at the border line with Uganda, Democratic Republic of Congo (DRC) & Central African Republic (CAR) were recorded . Reports of Rebel Militia Groups in Jonglei states were also recorded this week with no c asualties but with displacements.  The continued influx of refugees in to Maban county is straining the humanitarian operation. There are currently 105,000 refugees in Maban County, 65,000 in Yida, Pariang, in addition to 15,000 in Lasu ( CES) and Makpandu (WES). These are living in extremely dire conditions characterized by poor water and sanitation resulting in large public healt h risks for both the refugee and host communities. In August 2012, the WHO STAFF TOGETHER WITH STAFF AT A HEALTHY FACILITY IN LAKES STATES CHECKING THE CONSULTING Ministry of Health declared hepatitis E virus outbreak REGISTER FOR MORBIDITY TRENDS in Maban County. With renewed fighting in the bordering states, it is anticipated that there will be an During this week, WHO; increased refugee influx o f 150,000 in the next few month. Currently, Yida has additional new refugees 1. Supported the County health department in compared to the Maban , mainly due to poor access due to the rains. Maban to coordinate the refugee response with emphasis on disease surveillance in the  South Sudan, remains a very expensive and challenging country due to the poor infrastructure. Up to 60% of community. the country is currently cut off due to the heavy rains 2. Conducted an assessment for Kala azar upsurge and floods making delivery of emergency assistance in Koch County, Unity State to verify reported very costly. cases  Returnees continue to arrive in from the Sudan. To 3. Supported the SMOH W estern State date 120,000 persons have returned to South Sudan. to verify rumors of s uspected Ebola case from This reporting week, a total of 480 returnees were flown in by African Inland Church from Khartoum. Bazungua Boma, Yambio Payam. Emergency assistance and a re-insertion package were provided to the returnees in the final area of destination. 4. Participated in an interagency assessment of An estimated 12,000 others are still stranded in Renk flooding in Maban County . (Mina, Abyouk and Pay er sites) , 3000 are in the ways stations in Juba and National Teachers Training Institute, and 3000 stranded in Kosti, White Nile State, 5. Supported Akoka and Longechuk counties with Sudan. Kala azar drugs, rapid tests and syringes to support the rising cases .

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2. Public Health threats and concerns

i. The hepatitis E outbreak in Maban is still evolving; this peaked in Jamam the epicenter . However it’s too early to judge as to whether rain s still hamper efforts to improve sanitation and availability of clean water at the camps. With surface floods affecting the refugee camps, the water and sanitation condition of the water will deteriorate due to repeated contamination duelto low latrine coverage

ii. Floods remained a main public health risk this week. WHO/MOH received reports from the states showing a growing trend of malaria, diarrhea and eye infection cases . T he potential of a disease outbreak remains a key concern in the areas affected by floods in Northern Bah r el Ghazal, Lakes, Jonglei, Unity and Upper Nile state.

iii. In Warrap state, two AFP cases were reported from Gogrial West County while in Western Bahr el Ghazal states, 4 new case s of anthrax were reported and are currently under investigations.

3. Coordination, Emergency Preparedness and Response

1. With torrential rains affecting the refugee settlements in Uppernile. WHO took part in the interagency assessment of flooding in Maban County. The team led by the Deputy Governor of Upper Nile State included other NGO partners. The main objective of the assessment was to identify the critical needs that are affecting the population in the county following the influx of over 105,000 refugees from North Sudan. This has greatly impacted on the thin social services available for the host community ( 45,000) and most especially the health services. In resp onse

to the identified gaps, WHO provided WHO TECHNICAL OFFICER CONDUCTS AS ASSESSMENT IN AWEIL TOWN FOLLOWING FLOODING.

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Basic kits, Inter agency Emergency Health Kits and anti-malarials weighing 500kg . These were given to support service delivery at the Primary Health Care Centers (PHCCs) and Primary Health Care Units (PHCUs) run by the County Health Department (CHD) .

2. There is an anticipated arrival of 600 returnees from Khartoum to Malakal by air. To ensure that the health needs of the returnees are taken care of, WHO prepositioned 2 basic kits and 3 boxes of antimalarials to Malakal way Stations managed by INTERSOS in preparation for the receipt of the r eturnees.

3. During the week an al ert case of Ebola rumors was reported from Bazungua Boma, Yambio Payam . As a follow up, WHO in collaboration with the State Ministry of Health (S MOH ) emergency team investigated and verified the suspected case. The team established that the suspected case did not present with signs and symptoms to match the criteria for the case definition of Ebola. The patient was however diagnosed with ‘Acute Renal Failure.

4. In Northern Bahr el Ghazal state, persons affected by floods were relocated to Adapa. WHO contin ued WHO STAFF CONSULTANTS WITH THE COMMUNITY DURING AN to support a mobile clinic in the ASSESSME NT OF THE FLOODED HOMES IN AWEIL TOWN. affected areas by providing drugs and incentives for health workers operating the clinic. In this reporting week, 877 patients were treated for common illnesses, 79% of them being malaria cases. The State Rapid Respons e Team continues monitoring disease trends in the state in anticipation of epidemic prone diseases. More focus and emphasis has been put in the Apada area hosting persons affected by the floods. .

5. In this reporting week, WHO conducted a verification exercise following reports of an upsurge of Kalazar cases in Koch County, Unity state . The team established that over 314 cases have been reported since the start of 2012, with a slight increase in cases reported in the last three weeks. The drug situation was also found to be relatively below the acceptable level . In order to support the health authorities in Unity state, WHO provided test kits and assorted Kalazar drugs of Ambisome,Paramay ocin and R apid Diagnostic Tests kits to respond to the increasing number of cases in the PHCC where the patients are managed . In the Upper

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Nile state, WHO also supported Akoka and Longichuk counties with Kalaazar drugs, rapid tests and syringes to support the increase of the reported cases of Kalaazar in the two counties.

4. Communicable Disease Update

Maban response

1. WHO maintained an epidemiologist in the county of Maban to support the county health department. The Epidemiologist was deployed to the county to assist the health authorities and health cluster members to strengthen Early Warning, Alert and Response Network (EWARN) system at county level. In Maban and Yida refugee camps, reporting performance from health facilities serving the refugees and surrounding ho st communities has greatly improved and remained high due to WHO interventions . The current early warning surveillance system in the refugee camps and host community is also very effective, timely and sensitive. Acute Jaudice Syndrome continued to be reported in the 120 refugee community in Jamam, Epi Curve by Camp Gendrassa, and Batil Camps. 100 Follow up of cases that were reported from the host 80 community at Jamam PHCC was not successful. The 60 cumulative number of cases Gendrassa from Maban in week 39 stood 40 Batil 783 and 22 deaths(CFR is of No. AJS Cases of No.AJS Cases Jamam 2.8%.) 20

Factors for the decline in the 0 incidence rates could be 30 31 32 33 34 35 36 37 38 39 attributed to increased safe Week water, and improved sanitation and hygiene practices in the camps. At the beginning of this reporting week there was limited movements of people in Batil and Gendrassa d ue to clashes between the refugees and the host community. This affected Out Patient Department attendance and active search of cases. Another factor could be the tendency of some members of the community to seek medical treatment from traditional healers. This calls for increased community sensitization. There is need to strengthen inter agency collaboration and support NGOs that are promoting behavioral ch ange in the camps. In week 39, nine (9) out of 15 C ounty Health Department facilities reported. Six Primary Health Care Units did not report while five were inaccessible. Notifiable diseases that caused high morbidity in both host and refugee communities i ncluded Malaria, Acute Watery Diarrhea, and Diarrhea with blood (Shigellosis).

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The table below shows details and a graphic presentation of the analysis.

Malaria Acute Water Diarrhea with Total OPD Diarrhea Blood attendance Host Community 617 (31.92%) 124 (6.42%) 54 ((2.8) 1,933 Refugees 1937 (20.4%) 703 (7.4%) 78 (0.83%) 9,488 Total 2554 (22.37%) 827 (7.25%) 132 (1.16%) 11,421

The statistics above shows malaria as the highest cause of morbidity followed by Acute Watery diarrhea. The host community is affected more by malaria than the refugees and the Comparison of Incedence Rates between Host and reverse is true for Watery Diarrhea. Refugee Communities The distribution of mosquito bed 35 nets to every house hold in the 30 camps might be responsible for the 25 relatively low incidence rate. No much attention has been focused on 20 15 host communities in this regard. Host community Statistics on watery diarrhea might 10 Refugees be a reflection of low sanitation 5

standards and hygiene practices in of %total OPD attendance 0 the camps. Yousuf Batil recorded AJS Malaria Acute Diarrhea the highest number of watery watery with Blood diarrhea followed by Doro. diarrhea

There is need for WASH partners to construct permanent sanitation facilities, provide adequate safe water, and sensitize the community on good practices in order to reduce the high incidence rates. There is an acute shortage of health workers in the county, and the majority of health partners serving the host community are concentrated in and around Bunj Payam. Irregular and inadequate supply of drugs and EPI materials by MOH coupled with inadequate number of health

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Office f or the Republic of South Sudan workers has aggravated the low health services .

2. The trend of acute watery diarrhea from the refugee camps in Maban continued declining in the past few weeks, with a low case fatality rate, while the trend of AWD in Yida shows declining trends from week 34. Hygiene and sanitation conditions in the refugee camps shows improvements as par tners on the ground make good progress in scaling up WASH and health interventions to prevent the spread of water borne diseases particularly watery diarrhea. In the reportin week, WHO participated in the health coordination and task force meeting for the hepatitis E response at county level, conducted support supervision in the facilities of Doro(SIM),Bunj PHCU(RI) and Bunj County health department hospital.

3. This part of the weekly updates uses statistics from the previous week, in this case week 38. Dur ing this week, a total of 34,313 health events and 38 deaths were recorded from all the health facilities in the country. Over 80% of all reported health events and 65% of all deaths were as a result of malaria, followed by acute watery diarrhea and bloody diarrhea.

4. The average state timeliness of reporting in week 38 was 38%. However, this rate varied from state to state. The best performing states included; WES, Unity, WBeG, Warrap and Upper Nile ( refer figure 1 for details). On Average, 51% of all expected health facilities submitted their weekly reports in week 38. Completeness rate also varied from state to state with the best performing states being WES, Unity, Lakes, Upper Nile, WBeG and Warrap States.

5. During week 38, a total of 5,661 AWD cases ( Incidence rate of 56.4 per 100,000 population ) were reported nationwide with eight (8) related deaths (CFR 0.17 %). Children below five years of age accounted for 56% of all reported AWD cases and 25% deaths. No cholera alert or confirmed case was rep orted this period. Table 2 shows a comparison of AWD cases and deaths from the ten states. WBGZ, Unity, Upper Nile and WES states recorded the highest AWD incidence rat e this week. Figure 2 below shows a comparison of AWD cases reported by Epi -week and year 2010 -2012. The overall incidence rate of AWD across the counties remained higher on week 38 as compared to the same period in 2010 and 2011. Western Bahr el Ghazal State, Unity, WES and Upper Nile states recorded the highest AWD incidence rates

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of 173 , 150, 108 and 107 respectively per 100,000 populations. Counties that recorded the highest AWD cases are Wau, Pariang, Renk and Maban.

Seasonal flooding continued to affect many communities in all the states, with thousands of people being displaced. Jonglei state is the most affected state, with 11 out of 12 counties being affected. OCHA and other humanitarian partners are making extra e fforts to assess the affected communities but access to flood affected areas is a major challenge. The Ministry of Health together with WHO alerted health authorities and partners to closely monitor the flood affected areas for any potential outbreak of w ater borne diseases.

6. A total of 27,933 suspected malaria cases ( incidence rate of 338.2 per 100,000 populations ) with twenty four (24) related deaths (CFR 0.09 %) were reported in week 38. Of these, 37% of the cases and 75% of deaths were in children below five years of age. The overall 600.0 Figure 3: Comparisons of Malaria Incidence Rate by Epi incidence rate slightly - Week by Year 2010 - 2012 (Wk 1 - 38)2010 decreased this week as 500.0 compared to the previous week. WBGZ, Upper Nile, 400.0 WES, CES and Unity states accounted for the majority 300.0 of cases reported during this period. Central Equatoria 200.0 State, Lakes and Upper Nile states reported the majority 100.0 deaths. Counties that

recorded the highest malaria PrevalenceRate (100,000 Population) 0.0 cases include; Yambio, Juba, Yei, Kajokeji, Rumbek

Center, Rumbek East, Wau, 01 Wk 03 Wk 05 Wk 07 Wk 09 Wk 11 Wk 13 Wk 15 Wk 17 Wk 19 Wk 21 Wk 23 Wk 25 Wk 27 Wk 29 Wk 31 Wk 33 Wk 35 Wk 37 Wk 39 Wk 41 Wk 43 Wk 45 Wk 47 Wk 49 Wk 51 Wk Epi Week Jur River, Gogrial West, Tonj East, Tonj South, Pariang, Rubkona, Leer, Renk, Longochu k, Maiwut, Malakal and Maban. Figure 3 above shows comparisons of malaria trends by Epi -week in 2010-12. The reported cases in the last few weeks were slightly lower as compared to the previous weeks and the same period in 2011.

5. Capacity building

1. WHO in collaboration with the SM OH carried out an H1N1 and Hepatitis E sensitization workshop in Malakal. Forty (40) participants were trained for 2 days. The training target medical officers, Nurses, Midwives and some community health workers who are depl oyed in the health facilities in the respective

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states. Similar trainings were conducted in Lakes State with an attendance of 30 participants drawn from all health facility levels in the counties of Lakes states.

2. WHO facilitated at the Maternal and Neonatal Tetanus (MNTE) Campaign Micro - planning workshop organized by the SMOH in collaboration with UNICEF, State (WES). The training was conducted in preparation for the upcoming MNTE vaccination campaigns.

3. The program in collaboration with the SMOH - WES conducted an integrated support supervision visit to Tumbura County. During the visit the team supported the H uman African Trypasomiasis (HAT) program WHO STAFF TRAINS AN EPI OFICER OF PANYIKAN ON SAMPLE COLLECTION FOR AFP conduct an assessment to Tambura and S/Yubu Payams to establish the quality of HAT health services provided by the health department at county level. The team established that the HAT services implementation was on track and with adequate drug stock levels and human resource. The team also conducted a detailed case investigation and sixty day follow up for the reported AFP cases in the county . The two patients earlier on reported were discarded as non olio AFP cases.

6. Partnership

1. During the week, WHO facilitated the weekly T echnical Working Group meeting for the rainy season campaign in Upper Nile state, chaired by the Director General of the Upper Nile state . WHO will continue to provide drugs to support the rainy season campaign.

2. Participated in a meeting at Relief Rehabilitation Commission Office for the assessment of floods in Nzara County, Ibba County and Mundri East .

3. Finally, the organization participated in a two days workshop on EPI survey coverage organise d by UNICEF in Rumbek. weakness in both campaigns and routine EPI were discussed in the training and strategies to address the weaknesses in the future designed and agreed on. The meeting brought together four states of Warrap, Western Bahr el Ghazel, Northern Bahr el Ghaze and Lakes.

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7. Planned activities

 Conduct training for accelerated IDSR reporting to be extended to other counties especially Nasir.  Facilitate at the IDSR sensitization to DHIS training conducted by Save the Children in Malakal.

8. Acknowledgments: The progress achieved by WHO/EHA South Sudan was made possible through c on tributions from the following partners:

For further information, please contact: Dr. Allan Mpairwe, Emergency Coordinator, Email: [email protected] or Ms Pauline Ajello, Communication Officer, Email: ajellop [email protected]

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