Early Warning and Disease Surveillance System

Republic of South Sudan

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

Week 43 20 October – 26 October 2014

General Overview

Completeness for weekly reporting increased from 66% to 82% while timeliness increased from 36% to 54% in week 43 when compared to week 42. Malaria remains the top cause of morbidity with Malakal, Tongping, UN House, Renk, and Melut reporting the highest incidence in week 43. Malakal PoC had the highest incidence for Malaria, ARI, AWD, and ABD during week 43; highlighting the need to enhance communicable disease prevention and control interventions in the PoC. Sixteen measles cases were reported from Melut (11 cases), Lankien (4 cases), and Mingkaman (1 case). One new probable HEV case was reported in Bentiu PoC in week 43. The cumulative for HEV is 113 cases and 4 deaths (CFR 3.7%) after one new case was reported from Mingkaman in week 43. Forty seven cholera cases and two deaths were reported from Lobonok in Juba, Central Equatoria State, as well as Lofus, Lorum and Imatong in Ikotos County; Ohilang and Ibele in Lopa-Lafon County; and Kapoeta South Town in Eastern Equatoria State in week 43. The cumulative stands at 6,297 cases with 160 deaths (CFR 2.26%). Kala-azar trend continues to surge to its seasonal peak with 5,713 cases and 163 deaths reported this year. The under-five and crude mortality rates in all IDP sites were below the emergency threshold in week 43.

Completeness and Timeliness of Reporting

Completeness for weekly reporting increased from 33 (66%) in week 42, to 41 (82%) in week 43. Timeliness for weekly reporting increased from 18 (36%) in week 42 to 27 (54%) in week 43.

Figure 1

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

42 45 41 41 38 38 37 40 36 35 33 34 34 34 33 34 32 31 35 29 29 29 28 27 28 30 26 26 26 26 24 24 23 21 21 25 20 19 17 17 17 18 18 20 Number of sites of Number 15 13 15 8 10 5 6 2 5 1 0 51 52 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Epidemiologic Week 2013 2014 This Bulletin is produced by MOH, RSS with Technical support from WHO 1 Early Warning and Disease Surveillance System

In week 43, we did not receive reports from 6 facilities (table1). Three outreach sites including Yalakot mobile (IMC), Panculim mobile (IMC), and Man-Awan (Goal) were not visited but zero reports were submitted. 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 43, 2014 No. IDP site Health Facility/Partner 1 Mingkaman 1. Kalthouk PHCU CCM 2. Mingkaman PHCC CCM 2 Bentiu PoC 1. PoC2 Clinic IRC 2. Rubkona PHCC CARE 3 Lul Lul MSF-E 4 Malakal PoC PoC Clinic MSF-E

Consultations (All patients seen at Outpatient and Inpatient facilities) The total number of consultations increased from 13,552 in week 42 to 15,809 in week 43. During week 43, most of the consultations were reported from Malakal, Renk, Awerial, Melut, UN House, and Bentiu (Figure 2).

Figure 2

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) in the IDP sites and communities. Malaria, ARI and AWD were the top three causes of morbidity among IDPs in week 43 (Figure 3 and 4). During week 43, malaria had the highest proportionate morbidity and incidence when compared to the other top five causes of morbidity among IDPs (Figure 3 and 4). The overall incidence for malaria, ARI, ABD, AWD, and suspected measles increased in week 43 when compared to week 42 (Figure 4).

This Bulletin is produced by MOH, RSS with Technical support from WHO 2 Early Warning and Disease Surveillance System

Figure 3

The weekly number of cases for the current and preceding weeks, and 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 No. Disease 42 43 week 51 of 2013 1 Malaria 2968 3510 120,216 2 AWD 786 1068 55,013 3 ARI 1357 2941 94,375 4 ABD 136 218 9,205 5 Measles 7 16 1,473

Figure 4 Incidence for Priority Diseases, week 1 - 43, 2014

140

120

100

80

60

40 Cases per 10,000per Cases 20

- 01 03 05 07 09 11 13 15 17 Epidemiological19 21 23 Week25 201427 29 31 33 35 37 39 41 43

ARI Bloody Diarrhea Malaria Suspected Measles Watery Diarrhoea

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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). ARI registered the second highest proportionate morbidity of 18.6% and incidence (52 cases per 10,000 population) in week 43 (Figure 5).

Figure 5

During week 43, a total of 2941 cases of ARI were reported with the highest ARI incidence (cases per 10,000) being reported in Malakal (984), UN House (270), Bor (46), Bentiu (46), and Akoka (44).

Acute Watery Diarrhoea

As seen from Figure 6, the AWD proportionate morbidity increased from 5.9% to 6.8% and the overall AWD incidence (cases per 10,000) increased from 14 to 19 in week 43 when compared to week 42 (Figure 4). Overall, the AWD trend has been on the decline since the beginning of the year.

Figure 6

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During week 43, a total of 1068 AWD cases were reported with the highest AWD incidence (cases per 10,000) being reported in Malakal (120), Melut (78), UN House (52), Renk (44) and Akoka (37) as illustrated in Figure 7).

Figure 7 AWD Incidence, by IDP site, for week 1 - 43, 2014 700

600

500

400

300

200 Cases Cases per 10,000 100

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

Bentiu Renk Akoka Malakal UN House Tongping Melut

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. The high AWD incidence during weeks 17-25 corresponds to the peak of the cholera outbreak in South Sudan. 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 43, 2014 200 100%

180 90%

160 80%

140 70% s

120 60% e n e 0 t 0 e l 0

, 100 50% p 0 1 m o r e 80 40% C p s e

s 60 30% a c 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 Epidemiological week 2014 Completenes ≥5 yrs <5 yrs

Dysentery / Acute Bloody Diarrhoea

Figure 8 shows Acute Bloody Diarrhoea (ABD) trends during week 1-43 of 2014. 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. The incidence (cases per 10,000) of ABD increased from 2 to 4 while the proportionate morbidity (%) increased from 1.0 to 1.4 in week 43 when compared to week 42. Figure 9 shows ABD incidence trends by IDP site from week 1 to week 43 in 2014. During week 43, the highest ABD incidence was reported in Malakal PoC as compared to other IDP sites. During week 43, 218 ABD cases were reported with the highest ABD incidence (cases per 10,000) being reported in Malakal (21), Renk (19), Melut (14), Akoka (Rom) (12), and Ogod (9).

This Bulletin is produced by MOH, RSS with Technical support from WHO 5 Early Warning and Disease Surveillance System

Figure 8

These ABD trends highlight the need to improve access to safe drinking water and sanitation facilities in all IDP camps. Stool samples should be obtained from suspected cases to facilitate laboratory testing. Laboratory confirmation will allow better clinical case management and the initiation of tailored public health interventions.

Figure 9 ABD Incidence, by IDP site, for week 1 - 43, 2014

200 180 160 140 120

Cases Cases per 10,000 100 80 60 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

Malakal Renk Akoka Bentiu Melut Ogod 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). 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 in Thol Payam, Nyirol County in Jonglei State. During week 43 a total of 16 suspect measles case were reported; from Mingkaman (1), Melut (11), and Lankien (4).

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Figure 10

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. Overall, the malaria trend since week 1 of 2014 shows an increase that is expected given the ongoing rainy season. During week 43, malaria recorded the highest proportionate morbidity of 22.2% and the malaria incidence (cases per 10,000) increased from 53 in week 42, to 61 in week 43. During week 43, a total of 3,510 malaria cases were reported with the highest malaria incidence (cases per 10,000) being reported in Malakal (469), Tongping (232), UN House (184), Renk (155), and Melut (83) as seen in Figure 12.

Figure 11 Suspected Malaria Adjusted Proportionate Morbidity , week 1 - 43, 2014

40% 36.8% 100% 33.8% 32.1% 35% 31.5% 31.5% 90% 26.7% 27.6% 27.3% 80% 30% 25.5% 24.8% 23.5% 23.5% 24.2% 70% 21.5% 21.5% 22.2% 25% 19.7% 20.4% 19.3% 20.3% 60% 19.1% 18.0% 18.1% 16.8% 20% 15.1% 16.1% 50%

14.5% Completeness 13.0% 14.1% 13.8% 15% 10.9% 40% 30% 10% Percent Percent of total consultations 20% 5% 10% 0% 0% Epidemiologic week 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43

Completeness Malaria Adj. Linear (Malaria Adj.) Malaria prevention and control interventions should be strengthened in the camps with priority accorded to eliminating vector breeding grounds, while promoting Indoor Residual Spraying activities, distribution of insecticide treated bed nets, as well as prompt and effective management of all cases.

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Figure 12 Malaria Incidence, by IDP site, for week 1 - 43, 2014

1,800 1,600 1,400 1,200 1,000 800 Cases Cases per 10,000 600 400 200 - 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

Malakal Akoka Renk UN House Tongping Bentiu Melut 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 seven cases were confirmed through laboratory testing. During week 43, one new HEV case was reported from Mingkaman, increasing the cumulative number to 113. Deaths remain four (CFR 3.51%), three (75%) of whom were among pregnant women (figure 13). One new probable HEV case was reported in Bentiu PoC in a 22-year-old male refugee from PoC 5. His illness started on 8/12/2014 and had a positive RDT for HEV. A blood sample has been sent to Juba for laboratory confirmation. Cumulatively, 137 AJS cases have been reported from various camps (figure 14).

Figure 13

Hepatitis E Virus trends in Mingkaman, week 10-43, 2014

18 16 14 12

No. No. cases 17 10 8 11 11 9 7 7 7 6 6 5 5 5 5 4 4 3 3 3 3 3 4 2 2 2 1 1 1 1 2 0 0 0 0 0 0 0 0 0 0 Epidemiological week 2014 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 Cases Deaths

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Several interventions including supportive case management, targeted preventive interventions during antenatal visits, soap distribution, shock chlorination of boreholes, and house-to-house hygiene and sanitation promotion visits are being implemented by partners in response to the HEV trends. Figure 14 Acute Jaundice Syndrome cases by Camp, week 3-42, 2014

18 16 14 12 10 No. No. cases 8 6 4 2 0 4 6 8 10 12 14 16 18 20Epidemiological22 24 26 28week30 201432 34 36 38 40 42 Awerial Bentiu Bor Malakal Tongping Lul Juba 3

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.

Table 3: Cholera cases and deaths by county week 17 – 43, 2014 No. State County New cases by Epidemiological week Total cases Total CFR[%] 2014 deat hs 35 36 37 38 39 40 41 42 43 1 CES Tongping PoC 0 0 0 0 0 0 0 0 0 72 3 4.2 2 (IDP) Juba 3 PoC 0 0 0 0 0 0 0 0 0 97 0 0 3 CES Juba 22 18 9 4 3 0 8 3 2 2,091 43 2.1 4 Kajo-Keji 3 0 2 0 0 0 0 0 0 93 7 7.5 5 Yei River 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 1 0 0 7 EES Torit 6 1 0 3 0 0 0 0 0 2,032 36 1.8 8 Lopa-Lafon 0 0 0 0 0 0 0 53 3 260 15 5.8 9 Kapoeta North 0 1 1 3 7 1 0 0 0 83 1 1.2 10 Ikotos 9 2 0 6 7 6 5 21 42 191 21 11 11 Magwi 19 0 3 2 0 0 0 0 0 301 11 3.7 12 Budi 0 0 0 0 0 0 0 0 0 1 0 0 13 UNS Manyo 0 0 0 0 0 0 0 0 0 1 0 0 14 Malakal 0 0 0 0 0 0 0 0 0 1,024 21 2.1 15 WES Mundri East 0 0 0 0 0 0 0 0 0 3 0 0 Total South Sudan 59 22 15 18 17 7 13 77 47 6,297 160 2.26

By the end of week 43, a total of 6,297 cholera cases including 160 deaths (CFR 2.26%) had been reported from five (5) states and 15 counties in South Sudan (Table 3). During week 43, 47 cholera cases including two deaths were reported from Lobonok in Juba, Central Equatoria State, as well as Lofus, Lorum and Imatong in Ikotos County, Ohilang and Ibele in Lopa-Lafon County and Kapoeta South Town in Eastern This Bulletin is produced by MOH, RSS with Technical support from WHO 9 Early Warning and Disease Surveillance System

Equatoria State. Partners are responding through case management, hygiene and sanitation promotion through house-to-house health education and distribution of chlorine tablets and soap while surveillance continues. These new clusters of cholera cases justify the need to sustain the recommended interventions for cholera prevention and control.

Acute Flaccid Paralysis (AFP)

There were no new AFP cases reported in IPD settlements during week 43. For populations living outside IDP settlements, 13 new AFP cases were reported during week 43. Since the beginning of 2014, a cumulative of 254 AFP cases has been notified (Table 4). The annualised non-Polio AFP (NPAFP) rate is 3.74 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%) states (Jonglei, Upper Nile, and Unity) have attained the targeted NPAFP rate (Table 4). The non-Polio Enterovirus (NPEV) isolation rate (a measure of the quality of the specimen cold chain) is 14.3%, which is above the global threshold of ≥10%. Stool adequacy is 98%, a rate that is higher than the global target of 80% (Table 4).

Table 4: Summary of AFP indicators by state as of week 43, 2014

Other diseases of public health importance

Guinea worm (Dracunculiasis)

There are no new cases of suspect Guinea worm reported during week 43.

Viral Haemorrhagic Fever

The Republic of South Sudan has continued 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). The most recent alert was a 39-year-old woman, from Gudele in Juba, with a three-day history of vomiting blood but without fever was received in Juba Teaching hospital on 26 October 2014. She was known to suffer from peptic ulcers and had history of travel or exposure to a case with haemorrhagic manifestations. Her sample tested negative for Marburg and for Ebola Sudan and Zaire strains.

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Community sensitization on Ebola prevention and control is ongoing through radio messages, talk shows on radio and television, and through the print media (posters and brochures).

Visceral Leishmaniasis (Kala azar)

Kala-azar cases are on the increase as the disease surges to its seasonal peak that is usually reached during December and January. Since the beginning of the year, 5,713 Visceral Leishmaniasis (Kala-azar) cases and 163 deaths (CFR 2.9%) have been reported from 15 treatment centres. Of these, 5,310 were new cases and 403 relapses or Post Kala-azar Dermal Leishmaniasis (PKDL), while 181 were defaulters. In comparison, 2,137 cases and 66 deaths were reported during the same period in 2013, of which 1,951 were new cases, 186 relapses/PKDL, and 35 defaulters. Lankien, Chuil, and Walgak are worst affected, with Lankien accounting for 3,410 of the cases, while Chuil and Walgak account for 960 and Walgak 581 respectively The escalation is attributed to several factors including displacement of non-immune populations to endemic areas, malnutrition, poor housing and late detection and diagnosis of cases. Interventions are being hampered by insecurity and inaccessibility in endemic areas. WHO is supporting implementing partners with case management supplies and adequate stockpiles have been assembled in endemic states.

All-Causes Mortality Data

During week 43, mortality lists were received from Bentiu, Malakal, Mingkaman, Tongping, and Juba 3. Thirteen deaths were reported this week, with the majority being from Bentiu 5 (38%) see Table 5. Four (31%) deaths occurred in children under five years. The causes of death during week 43 are listed in table 5.

Table 5: Causes of death by IDP camp during week 43 of 2014 Cause of death by site Deaths by age-group Total deaths <5yrs ≥5yrs Bentiu 5 5 Unknown 1 1 TB/HIV/AIDS 2 2 Obstructive jaundice 1 1 Drowned 1 1 Juba 3 3 3 Acute watery diarrhoea 1 1 Malaria 1 1 Neck tumor 1 1 Malakal 2 1 3 Perinatal death 1 1 Septicemia 1 1 Breast Cancer 1 1 Mingkaman 2 2 Malaria 2 2 Total deaths 4 9 13

Under-five Mortality Rate

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The under-five mortality rates (U5MR) per 10,000 per day from week 51 of 2013 to week 43 of 2014 are shown in Figure 15. During week 43, Malakal PoC had the highest under-five mortality rate (deaths per 10,000 per day) of 0.777. The under-five mortality rates for all the sites that reported during week 43 were lower than the emergency threshold of 2 deaths per 10,000 per day. The causes of death among under-five year olds in the reporting sites during week 43 are listed in table 5.

Figure 15 Under-5 Mortality Rate per 10,000 per day by Site - week 51 of 2013 to week 43 of 2014 18 16 14 12 10 8 6 Rate per10,000 Rate 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 Epidemiologic Week Bentiu Bor Juba 3 Malakal

Crude Mortality Rate The crude mortality rates (CMR) for week 43 are shown in Figure 16. During this week the CMRs were below the emergency threshold for the three camps that submitted mortality statistics.

Figure 16

Crude Mortality Rate per 10,000 persons per day, week 51 of 2013 to week 43 of 2014

8 7 6 5 4 3 Rate Rate 10,000 per 2 1

0 Epidemiologic week 51 1 3 Bentiu5 7 9 11 13 15Bor17 19 21 23 Juba25 273 29 31 33 Malakal35 37 39 41 43

Disease specific mortality

Acute watery diarrhoea related deaths

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Figure 17 shows mortality due to AWD from week 52 in 2013 to week 43 in 2014. One AWD death occured Juba 3 PoC during week 43. AWD has caused the highest number of deaths with a cumulative of 146 deaths since the onset of the crisis. The majority of AWD related deaths have been reported from Mingkaman, Tongping, Malakal, and Bentiu.

Figure 17 Mortality due to AWD by camp, week 51 of 2013 to week 43 of 2014 25

20

15

10

Number Number of deaths 5

0 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 2013 2014 Epidemiological week

Bentiu Bor Juba 3 Malakal Mingkaman Tomping

Overall Mortality

Since the onset of the crisis, at least 1,207 deaths have been reported from the IDP camps. Children under five years of age have accounted for 599 (49.6%) of the deaths. The majority of the deaths occurred in Bentiu, Tongping, Malakal, Mingkaman, and Bor. The top causes of mortality during the period include acute watery diarrhoea, severe pnuemonia, measles, and malnutrition (table 6).

Table 6: Overall mortality by settlement, week 51 of 2013 to week 43 of 2014 a Azar - alaria aternal death easles cute watery loody diarrhoe ancer ypertension erinataldeath neumonia rauma IDP SITE Acute Jaundice Syndrome A diarrhoea B C Gunshot wound Heart disease H Kala M M M P P SAM Septicemia Stroke TB/HIV/AIDS T Others Grand Total Agok 1 2 3 Bentiu 46 2 6 1 2 14 10 2 46 47 10 1 19 6 107 319 Bor 2 1 1 1 42 2 10 3 2 57 121 Juba 3 1 7 3 1 2 8 1 1 27 8 5 1 2 13 16 96 Kodok 1 0 1 Malakal 1 29 38 12 1 10 11 12 3 14 5 1 16 6 78 237 Melut 1 4 7 2 2 3 3 1 3 26 Mingkaman 6 30 4 2 1 1 15 1 4 8 9 3 8 1 4 2 42 141 Tomping 32 2 4 6 10 1 10 37 15 24 16 1 3 3 96 260 (blank) 1 1 1 3 Grand Total 8 146 8 9 51 28 7 14 66 4 94 69 104 91 26 8 58 14 402 1207

General recommendations

Initiate a comprehensive response to the new clusters of cholera cases in Juba, Lopa/Lafon, Ikotos, and Kapoeta South through effective case management, improving access to safe drinking water, and using home hygiene promoters to conduct house-to-house health education on personal hygiene and sanitation. This Bulletin is produced by MOH, RSS with Technical support from WHO 13 Early Warning and Disease Surveillance System

Cholera interventions should be sustained in the affected counties and development plans should be updated to address the underlying risk factors. Since malaria remains the top case of morbidity in the settlements, malaria preventive interventions including the use of Long Lasting Insecticide Treated Nets [LLITNs] and prompt case management should be sustained. In response to the HEV cases in Mingkaman and Bentiu PoC, 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. In response to the escalating Kala-Azar trends in endemic areas in Jonglei, Upper Nile, and Unity 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. Stockpiles for diagnostic kits and case management supplies should be enhanced in endemic states d. Communications on kala-azar prevention and control should be initiated Submit biological samples to allow laboratory confirmation of emerging outbreaks of suspect measles, acute jaundice syndrome, and cholera. 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

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