Early Warning and Disease Surveillance System

Republic of South Sudan

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

Week 47 17 – 23 November 2014

General Overview

Completeness for weekly reporting increased from 92% to 98% while timeliness increased from 66% to 72% in week 47 when compared to week 46. Malaria remains the top cause of morbidity with Bor, UN House, Tongping, Melut, and Lankien reporting the highest incidence in week 47. During week 47, UN House had the highest incidence for ARI and ABD, while Bor PoC had the highest incidence for malaria and Melut had the highest incidence for AWD. A total of 12 suspect measles cases were reported from Melut (6 cases), Lankien (5 cases), and Bentiu (1 case) during week 47. There were no new HEV cases reported during week 47. The cumulative for HEV in Mingkaman remains at 124 cases including four deaths (CFR 3.23%). There were no new cholera cases reported during week 47. The cumulative now stands 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 47. During week 47, the majority of the deaths 5 (36%) were attributed to TB/HIV/AIDS. Seven suspect meningitis deaths have been reported from Chotbora PHCC in Longechuk County. Verification is underway with support from WHO and MedAir.

Completeness and Timeliness of Reporting

Completeness for weekly reporting increased from 46 (92%) in week 46, to 48 (98%) in week 47. Timeliness for weekly reporting increased from 33 (66%) in week 46 to 35 (72%) in week 47. Figure 1 Number of sites (clinics) reporting per week (n=49)

60 46484748 50 41 42 42 38 38 36 35 37 40 32 33 34 34 343334 29 2931 29 2626 26282726 28 30 24 2423

Number of sitesof Number 21 20 21 17 171718 1819 20 1315 6 8 10 5

0 0102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647 2014 Epidemiologic Week Early Warning and Disease Surveillance System

In week 47, we did not receive reports from one facility (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 47, 2014 No. IDP site Health Facility/Partner 1 Mingkaman Kalthouk PHCU CCM

Consultations (All patients seen at Outpatient and Inpatient facilities) The total number of consultations decreased from 19,006 in week 46 to 18,545 in week 47. During week 47, most of the consultations were reported from Bentiu, Awerial, Renk, and Melut (Figure 2).

Figure 2 Consultations by IDP Camp & Partner, week 47, 2014

3500 3000 2500 1319 643 2000 66 509 1500 1125 1036 833 Number of consultationsof Number 1000 987 1366 1137 658 500 772 299 292 788 796 825 828 427 302 269 401 472 355 186 433 292 282 405 190 152 Lul Bor 0 50 50 0 Yuai Renk Ogod Melut Nyirol Akoka Akobo Kodok Bentiu Awerial Malakal Lankien Tongping Twic East Twic UN HOUSE UN Man-Awan 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, 698,246 consultations have been registered from all IDP sites with an overall annualised OPD utilization rate of 1.3 consultations per person per year (Figure 2.1). The site specific annualised OPD utilisation rates are shown in Figure 2.1.

Figure 2.1 Annualised OPD Utilisation Rates by IPD site, week 1-47, 2014

6.0 5.0

4.0 5.5 3.0 4.0 Consultations 3.1 2.4 2.7 per person per year perperson per 2.0 2.0 1.6 1.9 1.7 1.6 1.3 0.3 0.3 0.6 1.2 0.5 0.6 0.4 0.1 0.5 0.2 0.1 0.1 1.3 1.0 -

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

Figure 3 Priority Disease Proportionate Morbidity - Week 1 - 47, 2014

45% 100% 40% 35% 80% 30% 60% 25% Completeness 20% 40% 15% Percent of allconsultations of Percent 10% 20% 5% 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 45 47 Completeness ARI Bloody Diarrhea

Malaria, ARI and AWD were the top three causes of morbidity among IDPs in week 47 (Figure 3 and 4). During week 47, malaria had the highest proportionate morbidity and incidence (Figure 3 and 4). The overall incidence for malaria, ARI, AWD, and suspect measles, decreased, while the ABD incidence increased in week 47 when compared to week 46 (Figure 4). The weekly number of cases for the current and preceding week, 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 week No. Disease 46 47 51 of 2013 1 Malaria 4058 3829 136,708 2 AWD 1486 1462 60,860 3 ARI 2524 2521 105,073 4 ABD 235 264 10,136 5 Measles 15 12 1,513

Figure 4

Incidence for Priority Diseases, week 1 - 47, 2014

140

120

100

80

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 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). Early Warning and Disease Surveillance System

Figure 5 ARI Adjusted Proportionate Morbidity , for week 1 - 47 2014

35% 100% 90% 30% 30% 26.4% 80% 25% 25% 24% 24% 70% 21.5% 21% 20% 60% 20% 18.8% 19% 18.5% 18% 18% 17% 50% 15.9% 16% 16% 16% 15% 14.3% 14% 40% [%] Completeness 13% 12% 12% 11.1% 11.4% 11% 11% 11% 10% 10% 30%

Percent of total consultations total of Percent 20% 0 5.4% 5.0% 5% 3.5% 2.0% 10% 0.7% 0% 0% 01 03 05 07 09 11 13 15 17 19 21Epidemiologic23 25 27 Week29 31 33 35 37 39 41 43 45 47

ARI registered the second highest proportionate morbidity of 13.6% and incidence (44 cases per 10,000 population) in week 47 (Figure 5). During week 47, a total of 2,521 cases of ARI were reported with the highest ARI incidence (cases per 10,000) being reported in UN House (269), Bentiu (160), Bor (89), Melut (69), and Ogod (63).

Acute Watery Diarrhoea

As seen from Figure 6, the AWD proportionate morbidity increased from 7.9% to 8.0% while the overall AWD incidence (cases per 10,000) decreased from 26.3 to 26.1 in week 47 when compared to week 46 (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 47, 2014

30% 100% 90% 23% 21% 21% 80% 70% 20% 60% 12% 13% 50% 11% 11% 11% 11% 10% 10% 9.8% 9% 9% 9% 9.1% 40% 9% 8% Completeness 10% 8% 7% 7% 6.1% 6.1%6.3%6.3% Percent of total consultations total of Percent 5.7% 30% 4.9%5.6%5.4% 5.5% 4.1% 20% 10% 0% Epidemiologic week 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

During week 47, a total of 1,488 AWD cases were reported with the highest AWD incidence (cases per 10,000) being reported in Melut (83), UN House (81), Bentiu (79), Tongping (77), and Bor (58) as illustrated in Figure 7). Early Warning and Disease Surveillance System

Figure 7 AWD Incidence, by IDP site, for week 1 - 47, 2014

700

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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 UN House 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 47, 2014

200 100% 180 90% 160 80% 140 70% 120 60% 100 50% Completenes cases per 10,000per cases 80 40% 60 30% 40 20% 20 10% 0 0% 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

Completenes ≥5 yrs <5 yrs Dysentery / Acute Bloody Diarrhoea

Figure 8 ABD Proportionate Morbidity , for week 1 - 47, 2014

7.0% 6.4% 100% 90% 6.0% 80% 5.0% 70% 60% 4.0% 3.3% 3.2%

50% Completeness 2.5% 2.3% 3.0% 2.1% 2.2% 2.1% 1.9% 40% 1.7% 1.8% 1.6% 1.5% 1.6% 1.5% 1.5% 1.6% 2.0% 1.4%1.4% 1.3% 1.4% 30% Percent of total consultations total of Percent 1.2% 1.2% 1.1% 1.1% 1.0% 1.1% 1.0% 1.1%1.0% 1.1%1.1% 0.8% 0.8% 0.7% 20% 1.0% 10% 0.0% 0% 01 03 05 07 09 11 13 15 17 19Epidemiologic21 23 25 Week27 29 31 33 35 37 39 41 43 45 47 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 increased from 4 to 5 while the proportionate morbidity (%) increased from 1.2 to 1.4 in week 47 when compared to week 46. During week 47, 265 ABD cases were reported with the highest ABD incidence (cases per 10,000) being reported in UN House (20), Melut (14), Renk (13), Bentiu (8), and Bor (4) (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 - 47, 2014

200 180 160 140 120 100

Cases per 10,000per 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 Bor 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 - 47, 2014

3.5% 100% 90% 3.0% 80% 2.5% 70%

2.0% 60% 50% 1.5% 40% Completeness

Percent of total consultationstotalof Percent 1.0% 30% 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 This trendCompleteness is attributed to a seriesSuspected of reactive Measlesmeasles Adj. vaccinationLinear campaigns (Suspected Measles conducted Adj.) 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 47 a total of 12 suspect measles case were reported from Melut (6 cases), Lankien (5 cases), and Bentiu (1 case). 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 47, malaria recorded the highest proportionate morbidity of 21.2%. The malaria incidence (cases per 10,000) decreased from 74 in week 46, to 69 in week 47.

Figure 11 Suspected Malaria Adjusted Proportionate Morbidity , week 1 - 47, 2014

40% 36.8% 100% 33.8% 33.1% 35% 31.5% 32.1% 90% 26.7% 27.6% 27.3% 80% 30% 25.5% 24.8% 23.1% 23.5% 23.5% 24.2% 70% 21.5% 22.2% 25% 21.5% 20.4% 19.2% 19.7% 19.3% 19.9% 60% 17.4% 18.0% 18.1% 17.7% 20% 16.1% 16.8% 16.5%16.4% 50% 15.1% 14.5% 14.1% Completeness 13.0% 13.8% 15% 10.9% 40% 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 47, a total of 3,928 malaria cases were reported with the highest malaria incidence (cases per 10,000) being reported in Bor (164), UN House (162), Tongping (141), Melut (109), and Lankien (89) as seen in Figure 12.

Figure 12 Malaria Incidence, by IDP site, for week 1 - 47, 2014

1,800 1,600 1,400 1,200 1,000

Cases per 10,000per 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 UN House Bentiu Tongping Melut Bor 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 seven cases were confirmed through laboratory testing. During week 47, no new HEV case was reported from Mingkaman, hence the cumulative remains at 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 10-47, 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 3-47, 2014

18 16 14 12 No. casesNo. 10 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 47. 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).

Table 3: Cholera cases and deaths by county week 17 – 47, 2014 No. State County New cases by Epidemiological week Total cases Total CFR 2014 deaths [%] 36 37 38 39 40 41 42 43 44 45 46 47 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 18 9 4 3 0 8 3 2 0 0 0 0 2,091 43 2.1 4 Kajo-Keji 0 2 0 0 0 0 0 0 0 0 0 0 93 7 7.5 5 Yei River 0 0 0 0 0 0 0 0 0 0 0 0 47 2 4.3 Early Warning and Disease Surveillance System

No. State County New cases by Epidemiological week Total cases Total CFR 2014 deaths [%] 36 37 38 39 40 41 42 43 44 45 46 47 6 JS Bor 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 7 EES Torit 1 0 3 0 0 0 0 0 0 0 0 0 2,032 36 1.8 8 Lopa-Lafon 0 0 0 0 0 0 53 3 4 0 0 0 264 16 6 9 Kapoeta North 1 1 3 7 1 0 0 0 0 0 0 0 83 1 1.2 10 Kapoeta South 0 0 0 0 0 0 0 0 12 2 0 0 14 0 0 11 Ikotos 3 5 25 19 19 5 41 30 31 4 10 0 297 27 9 12 Magwi 0 3 2 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 23 20 37 29 20 13 97 35 47 6 10 0 6,421 167 2.60

Acute Flaccid Paralysis (AFP)

During week 46, four new AFP cases were reported making cumulative of 274 cases since the beginning of 2014 (Table 4). The annualised non-Polio AFP (NPAFP) rate is 3.77 cases per 100,000 population children 0- 14 years (target ≥2 per 100,000 children 0-14 years). All states except three 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 15%, 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: Summary of AFP indicators by state as of week 46, 2014 State Polio cases Pending Stool Adequacy Lab indicators

NPEV Sabin like nding Cases of Week 46 of Week Cases Population <15 Population years AFP Cumulative Cases Cases Non Polio Confirmed WPV1 VDPV Pending Lab/CLT Pending Lab/ITD Pe ECR Rate NPAFP Specimens Adequate (#) Specimens Stool adequacy Number Percent Number Percent CENTRAL EQUATORIA 737148 25 20 3 0 0 5 0 0 3.83 24 24 100% 5 21% 0 0% EASTERN EQUATORIA 674008 24 23 0 0 0 1 0 0 4.03 23 22 96% 1 4% 2 9% JONGLEI 982693 9 7 0 0 0 2 0 0 1.04 9 8 89% 3 33% 0 0% LAKES 791864 49 48 0 0 0 1 0 1 7 49 47 96% 7 14% 0 0% NORTHERN BAHR EL GHAZAL 987309 28 27 0 0 0 1 0 0 3.21 28 27 96% 6 21% 0 0% UNITY 864151 10 8 0 0 2 0 0 0 1.31 10 8 80% 1 10% 2 20% UPPER NILE 895541 10 6 0 0 0 4 0 0 1.26 10 7 70% 2 20% 0 0% WARRAP 1456973 38 32 1 0 0 5 0 0 2.95 38 34 89% 4 11% 1 3% WESTERN BAHR EL GHAZAL 316372 31 24 0 0 0 6 0 1 11.08 30 23 77% 4 13% 0 0% WESTERN EQUATORIA 516397 50 47 0 0 0 3 0 0 10.95 50 49 98% 9 18% 3 6%

2014 SOUTH SUDAN 8222455 274 242 4 0 2 28 0 2 3.77 271 249 92% 42 15% 8 3%

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 47.

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. Early Warning and Disease Surveillance System

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, and through 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. During week 47, 4 (24%) of the treatment centres reported a total of 49 new cases and one death. During the same period last year, 18 new cases and one death were reported. Since the beginning of the year 6,802* Visceral Leishmaniasis (Kala-azar) cases and 195 deaths (CFR 2.9%) have been reported from 17 treatment centres. Of these 6,357 were new cases and 435 relapses or Post Kala-azar Dermal Leishmaniasis (PKDL), while 223 were defaulters. In comparison 2,673 cases and 77 deaths were reported during the same period in 2013, of which 2,472 were new cases, 201 relapses/PKDL, and 40 defaulters. [*cases updated following data cleaning]. Lankien, Chuil, and Walgak are worst affected, with Lankien accounting for 4,054 of the cases, while Chuil and Walgak account for 1166 and Walgak 622* respectively [*cases updated following data cleaning]. 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. Training of health workers in Visceral Leishmaniasis case management, prevention and control is underway with the next training scheduled to take place in Kapoeta South.

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. WHO has already prepared supplies including ceftriaxone, lumbar puncture kits and transport media, and will charter a flight for a team led by MedAir to conduct the verification.

All-Causes Mortality Data

During week 47, mortality lists were received from Bentiu, Mingkaman, Malakal, Melut, Tongping and Juba 3 IDP sites. A total of 14 deaths were reported this week, with the majority 4 (29%) being reported from Bentiu PoC, see Table 5. Two (14%) deaths occurred in children under five years. The causes of death during week 47 are listed in Table 5.

Table 5: Causes of death by IDP camp during week 47 of 2014 Cause of death Deaths by age-group Total deaths <5yrs ≥5yrs Bentiu 4 4 TB 1 1 Early Warning and Disease Surveillance System

Cause of death Deaths by age-group Total deaths TB/HIV 1 1 GSW 2 2 Juba 3 1 1 TB 1 1 Malakal 1 1 Malaria 1 1 Melut 2 1 3 Hepatitis 1 1 SAM/Sepsis 2 2 Mingkaman 2 2 Stroke 1 1 HIV/AIDS (Stage 4) 1 1 Tongping 3 3 TB/HIV/AIDS 1 1 Strangulated Hernia 1 1 Diabetes (Diabetic Foot) 1 1 Total deaths 2 12 14

Under-five Mortality Rate The under-five mortality rates (U5MR) per 10,000 per day from week 51 of 2013 to week 47 of 2014 are shown in Figure 15. The under-five mortality rates for all sites that reported in week 47 were lower than the emergency threshold of 2 deaths per 10,000 per day. There were only two deaths in children under five years of age, both of which occurred in Melut and were attributed to severe acute malnutrition.

Figure 15 Under-5 Mortality Rate per 10,000 per day by Site - week 51 of 2013 to week 47 of 2014 18 16 14 12 10 Rate per 10,000 per Rate 8 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

Crude Mortality Rate Early Warning and Disease Surveillance System

Figure 16

Crude Mortality Rate per 10,000 persons per day, week 51 of 2013 to week 47 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 The crude mortality rates (CMR) for week 47 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 47, the majority of the deaths 5 (36%) were attributed to TB/HIV/AIDS.

Disease specific mortality

Acute watery diarrhoea related deaths

Figure 17 shows mortality due to AWD from week 52 in 2013 to week 47 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 Mingkaman, Tongping, Malakal and Bentiu (Figure 17).

Figure 17

25 Mortality due to AWD by camp, week 51 of 2013 to week 47 of 2014

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Number of deaths of Number 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 45 46 2013 2014

Epidemiological week

Bentiu Bor Juba 3 Malakal Mingkaman Tomping

Overall Mortality

Since the onset of the crisis, at least 1,270 deaths have been reported from the IDP camps. Children under five years of age have accounted for 611 (48%) 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 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 47 of 2014 Azar - ala IDP site Jaundice Acute Syndrome watery acute diarrhoea diarrhoea bloody cancer wound Gunshot disease Heart hypertension K malaria death maternal measles death perinatal pneumonia SAM Septicemia Stroke TB/HIV/AIDS trauma Others Grand Total Agok 1 2 3 Bentiu 47 2 9 1 2 14 8 2 46 47 12 1 25 6 110 332 Bor 2 1 1 1 42 2 10 3 2 57 121 Juba 3 1 8 3 1 2 8 1 1 27 8 5 1 2 14 16 98 Kodok 1 0 1 Malakal 1 29 38 12 1 11 11 12 3 15 5 1 16 6 86 247 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 44 144 Tongping 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 9 54 29 7 21 67 4 92 68 106 94 28 8 68 15 434 1270

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. Submit biological samples to allow laboratory confirmation of emerging outbreaks of suspect measles, AJS, 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 urgently 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, 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. 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. Communications 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