Rift Valley Fever (RVF) outbreak Yirol East, Eastern Lakes State, Republic of South Sudan

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1 Summary Statistics Rift Valley Fever (RVF) outbreak Yirol East, Eastern Lakes State, Republic of South Sudan Situation Report (Sitrep No. ) as at 7. Hours; January 8 No. Summary of cases Total New suspect cases (deaths) week ending 8 th January 8 () Cumulative suspect cases (deaths) in Health Facilities Community () 8() Total number of suspect cases on admission Cumulative suspect cases discharged Number of health workers affected Number of domestic animal events I. Abortion in goats II. Abortion in sheep III. Domestic animal abortions IV. Dead goats (with bleeding into tissues) 8 V. Disease in cattle 7 Wild bird deaths 8 Specimens collected Human new since last update Human cumulative 7 Animal sheep cumulative Animal goats cumulative Animal cattle cumulative 9 Total samples shipped to WHO/FAO collaborating laboratories Human Animal Cumulative specimens (blood) collected Human Animal Number of cases with laboratory confirmation Human samples - PCR negative for Ebola, Marburg, CCHF, RVF, Sosuga Human samples - RVF serology IgM and IgG positive (high titres) Human samples - RVF serology IgG positive (high titres) Animal samples - RVF serology IgG positive (high titres) 7 7 7

2 Situation update Since the last update (of January 8), five new suspect RVF cases have been reported in Yirol East. These include one male and four females aged - years, two of whom are still hospitalised (but ready for discharge) from the treatment facility in Yirol East. Their blood samples have been collected and are in the process of being shipped to Juba en route to Entebbe, UVRI for testing. As of January 8, a total of suspect RVF human cases have been reported in Eastern Lakes State. Out of the suspect human cases reported since 7 December 7, three human cases have been confirmed, three died and were classified as probable cases with epidemiological linkage to the three confirmed cases, four were classified as none-cases following negative laboratory results for RVF, and are still classified suspect cases due to pending or partial laboratory sample testing. During the week, six new samples were sent to Uganda Virus Research Institute (UVRI) for testing on Jan 8 and the test results released on Jan 8 showed that all the six samples were Negative by PCR for Ebola, Marburg, CCHF, RVF and Sosuga viruses. Further serological sample testing is underway. The first batch of seven human samples initially tested negative on January (by PCR) for Ebola, Marburg, CCHF, RVF and Sosuga viruses. Follow up serological testing showed one sample had high RVF IgM and IgG and another two samples had high RVF IgG titres. A cumulative of 7 human samples have been collected out of which, have been shipped and tested at UVRI. All the samples tested Negative by PCR for Ebola, Marburg, CCHF, RVF and Sosuga viruses. Serological testing completed for the initial batch of 7 samples but pending for the recent batch of samples. A total of seven animal (two sheep; two goats; and three cattle) samples have also been shipped to UVRI for testing. Test results showed that one cow sample was positive for past RVF infection (RVF IgG). Initial reports on the event On 8 December 7, the Eastern Lakes Ministry of Health reported a suspect viral hemorrhagic fever cluster to the National Ministry of Health and WHO. The initial cluster involved three deaths in Thonabutkok village, Yali Payam, Yirol East county with 7 December 7 as the earliest date of onset. Preliminary investigations conducted by the County Health Department, State and National MoH, CUAMM, and WHO show that the three deaths had a severe hemorrhagic illness and were epidemiologically linked by place (Thonabutkok village) and time (with 9 and as the respective epidemiological weeks of illness onset). However, there was no history of close physical contact between the cases and travel history was not significant. In addition, the symptoms were not reported in the respective close case contacts during the clinical illness or even after death. There is significant history suggesting a zoonotic hemorrhagic illness as abortions in goats and sheep; deaths/disease in goats and cows; wild bird die-offs have been reported in association with this event cluster. Brief Case Clinical and Epidemiological Findings The putative initial case was a -year-old female Gravida Para +; housewife from Thonabutkok village in Yirol East county. Her illness started on 7 th December 7 with fever, headache, neck pain and sudden nose, gum, and injection site bleeding. She reported to a health facility the same day where she was admitted in maternity ward since she was pregnant. After 8days of treatment with no improvement, she moved to a private clinic for days where she was treated for malaria and typhoid fever. The illness worsened on 9 th December 7 and requested to return home. She died at home the same day. No supervised burial was done and no symptomatic cases have been reported among the close contacts during the clinical illness and after death. The second case was a -year-old female from Thonabutkok village (approximately meters from the putative initial case). Her illness started on th December 7 with headache, joint pain, neck pain, fever, generalized swelling at the joints which were painful (ecchymosis), bleeding from the nose and gums. She died at home on th December 7 after the she developed bleeding from the skin blisters. Goat and sheep abortions were reported in association with this case. No supervised burial was done and no symptomatic cases have been reported among the close contacts during the clinical illness and after death.

3 The third case was a -year-old male from Thonabutkok village. His illness started on th December 7 with headache, fever, sweating, and neck pain, nose bleeding, vomiting of blood and gum bleeding, convulsions and loss of consciousness. He died at home on 7 th December 7 after failing to improve on treatment in a private clinic. Eight goat deaths with extensive hemorrhage were reported in the case neighborhood (the goats were skinned, cooked and eaten). No supervised burial was done and no symptomatic cases have been reported among the close contacts during the clinical illness and after death. As of January 8, the cumulative number of suspect RVF cases had risen to total of suspect RVF cases including three deaths, all reported in Eastern Lakes State. Active surveillance is ongoing to detect, investigate, and initiate supportive care for new suspect cases. The case fatality rate among suspect, probable and confirmed cases (excluding none-cases) is 8.7% (/). More cases have been reported among females (8.7%) than males (.%) (Figure ). Most of the cases have been reported in the -9 years and -9 years age groups with most cases occurring the -9- year age-group in the males while in the females, most cases are reported in the -9-year and -9-year age-groups (Figure ). The deaths occurred in the -9-year and -9-year age-groups (Figure ). Figures and show the distribution of cases by time and outcome/epi-classification. The initial probable cases occurred between week 9-, 7. During weeks and, an increase in suspect cases has been registered though none have been confirmed. Figure shows the distribution of clinical symptoms among suspect, probable, and confirmed cases (excluding nonecases). The most frequent symptoms are non-specific and include fever, headache, neck pains, and joint pains. Bleeding has been reported in % of suspect cases but none of the confirmed cases had bleeding. All the probable, confirmed, and suspect cases (excluding the non-cases) have been reported from Yirol East county in Eastern Lakes state (Figure 7). In Yirol East county, cases have been reported from five payams with most 9 (.%) cases and all the three deaths reported from Yali payam. All the probable and confirmed cases are clustered in Yali Payam, Thonabutkok village (Figures 8 and 9). Response updates Overall coordination of investigation and response activities The overall coordination of investigation and response activities is currently coordinated by a multi-sectoral taskforce that is meeting at least three times weekly at the national level and daily in Yirol East. The terms of reference for multi-sectoral taskforce have been developed and the outbreak plan of action has been drafted for review by the taskforce working groups. Yirol East taskforce meeting held on Jan 8 The State Minister of Health and the Director General acknowledged receipt of three cars donated by the Minister of Health Dr. Riek Gai Kok. A draft action and Terms of Reference for the five thematic areas were presented. At the national level, the taskforce convened on Jan 8 to review the situation and status of investigations at field level. The Epidemiology, laboratory, entomology, and animal investigation sub-committee met on Jan 8 to review their ToRs and activities in the action plan. In light of the increasing reports of sustained animal deaths in the index case payam, WHO convened a meeting with FAO on Jan 8. During the meeting, FAO committed to support the animal health investigation team to travel to Yirol East on 9 Jan 8. The joint MoH/WHO rapid response team arrived in Yirol East on 9 January 8 and undertook the following activities during the week.

4 o Epidemiological investigation and sample collection from the emerging alerts. o Training of active case search teams in Wunthou (Yali) Payam. o Case management training for Health care workers at the Yirol State Hospital on the rd of January. Planned activities and Way forward FAO will support and deploy a team of technical officers from the Ministry of Livestock and Fisheries to Yirol East on 9 Jan 8 to support animal health investigations and sample collection; training of community animal health workers on RVF surveillance and response; and community mobilization to report sick animals and adopt hygienic practices for handling animals. WHO is working on deploying a rapid response team to replace the current one that is supporting field investigations. WHO is also replenishing stocks of sample collection and triple packaging kits. A mission by MSF to assess the current state of case management facilities, the quality of patient care, and infection prevention and control practices in Yirol East is planned for next week. Review and update messages and the question and answer fact sheet. The social mobilization working group meeting in Juba is slated for Jan 8. Consultations on the RVF outbreak declaration are underway at the highest level of government with the Ministry of Health and Ministry of Livestock and Fisheries providing the technical backstopping. Ministry of Health/Ministry of Livestock and Fisheries continue to convene regular multisectoral and multi-agency meetings to coordinate investigation and response activities. Updating the Viral Hemorrhagic Fever response plan to conform to the standard RVF recommended interventions that are tailored to the South Sudan context. Conduct extended public health, animal health, and entomological investigations into the event by Ministry of Health; Ministry of Animal Health Resources and Fisheries, WHO, FAO, Health Cluster, and partners Disseminate regular updates by way of situation reports and/or press statements/releases as the situation evolves.

5 Tables and Figures Figure : RVF case distribution by sex in Yirol East, wk 9, 7 to wk, 8 RVF case distribution by sex in Yirol East, wk 9, 7 to wk, 8 Male. Female 8.7 Figure : RVF case distribution by age and sex in Yirol East, week 9, 7 - week, 8 RVF case distribution by age and sex, week 9, 7 - week, Age in years Percentage %

6 Figure : RVF case distribution by outcome in Yirol East, week 9, 7 - week, 8 RVF case distribution by outcome, Yirol East n= (exluding none-cases) Number of cases/deaths Alive Died -9yrs -9yrs -9yrs -9yrs -9yrs Figure : RVF case distribution by time and outcome in Yirol East, week 9, 7 - week, 8 RFV case distribution by time and outcome in Yirol East, wk 9, 7 to week, 8 Number of cases Alive Died Epidemiological week of onset in 7 and 8

7 Figure : RVF case distribution by time and epi-classification in Yirol East, week 9, 7 - week, 8 RFV case distribution by classification in Yirol East, wk 9, 7 to week, 8 Number of cases confirmed probable none-cases suspected Epidemiological week of onset in 7 and 8 Figure : Clinical symptoms among suspect, probable, and confirmed cases, Yirol East, wk 9, 7 to wk, 8 Clinical symptoms among suspect, probable, and confirmed cases, Yirol East, wk 9, 7 to wk, 8 Convulsions % Bleeding 7% Joint pains 88% Neck pains % Headache Fever 9% 9% % % % % % % % 7% 8% 9% % 7

8 Figure 7: RVF cases by County and Payam, outcome, Eastern Lakes wk 9, 7 to wk, 8 Number cases/death RVF cases by County and Payam, outcome, Eastern Lakes wk 9, 7 to wk, 8 Alive Died Agal Mangar Pagarau Yali lekakodu Yirol east Figure 8: RVF cases by County and Payam, classification, Eastern Lakes wk 9, 7 to wk, 8 RVF cases by County and Payam, classification, Eastern Lakes wk 9, 7 to wk, 8 Number cases/death 8 confirmed propable none-cases suspected Abang Agal Mangar Pagarau Yali Yirol east 8

9 Figure 9: RVF cases by County, Payam, village, and classification, Eastern Lakes wk 9, 7 to wk, 8 RVF cases by County, Payam, village, and classification, Eastern Lakes wk 9, 7 to wk, 8 7 Number cases/death confirmed propable Aruau Agal jamith Amethic koiwic Pagarau Amethic Thonabutkok Wunthou Yecliet nyang none-cases suspected Abang Agal Mangar Pagarau Yali lekakodu Yirol east 9