Sudan del Sur: Guerra, Hambre y Cólera Otra vez!

Transcription

1 Dra Lucy Anne Parker Epidemióloga Médicos sin Fronteras Directora Master de Cooperación al Desarrollo Especialidad Salud en Países en Desarrollo (UMH) Sudan del Sur: Guerra, Hambre y Cólera Otra vez!

2 Plan Sudan del Sur Conflicto, hambruna, desplazamiento de población Epidemias de Cólera Vacuna Oral de Cólera invesigación operacional

3 South Sudan Population 12,5 million Independence from Sudan in July, 2011 Civil war broke out in million people (40% of the population) are in need of food More than 3 million people have been forced to leave there homes IDPS Refugees Image :

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5 Literacy South Sudan (est. 2009) % aged 15yrs+ who can read and write Male Female 27% total both males and females

6 Population: 12,042,910 (July 2015 est.) Ethnic groups: Dinka 35.8%, Nuer 15.6%, Shilluk, Azande, Bari, Kakwa, Kuku, Murle, Mandari, Didinga, Ndogo, Bviri, Lndi, Anuak, Bongo, Lango, Dungotona, Acholi (2011 est.) Languages: English (official), Arabic (includes Juba and Sudanese variants), regional languages include Dinka, Nuer, Bari, Zande, Shilluk

7 Maternal and Infant mortality Maternal mortality rate: 789 deaths/100,000 live births (2015 est.) country comparison to the world: 1 Infant mortality rate: total: deaths/1,000 live births male: deaths/1,000 live births female: deaths/1,000 live births (2015 est.) country comparison to the world: 16

8 Plan Sudan del Sur Conflicto, hambruna, desplazamiento de población Epidemias de Cólera Vacuna Oral de Cólera invesigación operacional

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10 AcOvidades dificultada por: Conflicto acivo Ataques dirigidas a personal y centros médicos Infraestructura deficiente, transporte etc. Rupturas en la cadena de suministro (medicamentos, herramientas )

11 Photos: Nicolas Peissel/MSF

12 Pensamos en las condiciones de vida de las personas desplazadas. Forcibly displaced people Refugees Stateless people 65.3 million (2016) 21.3 million (2016) 10 million (2016) Photo: UNHCR (accessed 8 October 2016)

13 Improved sanitation Only 6.7% of the population have access to Improved sanitation (7lush or pour 7lush to a piped sewer system, septic tank or pit latrine; ventilated improved pit latrine; pit latrine with slab; or a composting toilet) Over 7,500 medically attended cholera cases in 2014 and 2015

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15 Sensibilización y WATSAN

16 Vigilancia epidemiológica y respuesta rápida NoIficación de nuevos casos Ambulancia Desinfección de la vivienda si necesario Enterramientos seguros Búsqueda aciva de casos

17 Plan Sudan del Sur Conflicto, hambruna, desplazamiento de población Epidemias de Cólera Vacuna Oral de Cólera invesigación operacional

18 Oral Cholera Vaccine 3 vaccines prequalified by WHO OCV Shanchol (2011) Semi-affordable (<2USD/vial) 2 doses proven feasible and effective Preventative Reactive (response to outbreaks) Vaccine shortage is a major obstacle Photo: Jacob Kuehn, MSF Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

19 Rational: Single-dose OCV Juba Juba appears to serve as a hub of transmission for the country Limited number of vaccines available Single dose of OCV has potential to save more lives Herd protection, immunological studies, preliminary trial data, mathematical modelling Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

20 Juba appears to serve as a hub of transmission for the country

21 Rational for the dosing regimen proposed Limited number of vaccines in stockpile Potential for greater public health impact Reduced logistical complexity

22 Average one and two dose effectiveness from previously published studies Figure 2. Average One and Two Dose Effec8veness from Previously Published Studies 1 6

23 Population Impact Single dose OCV Double dose OCV Vaccines 100, ,000 Number of people vaccinated 100,000 50,000 EfCicacy 50% 75% Immunity 50,000 persons 37,500 persons Cholera cases averted

24 Cholera Timeline, Juba, 2015 Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

25 Northern Bari 2009

26 Northern Bari 2015

27 OCV campaign (31 July-5 Aug 2015) Single-dose Shanchol offered to individuals aged 1 year targeted areas of Juba high risk groups Large fixed sites and mobile teams Limited social mobilisation Vaccination coverage survey using spatial random sampling Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

28 Aim To evaluate the feasibility, coverage, and vaccine effectiveness of this first ever use of single-dose OCV as an outbreak response Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

29 Methods: Case-cohort study Suspected cholera cases confirmed through multiple diagnostic tests Cohort of a spatially representative sample from across Juba Vaccination status ascertained by interview and inspection of vaccination card Unadjusted and adjusted vaccine effectiveness estimates were derived from proportional hazard regression models. Ethics: Approved by the John Hopkins Bloomberg School of Public Health IRB and the Ethical Committee of the Ministry of Health, Republic of South Sudan. Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

30 Results: Feasibility ~143,000 persons main campaign 31 July-5 Aug 2015 ~ 22,000 persons comprehensive package immediate neighbourhoods of suspected cases Vaccine coverage in targeted areas 68.8% (95%CI: %) Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

31 Vaccine coverage in targeted areas 68.8% (95%CI: %)

32 Results: Vaccine effectiveness (VE) Direct and Indirect protection offered by the vaccine: Unadjusted single-dose VE: 79.5% (95%CI ) Adjusted single-dose VE: 89.6% (95%CI ) Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

33 Limitations Observational study in challenging field conditions Confirmed cholera cases in Juba ceased within 2-weeks of vaccination campaign limited sample size, high uncertainty Nearly 50% of participants did not have their vaccination cards Potential for natural immunity in the study population due to cholera history in Juba Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

34 Discussion Important evidence for deciding on vaccine strategy in light of limited OVC supply A single-dose of OCV offers high levels of protection against severe cholera both direct and indirect herd protection A single dose also logistically simpler and less expensive to deploy in emergencies Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

35 Conclusions Until sufficient doses of OCV are available, flexible alternative vaccination strategies are needed including highly targeted vaccination campaigns and single-dose regimens. Our results from an outbreak in an urban context show that both are feasible and effective. Lucy A Parker MSF First mass vaccinaion with single dose oral cholera vaccine in response to an outbreak in Juba, South Sudan

36 Parker LA Lancet Inf Dis Azman AS Lancet Glob Health. 2016

37 Gracias

38 hjps://seguirconvida.msf.es/es 23 marzo a 9 abril en Valencia