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. Hours; 9 February 8 No. Summary of cases Total New suspect cases (deaths) week ending th February 8 () Cumulative suspect cases (deaths) in Health Facilities Community () () Total number of suspect cases on admission Cumulative suspect cases discharged 8 Epidemiological classification of human cases Total suspect cases Confirmed cases Probable Suspect (under investigation) None cases Deaths (CFR%) excluding none-cases Number of domestic animal events I. Abortion in goats II. Abortion in sheep III. Domestic animal abortions IV. Dead goats (with bleeding into tissues) V. Disease in cattle 8 8 (8.%) 8 Wild bird deaths 8 Specimens collected Human new since last update Human cumulative Animal new since last update Animal 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)

2 Situation update Since the last update (of February 8), two new suspect human RVF cases have been reported in Yirol East. These include a -year-old female and a -year-old male from Yali payam in Yirol East. There are currently no suspect human cases on admission in Yirol East. The number of human RVF alerts in Eastern Lakes have continued on a steady decline in the last three weeks. During the week, a total of animal (Livestock) samples were collected, shipped to Juba and eventually to South Africa for laboratory testing. On February, Uganda Virus Research Institute (UVRI) released results for human samples. Only two samples were positive on serology for RVF IgG. Overall, out of the 8 human samples tested for RVF (since the onset of the current event Dec ), five have been RVF positive with one sample being RVF IgM and IgG positive while the other four samples were RVF IgG positive. Initial reports on the event On 8 December, 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 December 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

3 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 th December 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 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 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 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. The third case was a -year-old male from Thonabutkok village. His illness started on th December 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 th December 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. Timeline of the Rift Valley Fever outbreak in Yirol East, week 9, to week, 8 Index Case Possibly exposed at around this time. Exposure preceeded by reports of deaths in animals PA symptom onset After 8 days of treatment PA moved to Privated clinic AM Symptom onset MM symptom onset MM was never taken to a health facility, Zoonotic events noted (8 deaths in goats ) Days from DOO to death Detection and notification by SMOH Key PA: 9 Yr Old F, st probable Case AM: Yr Old F, nd Probable case MM : Yr Old M, rd Probable case DOO: Date of Onset DOO of IgG Pos Case DOO of IgM & IgM positive case st Dec th Dec th Dec 9th Dec th Dec th Dec th Dec th Dec 8th Dec th Dec nd Dec rd Dec PA was pregnant PA Death AM was never taken to a health facility, Zoonotic events noted (abortion and deaths in goats and sheep) AM death MM Death & Safe burial NRRT Deployed samples collected Sample collected on th Jan Sample collected on th Jan days from DOO to death days from DOO to death As of 9 February 8, the cumulative number of suspect RVF cases had risen to total of 8 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 non-cases) is 8.% (/). More cases have been reported among females (.%) than males (.%) (Figure ).

4 Most of the cases have been reported in the -9-year and -9-year 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 agegroups (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-,. Most suspect cases have been reported in week though only two have been confirmed as RVF IgG. 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 ). 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). South Sudan: Rift Valley Fever by Epi classification, Yirol East County, Week 9 of to Week of 8 Panyijiar R. Moch White Nile Twic East R. Atem Rumbek East R. Lou (Dok/Dhok) Case classification by Payam Payam Confirmed Probable Suspected Total Cases Mangar Yali 9 Yirol East Lake Yirol Bor South White Nile Wonthou Moger Khap Total cases 8 Map creation date:..8 Yirol West Awerial Decimal Degrees... Disclaimer: The boundaries and names shown and the designations used on this map do not imply official endorsement by the United Nations 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 weekly at the national level and sub-national (Yirol East) level. During the week, the RVF taskforce meetings were held at the national and state level to review the situation and follow up on the implementation of investigation and response activities. The WHO/MoH rapid response team remains deployed to support investigation and response activities in Yirol East. Their main activities currently entail working with the community volunteers to investigate new alerts and collect blood samples for laboratory testing.

5 Community mobilisation, engagement, and sensitisation activities are ongoing with support from Unicef, CHADO, the County Health Department and the state Ministry of Health. Surveillance and case management Surveillance, investigation, and case management interventions are coordinated and led by the respective working group of experts. The committee convenes weekly meetings during which the major preoccupation currently entails developing and reviewing SoPs for surveillance, case management, investigation and prevention of RVF. With support from WHO, the MoH has developed health workers guidelines on RVF case surveillance, investigation, case management, and prevention. The guidelines have been disseminated to support RVF response activities at facility and community level. In Yirol East, active case search is ongoing to ensure that all new human cases are promptly detected and reported to the authorities to facilitate prompt investigation and response. In Yirol East, seven active case search teams linked to seven health facilities, namely, Nyang PHCC, Thonabutkok PHCU, Amethic PHCU, Pagarau PHCU, Khap PHCU were formed and deployed to conduct active RVF case search. A total of CHWs were trained and deployed to conduct house to house RVF case search. All new suspect RVF cases are referred to the nearest health facility. In Yirol West, active case search teams with members linked to Yirol Hospital, Anuol PHCU, Aluak Luak PHCU, Pabour PHCU, Wou Wou PHCU, Panaker and Mageng PHCUs were formed to conduct active case search. The Ministry of Livestock and Fisheries/FAO animal health team returned to Juba from Yirol East on Feb 8. A total of animal samples were collected and have now been shipped to South Africa for laboratory testing. In addition to investigating sick animals, the team conducted training of community animal health workers (CAHW) and supported social mobilisation activities to sensitise communities on sanitary animal handling to mitigate the risk of animal-human transmission of RVF. Weekly update on UNICEF support to the ongoing RVF outbreak ( nd - 8 th February 8) UNICEF partner, CHADO community mobilisers continued with social mobilization on door-to-door visit, community meetings and engagement of religious leaders in response to RVF outbreak in Yirol East, Eastern Lakes. The trained community mobilisers have visited 9 households (,9 individuals), 8 community meetings ( participated). UNICEF and WHO oriented community health workers and CHADO community mobilizers on the Signs/Symptoms and how to stop the transmission of RVF virus from animal to Human. UNICEF supported CHADO the distribution of long lasting treated nets in Yali Payam, pieces of LLINs distributed to households in Thonabutkok, the current transmission hotspot. The teams also conducted demonstrations on proper mosquito net use in the communities. Pending actions, gaps, and challenges There is need to develop a multisectoral rift valley fever preparedness and response framework that will facilitate the implementation of readiness activities to enhance resilience capacities to avert or minimize the impact of future rift valley fever outbreaks. Overall, there is need to strengthen national capacities for viral hemorrhagic fever preparedness, surveillance and response. This will allow the country to effectively respond to emerging threats of other viral hemorrhagic fevers. Technical support for developing a rift valley fever communication strategy that will be used for continued community engagement, social mobilization, and risk communication during the inter-epidemic and pre-epidemic period.

6 Review and update messages and the question and answer fact sheet. Planned activities and Way forward Conduct weekly meetings of the national and state-level RVF taskforce. Active surveillance and response to emerging human and/or animal alerts in the affected and at-risk counties. Community engagement and risk communication in the affected and at-risk counties. 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, and partners. Disseminate regular updates by way of situation reports and/or press statements/releases as the situation evolves. South Sudan: Rift Valley Fever by outcome, Yirol East County, Week 9 of to Week of 8 Panyijiar R. Moch White Nile Twic East R. Atem Rumbek East R. Lou (Dok/Dhok) Case classification by Payam Payam Alive Died Total Cases Mangar Yali 9 Wonthou Moger Khap Total Cases Yirol West Yirol East Lake Yirol Bor South White Nile Map creation date:..8 Awerial Decimal Degrees... Disclaimer: The boundaries and names shown and the designations used on this map do not imply official endorsement by the United Nations

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

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

9 Figure : RVF case distribution by time and epi-classification in Yirol East, week 9, - week, 8 RFV case distribution by classification in Yirol East, wk 9, to week, Number of cases confirmed probable suspected 8 9 Epidemiological week of onset in and 8 Figure : Clinical symptoms among suspect, probable, and confirmed cases, Yirol East, wk 9, to wk, 8 Clinical symptoms among suspect, probable, and confirmed cases, Yirol East, wk 9, to wk, 8 Convulsions % Bleeding Joint pains % % Neck pains % Headache % Fever 9% % % % % % % % % 8% 9

10 Figure : RVF cases by County and Payam, outcome, Eastern Lakes wk 9, to wk, 8 Number cases/death 9 8 RVF cases by County and Payam, outcome, Eastern Lakes wk 9, to wk, 8 Mangar Yali Wonthou Moger Khap Alive Died Yirol east Figure 8: RVF cases by County and Payam, classification, Eastern Lakes wk 9, to wk, 8 RVF cases by County and Payam, classification, Eastern Lakes wk 9, to wk, 8 Number cases/death 9 8 confirmed probable suspected Mangar Yali Wonthou Moger Khap Yirol east

11 Figure 9: RVF cases by County, Payam, village, and classification, Eastern Lakes wk 9, to wk, 8 RVF cases by County, Payam, village, and classification, Eastern Lakes wk 9, to wk, 8 Number cases/death confirmed suspected probable Aruau Agal jamith Amethic koiwic Pagarau Agal Amethic Thonabutkok Wunthou Yecliet nyang jamith Wunthou Athoibak koiwic Abang Agal Mangar Pagarau Yali lekakodu Wonthou Moger Khap Yirol east