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; 9 March 8 No. Summary of cases Total New suspect cases (deaths) week ending th March 8 () Cumulative suspect cases (deaths) in Health Facilities Community 8() () Total number of suspect cases on admission Cumulative suspect cases discharged 8 Epidemiological classification of human cases Suspect (pending lab results) Confirmed by IgG + IgM Confirmed by IgG Confirmed total Probable Non-cases (RVF lab test negative) Deaths (CFR%) excluding non-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 9 (9%) 8 7 Wild bird deaths 8 Specimens collected Human new since last update Human cumulative 7 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) 8 8 8

2 Animal sample serology IgG IgM Totals by case classification Positive 9 Suspect Negative Total Situation update Since the last update (of February 8), eight new suspect human RVF cases have been reported in Yirol East ( suspect cases) and Yirol West ( suspect cases). The samples have been obtained and shipped for laboratory testing. However, there are currently no suspect human cases on admission in Yirol East. During the week, one human sample tested RVF IgG positive. Thus, the cumulative for confirmed human RVF cases now stands at six (one RVF IgM+IgG positive and five IgG positive). On 7 March 8, seven human suspect RVF samples were shipped to Uganda Virus Research Institute (UVRI) in Entebbe for laboratory testing. The test results from the animal (Livestock) samples shipped to South Africa were released during the week. Out of the samples tested; eight (8) were RVF positive ( IgM and IgG); six () samples being RVF suspect (based on IgG and IgM serological titres); and seven (7) samples tested RVF negative (based on IgG and IgM serological titres).

3 Thus, a cumulative of 8 animal samples have been tested to date with nine (9) being RVF positive ( IgM and IgG); six () samples being RVF suspect (based on IgG and IgM serological titres); and samples testing RVF negative (based on IgG and IgM serological titres). Initial reports on the event On 8 December 7, the Eastern Lakes State 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/Wunthow 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 showed 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. Also, the symptoms were not reported in the respective close case contacts during the clinical illness or even after death. These initial investigations showed significant history suggestive of a zoonotic hemorrhagic illness as abortions in goats and sheep; deaths/disease in goats and cows; wild bird die-offs were 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 to 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 a 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 she developed bleeding from the skin blisters. Eight goat deaths with extensive hemorrhage were reported in the case neighborhood (the goats were skinned, cooked and eaten). Goat and sheep abortions were reported in association with this case where she was buried which was close to the index 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 7 with a 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. In the period 7 December 7 to 9 March 8, a total of suspect RVF cases were reported in Eastern Lakes state. These were reclassified based on epidemiological investigations and laboratory test results, such that as of 9 th March 8, there were a total of six () RVF confirmed cases, three () probable cases, and twelve () suspect RVF cases (laboratory results are pending). Nineteen (9) cases were discarded as non-cases following negative laboratory results for RVF and other common causes of viral haemorrhagic fever. The case fatality rate among suspect, probable and confirmed cases (excluding non-cases) is 9% (/). More cases have been reported among females (7%) than males (9%) (Figure ). Subject to change as the RVF laboratory case classification algorithm is currently being reviewed.

4 Most of the cases have been reported in the -9-year and -9-year age-groups in both males and female suspect, probable, and confirmed RVF cases (Figure ). The deaths occurred in the -9-year and -9-year age-groups (Figure ). Timeline of the Rift Valley Fever outbreak in Yirol East, week 9, 7 to week, 8 Figures and show the distribution of cases by time and outcome/epi-classification. The initial probable cases occurred between week 9-, 7. The most recent confirmed cases (RVF IgG positive) were reported in week and all the suspect cases reported in the subsequent weeks have been negative for RVF. 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 7% of suspect cases. At least half (%) of the six confirmed cases had bleeding. Most probable, confirmed, and suspect cases (excluding the non-cases) 8 (8%) 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 (%) cases and deaths (7%) were reported from Yali payam. Most (9%) of the probable and confirmed cases are clustered in Yali Payam, Thonabutkok village (Figures 8 and 9). The other three payams with confirmed RVF cases include Paragau, Khap, and Mangar (Figures 8 and 9). South Sudan: Rift Valley Fever by Epi classification, Yirol East County, Week 9 of 7 to Week 8 of 8 Panyijiar R. Moch White Nile Twic East R. Atem Rumbek East R. Lou (Dok/Dhok) Case classification by Payam Payam Confirmed Suspected Probable Total Cases Mangar Pagarau Yirol East Lake Yirol Bor South White Nile Yali Wonthou Moger Yirol West Khap Adior Awerial Total cases Map creation date:..8 Decimal Degrees... Disclaimer: The boundaries and names shown and the designations used on this map do not imply official endorsement by the United Nations

5 Response updates Overall coordination of investigation and response activities Following the confirmation of additional animal cases, a joint Ministry of Health and Ministry of Livestock and Fisheries press meeting will be held on March 8 to declare the Rift Valley Fever outbreak in Yirol East county. The declaration therefore reinvigorates the current one-health interventions aimed at containing the disease in Livestock and reducing the risk of animal to human transmission of the disease. Investigation and response activities are currently coordinated by a multi-sectoral task force that is meeting weekly at the national level and sub-national (Yirol East) level. On March 8, the Hon. Minister of Health led a high-level delegation of officials from the Ministry of Health, Ministry of Livestock and Fisheries, WHO, and FAO to Yirol East. The team was briefed on the current outbreak situation and the status of prevention and response activities in Yirol East and the surrounding at risk counties. During the week, the RVF taskforce meeting was held at the national level to review the situation and follow up on the implementation of investigation and response activities. The state rapid response teams continue to verify all emerging RVF suspect cases and are supporting the collection of samples to facilitate confirmatory laboratory testing. 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 During the week, four RVF alerts were reported, verified, and investigated by the state rapid response teams. The team also collected blood samples to facilitate confirmatory laboratory testing. There are currently no suspect cases on admission. Surveillance for human and animal alerts by community health workers (CHWs) and community animal health workers (CAHWs) is ongoing. Weekly update on UNICEF support to the ongoing RVF outbreak UNICEF partner, CHADO community mobilizers continued with social mobilization activities such as household interactive sessions, community meetings, water point and market sessions and church announcement in response to RVF outbreak in Yirol East, Yirol West and Awerial county. Pending actions, gaps, and challenges The development of a multisectoral RVF preparedness and response framework that will facilitate readiness activities to enhance resilience capacities to avert or minimize the impact of future rift valley fever outbreaks is ongoing. Overall, there is need to strengthen national capacities for viral hemorrhagic fever preparedness, surveillance and response. These capacities will allow the country to respond to emerging threats of other viral hemorrhagic fevers effectively. 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. Review and updating of RVF messages and IEC materials by the communications working group is currently ongoing. Local NGOs willing to respond to the outbreak have no funding in order to respond to the community engagement and health message dissemination. Planned activities and Way forward Conclude testing of the pending human samples. Conduct biweekly 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.

6 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. Extensive animal and human sampling of RVF cases covering the affected and neighboring states to document the extent of the outbreak and facilitate a comprehensive approach to outbreak prevention and control. Continue supporting the transfer of severe RVF cases from community/peripheral health facility to the hospital for prompt initiation of supportive clinical care and management. South Sudan: Rift Valley Fever by outcome, Yirol East County, Week 9 of 7 to Week 8 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 Pagarau Yali 7 Wonthou Moger Khap Adior Total Cases Yirol West Yirol East Lake Yirol Bor South Awerial White Nile Map creation date:..8 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, 7 to wk, 8 RVF case distribution by sex in Yirol East, wk 9, 7 to wk, 8 Male 9% Female 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 - Mar Age in years Percentage % 7

8 Figure : RVF case distribution by outcome in Yirol East, week 9, 7 - week, 8 9 RVF case distribution by outcome, Yirol East n= (exluding non-cases) Number of cases/deaths 8 7 Alive Died 8-9yrs -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 8

9 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 confirmed probable suspected Number of cases 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 7% Neck pains % Headache % Fever 7% % % % % % % % 7% 8% 9

10 Figure 7: RVF cases by County and Payam, outcome, Eastern Lakes wk 9, 7 to wk, 8 RVF cases by County and Payam, outcome, Eastern Lakes wk 9, 7 to wk, 8 Number cases/death 8 Alive Died Mangar Pagarau Yali Khap Adior (blank) Yirol east Yirol West Figure 8: RVF cases by County and Payam, classification, Eastern Lakes wk 9, 7 to wk, 8 Number cases/death 8 RVF cases by County and Payam, classification, Eastern Lakes wk 9, 7 to wk, 8 Mangar Pagarau Yali Khap Adior (blank) Yirol east confirmed probable suspected Yirol West

11 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 probable suspected Amethic Pagarau Amethic jamith Thonabutkok Wunthou koiwic Kap koiwic (blank) Mangar Pagarau Yali Khap (blank) Yirol east Yirol West