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; 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 5 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 8 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)

2 Situation update Since the last update (of January 8), six new suspect RVF cases have been reported in Yirol East. These include two males and four females aged 7- years, and clustered in Wonthow payam, Yirol East county. There are currently no suspect cases on admission. The number of alerts have continued to decline in the week with the last alert that met case definition being reported on 5 th January 8. Three alerts were reported from th Jan to 7 th Jan 8 but they all did not meet the case definition. From 8th Jan 8 to date, there have been no new alerts from all the areas under surveillance. However, reports of illness and death in Livestock are still rampant in the outbreak area where for example on Jan 8, the rapid response team witnessed four () sick goats, one aborted and two had nose bleeding in Acigoor village close to the Thonabutkok village. The MLF/FAO team is conducting follow up investigations. Additional reports of animal deaths after short illness of - days in Pem cattle camp, Awerial county are also being investigated. South Sudan: Rift Valley Fever event map, Yirol East County, Week 9 of 7 to Week 5 of 8 Panyijiar R. Moch Twic East R. Atem Rumbek East R. Lou (Dok/Dhok) Yirol East Lake Yirol Legend Burial site Bor South Index Case IgG & IgM positive lady Second porabable case Thonabutkok PHCU Yirol West Awerial Place where 8 goats died Teenage boy got sick Pagarau PHCU Third probable case Map creation date:..8 km radius 5km radius kilometers 5 5 Disclaimer: The boundaries and names shown and the designations used on this map do not imply official endorsement by the United Nations As of February 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 non-cases following negative laboratory results for RVF, and are still classified suspect cases due to pending or partial laboratory sample testing. During the week, five new samples were sent to Uganda Virus Research Institute (UVRI) for testing on Jan 8 and the test results are still pending.

3 During the week of Jan 8, six samples were sent to Uganda Virus Research Institute (UVRI) for testing on Jan 8 and the test results released on 5 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 8 human samples have been collected and shipped to UVRI. A total of 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 5 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 5 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 5 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. The third case was a 5-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 February 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 non-cases) is.% (/). More cases have been reported among females 5 (8.8%) than males 7 (.8%) (Figure ).

4 Most of the cases have been reported in the -9-year age-group with most cases occurring the -9-year age-group in the males while in the females, most cases are reported in the -9-year, -9-year, and -9-year age-groups (Figure ). The deaths occurred in the -9-year and -9-year age-groups (Figure ). Figures and 5 show the distribution of cases by time and outcome/epi-classification. The initial probable cases occurred between week 9-5, 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 8% 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 (.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 7 to Week of 8 Panyijiar R. Moch Twic East R. Atem Rumbek East R. Lou (Dok/Dhok) Case classification by Payam Payam Abang Agal Mangar Confirmed Non-Cases Probable Suspected Total Cases Yirol East Lake Yirol Bor South Pagarau Yali Iekakodu Wonthou Total Cases Moger Khap Yirol West Awerial Map creation date:..8 Decimal Degrees.5.. 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 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. The RVF taskforce meetings at the national and state level were held on Jan 8 and Feb 8 respectively. The Yirol East taskforce meeting was chaired by the Director General with the following partners in attendance WHO, UNICEF, FAO, CUAMM, LiveWell, HELP, CCOSS, and CHADO. The highlights of the meeting included: o The need to intensify animal health investigation and response interventions. o The arrival of the Ministry of Livestock and Fisheries/FAO team that will be in Yirol East for one week to conduct animal health investigations, train community animal health workers, and enhance community awareness to facilitate reporting animal cases and promote hygienic animal handling. o The Ministry of Health, WHO, and CUAMM are currently implementing active case surveillance and alert response. o There is need for logistical support(fuel) for the three () vehicles donated by MOH to continue supporting activities (WHO and CUAMM) have stepped in to provide fuel in the last weeks. o The draft contingency plan will be discussed in detail in the meeting next week once the animal health components are incorporated. Surveillance and case management The surveillance, laboratory, entomology, and case management sub-committee meeting convened on Jan 8 in Juba to review the terms or reference, action, plan and surveillance guidelines including the case definition. The WHO/MoH rapid response team is on the group to support the overall coordination, investigation, and response activities in Eastern Lakes state. With support from WHO, The MoH has drafted health workers guidelines on RVF case surveillance, investigation, case management, and control. The draft guidelines have been disseminated for input by committee members and subject matter experts at international level. WHO supported six teams with a total of 5 community health workers that are conducting active case in the Yirol East. These community health workers have detected and reported alerts from Yali, Pagarua, Tinagau, Khap, Nyanga and Lekakudu payams in the last one week. In Yirol West, the team of 5 community health workers conducted active case search in Anuol and Aruau payams in the last one week. The team also conducted active case search in Aruau PHCU, Acigoor PHCU and Pagarau PHCU. The Ministry of Livestock and Fisheries/FAO animal health team arrived in Yirol West on Jan 8 and participated in the Yirol East taskforce meeting of Feb 8. The team is expected to lead the animal health investigation and response interventions including sample collection and mobilisation of communities to report sick animals and promote sanitary animal handling. Weekly update on UNICEF support to the ongoing RVF outbreak (5th Jan- st February 8) CHADO (UNICEF implementing partner) continued with community engagement, case search and reporting of suspected cases and death of animals. The CHADO team of 7 volunteers is working in close collaboration with the active case search team to engage the community and conduct risk communication. Case searching and community mobilization has been activated in Awerial county following reports of cases and deaths of animals: between - January community mobilizers identified several cases in various locations (97 Goats died, Goat had abortion cows had sign and symptoms of RVF and cows died). However, these are pending verification by the MLF/FAO animal health team. 8,75 people in Yirol East and 59 people in Awerial county has been reached through house-to-house visits, community meetings; radio continues to air key messages on RVF. Orientation of eight CHADO Mobilizers on key preventive messages and IPC skills were conducted by UNICEF technical officers in Thonabutkok area. Flyers with key preventive messages on RVF were distributed to CHADO mobilizers today in Thonabutkok area for community sensitization and additional,5 IEC materials being produced ready for distribution. LLINs have been delivered to Thonabutkok area and will be distributed to households. Taskforce coordination meeting was attended by UNICEF CD & Health officers. 5

6 Pending actions, gaps, and challenges A joint outbreak declaration by the Ministry of Health and Ministry of Livestock and Fisheries is still pending and further investigations are underway to characterize the disease in Livestock. Resources are required to support the investigations and immediate response activities that are currently underway and which have been ongoing for the last four weeks. Technical support in epidemiological surveillance and risk communication to facilitate in-depth human and animal health epidemiological investigations, community engagement and risk communication. Finalize the review and disseminate the health workers guideline on surveillance, investigation and case management for use at the operational level. Finalize the RVF advisory and action plan to facilitate implementation of outbreak response activities at national and subnational levels. Extend human and animal RVF case surveillance to Awerial, Rumbek East, Panyijiar, Bor, Twic East, and Duk counties to ensure that no suspect cases are missed. 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. Finalize the updating of RVF healthcare workers guidelines and messages so that they can be used to inform RVF response activities at health facility and community level. 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 7 to Week of 8 Panyijiar R. Moch Twic East R. Atem Rumbek East R. Lou (Dok/Dhok) Case classification by Payam Payam Alive Died Total Cases Agal Mangar Pagarau Yali 9 Iekakodu Wonthou Moger Khap Total Cases 9 Yirol West Yirol East Lake Yirol Bor South Awerial Map creation date:..8 Decimal Degrees.5.. 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 5, 8 Male.8% Female 8.8% 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 - Jan Age in years Percentage % Figure : RVF case distribution by outcome in Yirol East, week 9, 7 - week, 8 7

8 RVF case distribution by outcome, Yirol East n= (exluding none-cases) 7 Alive Died Number of cases/deaths 5 5-9yrs -9yrs -9yrs -9yrs 5-59yrs 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 5, 8 Number of cases 8 Alive Died Epidemiological week of onset in 7 and 8 8

9 Figure 5: 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 5, 8 Number of cases 8 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 5, 8 Convulsions 5% Bleeding Joint pains 8% 8% Neck pains % Headache Fever 95% 95% % % % % 8% % % Figure 7: RVF cases by County and Payam, outcome, Eastern Lakes wk 9, 7 to wk, 8 9

10 Number cases/death RVF cases by County and Payam, outcome, Eastern Lakes wk 9, 7 to wk 5, 8 Alive Died Agal Mangar Pagarau Yali lekakodu Wonthou Moger wanthou Khap 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 5, 8 Number cases/death 8 confirmed none-cases propable suspected Abang Agal Mangar Pagarau Yali lekakodu Wonthou Moger wanthou Khap Yirol east Figure 9: RVF cases by County, Payam, village, and classification, Eastern Lakes wk 9, 7 to wk, 8

11 RVF cases by County, Payam, village, and classification, Eastern Lakes wk 9, 7 to wk 5, Aruau Agal jamith Amethic koiwic Pagarau Amethic Thonabutkok Wunthou Yecliet nyang jamith Wunthou Athoibak jamith Wunthou koiwic Number cases/death confirmed propable none-cases suspected Abang Agal Mangar Pagarau Yali lekakodu Wonthou Moger wanthou Khap Yirol east