WHO SOUTHERN SUDAN HEALTH UPDATE March 2004 HIGHLIGHTS WHO organizes a two day workshop on sleeping sickness WHO/southern Sudan team attends 7 th WHO advisory group meeting on Buruli ulcer CDC measles assessment team presents its findings A planning meeting on AFP surveillance training ends in Loki 1.0. DISEASE SURVEILLANCE AND EARLY WARNING AND RESPONSE NETWORK (EWARN) 1.1. Workshops, Training and orientation on EWARN 1.1.1. Mabior Integrated Health Workers Training An integrated health workers training on disease surveillance and EWARN was started in Mabior Northern Bor, UNL on March 29, 2004 and lasted for 5 days. A total of 15 health workers representing 4 NGOs and counterparts are participating. The workshop focused on outbreak early detection, investigation and response. In addition the role of the laboratory in epidemic investigation and confirmation will be emphasized. The training will combine lectures with outbreak case scenarios, group work, and discussions. Participants will be given an opportunity to discuss practical case investigations and share their experiences with colleagues. The five-day health workers training was be followed by a two-day community orientation on EWARN. The community training will focus on the role of community in outbreak detection and reporting, how and where to report. A total of 30 participants representing community leaders, church leaders, teachers and local administrators are expected to attend. Similar trainings are planned for Nimule, Katigiri and Ikotos in Equatoria region, Turalei and Lunyaker in Bahr el Ghazal, and Padak and Kiechkuon in Upper Nile. 1.1.2. Workshop on Scaling up Sleeping Sickness Control Activities in South Sudan Over forty people participated in a workshop on scaling up sleeping sickness control activities in South Sudan, organized by WHO/HQ and WHO Southern Sudan in Nairobi from March 1-3, 2004. The participants were from MOH Khartoum, SPLM/SOH, KEMRI, ICIPE, FAO, WHO/HQ, WHO/EMRO, WHO Southern Sudan and NGOs involved in sleeping sickness control activities. The meeting was called to examine the critical situation of sleeping sickness in South Sudan. 1
The specific objectives of the meeting were as follow: To increase the role of WHO in the coordination of sleeping sickness control in South Sudan To rehabilitate the sleeping sickness control infrastructure in Tambura and Ezo counties To investigate different ways to implement integrated disease and vector control activities in South Sudan with the other agencies. Following the recommendation of the workshop, WHO and SPLM/HS are planning an emergency intervention of treating sleeping sickness patients in Tambura and Ezo counties. The intervention will start in May 2004 before the rainy season. 1.1.3. WHO/southern Sudan attends 7 th WHO advisory group meeting on Buruli ulcer The seventh WHO advisory group meeting on Buruli ulcer was held this year again in Geneva, Switzerland from March 8 th 11 th, 2004. South Sudan was represented by WHO/South Sudan office and this was the second time Southern Sudan was invited in this meeting. This came as a result of detection and confirmation of more cases of Buruli ulcers in Mabia IDP camp in Tambura and Nzara in Yambio, South Sudan. More than 130 participants representing over 40 NGOs, research institutes, and foundations participated in the meeting. The meeting was a very important part of global 2
advocacy efforts and provided an opportunity to review achievements and constraints of the previous year and to make recommendations to guide the work of all partners. It also provided a forum to share and disseminate new information, and coordinate efforts among all partners (endemic countries, research community, NGOs and WHO). The specific objectives were: To review critical issues hampering effective implementation of control efforts To review national action plans for intensifying control activities for 2004 To review progress in the implementation of the research priorities on Buruli ulcer To provide essential equipment to health facilities to enhance the management of BU cases. Dr. Abdullahi Ahmed and Dr. Martin Opoka presented an update on Buruli ulcer in Sudan during the meeting. The officials also discussed with GBuI and other donors support to South Sudan Buruli ulcer control activities. Dr. Opoka also attended a three day training on the WHO Health Mapper program organized for participants from endemic countries by the Global Buruli ulcer Initiative alongside the advisory group meeting. 1.2. Preparedness, Detection and Response 1.2.1. CDC measles assessment team presents its findings Following reports by WHO Office for Southern Sudan of measles outbreaks in multiple areas of South Sudan since 2003, WHO/EMRO requested the US Centers for Disease Control and Prevention (CDC) to assist in investigating the outbreaks. The outbreaks were reported from Maridi, Ikotos, Tonj, Rumbek, Gogrial, Atar, Leer, Nyiluak and other locations. The outbreak was not completely characterized and CFRs were reportedly very high. CDC sent a team of two epidemiologists (Drs. Thomas Handzel and Thomas Boo) from February 16 March 24, 2004. They were accompanied by WHO and NGO staff on the ground and visited Ikotos, Tonj, and Leer areas and carried out assessments. The team conducted interviews with key informants, and visited villages, health facilities, IDP camps and cattle camps where they conducted retrospective surveys, active case search and collected specimens for laboratory analysis. The team presented its preliminary summary findings to UN agencies and NGOs in both Loki and Nairobi, and the following are the highlights: There were a large number of cases in both outbreaks Long duration of outbreaks Significant impact in terms of morbidity and mortality Both outbreaks are ongoing Not all areas are affected potential for immunization in unaffected areas There was a weak response to outbreaks The team recommended the following: o Enhanced case management practices - Increase CHW awareness of outbreak - CHW measles refresher training - Develop and disseminate case-management protocols - Provide additional resources to PHCUs 3
- Consider nutritional supplementation at PHCC o Targeted vaccination campaigns - Probable benefit to children in unaffected areas of the counties - short window before rains begin - Resource constraints faced by NGOs o Mass measles campaigns may be the most effective way of reducing measles morbidity and mortality - It is feasible in parts of South Sudan - Requires advanced planning due to logistical constraints - Requires funding for campaign 1.2.2. Detection, verification and response A total of three alerts of suspected disease outbreaks were received and followed-up in the month of March. These were a report of measles outbreak in Chukudum, Budi County reported by ADRA, measles outbreak in Leer, UNL discovered by EWARN public health coordinator for Upper Nile, and suspected chicken pox in Nyuak, North Bor County reported by SMC (See table below). WHO/EWARN and partners also continued to follow up some previously reported outbreaks; meningitis in Tali where there were no new cases reported since the beginning of the month. The last reported cases and deaths were 49 and 8 respectively. The other outbreaks followed were mainly those of measles Ikotos, Atar, Payuer and Nyiluak. Mass measles campaigns have been started in Payuer, parts of Rumbek and Tonj counties. WHO and UNICEF have also sent emergency drug kits and ORS to Ikotos as part of the continued response effort to the measles outbreak there. It should also be mentioned here that WHO has sent out appeals to NGOs operating in Budi, Torit and Magwi counties to assist in the implementation of the yellow fever mopup and measles vaccination campaigns in these counties. This will be combined with vitamin A distribution. So far only ADRA has taken up the challenge and will start campaigns in parts of Budi County. WHO will meet the costs of these campaigns and UNICEF will provide vaccines and supplies. 1.3.1. Leprosy program in Southern Sudan Leprosy is one of the major endemic health problems in South Sudan. Leprosy is an infectious disease caused by Mycobacterium leprae. Though precise prevalence and impact of leprosy is not known, the morbidity rate of the disease is very high in this area. This is a slow growing intracellular bacillus that infiltrates the skin, the peripheral nerves, the nasal mucosa and the eyes. The incubation period between infection and appearance of symptoms and signs is estimated to be two to three years. Leprosy is transmitted through close contact and affects both sexes and all ages. The most common symptoms are hypopigmented or reddish skin lesions with definite loss of sensation, involvement of the nerves, and muscle weakness. In untreated cases this can lead to chronic ulcers and destruction of bone. Visual impairment or blindness can complicate the disease. Leprosy is a treatable disease and with the introduction of the multi-drug therapy (MDT) by WHO, there has been significant reduction in the number of people affected by leprosy all over the world. Before the war broke out in 1983, German Leprosy Relief Association (GLRA) supported various leprosy treatment centres in South Sudan. However, in the last 20 years 4
of war, these centres were destroyed causing leprosy to re-emerge with great ferocity. Despite the war, the leprosy program in South Sudan restarted in the mid-1990 s and is being run by NGOs supported by WHO. There are 11 NGOs currently treating leprosy patients. These NGOs are operating 20 health centres and several primary health care units. From January to December of 2003, a total of 2,072 new cases were detected. About 1231 leprosy cases completed treatment during the same period. These numbers are still far below the expected numbers that need to be detected and cured to meet the WHO target of reducing leprosy prevalence to one case per 10,000 population. This year 5 new NGOs have shown interest in joining the program. This means that with time more and more NGOs will integrate leprosy treatment into their primary health care programs thus expanding the leprosy activities in South Sudan. In order to move the leprosy program forward, the WHO Office for Southern Sudan Office has planned several activities in 2004 aimed at strengthening the capacity of the NGOs managing leprosy. This begins with a training workshop for NGO Coordinators on the 17 th April 2004 followed by several training programs for NGO field staff. WHO is also providing MDT drugs free to NGOs. It is hoped that these activities will go a long way to reduce the high morbidity caused by leprosy towards the WHO elimination target for leprosy. Upcoming Events 1. Workshop on TB in Southern Sudan Date: April 1-2, 2004 Location: Nairobi, Kenya 2. Workshop on review of anti-malarial drug policy in Southern Sudan Date: April 7-8, 2004 Location: Nairobi, Kenya 3. Workshop on Leprosy Date: April 17, 2004 Location: Nairobi, Kenya 5
Table 1. Summary update of verified outbreaks: March 2004 Outbreak disease/syndrome Measles Chicken pox Location/Onset Chukudum, Budi County EQA Onset: 07/03/2004 Nyuak, Jonglei, UNL. Reported onset: Week 11 10/3/04 Source and date of update ADRA/s. Sudan Report date 08/03/2004 SMC Last update: 22/3/04 Reported cases/deaths/actions taken 4 cases. No deaths reported. Case management and health education. Mass vaccination campaigns are planned for the non-affected villages. 44 cases. No death Follow-up with SMC. Investigation by WHO public health coordinator. UTI 0% Abscess 1% Dressings Top Ten Disease in from 8 Hlfacilities Tonj County February 2004 Eye diseases Anaemia Wounds /trauma 4% Others 8% Malaria 39% W/diarrhea 15% Scabies Source: MSF-CH RTI 14% Int. Worms 11% 6
2.0. POLIO IMMUNIZATION AND AFP SURVEILLANCE 2.1. Planning meeting on AFP surveillance training A planning meeting on AFP surveillance training was held from March 23-25 in Lokichoggio. The participants of the meeting were all regional national and international focal points, regional public health coordinators for EWARN, the team in Lokichoggio and the technical officer in Nairobi. This year AFP training will be extended for three days to include measles and EWARN training. The field staff are then to do a one-day training for contact persons in their region on AFP surveillance. This is expected to motivate the contact persons and enhance the AFP surveillance activity. Training will start mid-april and end before the major rainy season. The meeting discussed and reached a consensus on issues including: 1. Agenda and training objectives of the upcoming AFP training 2. Training on measles for field assistants to enable them to do aggregate reporting on measles cases from their sentinel sites 3. Training on EWARN for county supervisors and field assistants 4. Enabling county supervisors to collect and report data on priority diseases using the EWARN reporting format from one sentinel site per county. This is believed to be the first step towards integrated disease surveillance reporting using the experience and personnel of AFP surveillance. 2.2. AFP cases: Two AFP cases were reported this month, one from Bahr-el-Ghazal and the other from western Equatoria. Both cases were detected and investigated within 2 weeks of onset of paralysis. 7