Cases Republic of South Sudan EARLY WARNING AND DISEASE SURVEILLANCE BULLETIN (IDP CAMPS) 9 24 th 2 nd March, 1. General Overview Nearly one million people have fled from their homes. A total of 75, 8 people displaced by violence since December 213 within South Sudan, and over 2, displaced in to the neighboring countries (UNOCHA). A total of 1 sites (66.7%) reported in week 9 compared to 11 sites (73%) in week 8. Measles outbreak is declining in all the major IDP sites that reported cases in the previous weeks. Suspected meningitis cases reported in Juba III IDP camp, Kajo Keji County and Abyei County. The 5 days OCV immunization campaign in Tongping IDP camp (Juba) ended on Tuesday 4th March, a total of 14,112 were vaccinated in round one. The 7 days OCV immunization campaign in Mingkoman camp (Awerial) ended on Tuesday 4th March, a total of 52,398 were vaccinated in round one. 2. Trends of priority diseases (cases) in IDP Camps, week 51 to week 9 The figure1 below shows the trends of acute bloody diarrhea, malaria, suspected measles, and acute watery diarrhea in the IDP camps. A general decline is observed in the last two weeks Trend for ABD, AWD and Malaria are likely to change with the onset of rains expected in April Figure 1: Trends of Priority Diseases in IDP camps 26 24 22 2 18 16 14 12 1 8 6 4 2 Wk 51-213 Wk 52-213 WK 1- WK 2- WK 3- WK 4- WK 5- WK 6- WK 7- WK 8- Bloody Diarrhoea Malaria Suspected Measles Watery diarrhoea WK 9- For comments or questions, please contact Surveillance Department, MoH-RSS E-mail: outbreak_ss_27@yahoo.com, HF radio frequency: 815 USP; CELL CALL: 72 1
Cases Number 3. Consultations (all conditions seen at outpatient and inpatient) The total numbers of consultations reported in week 9 were 7466 compared to 7897 in week 8. Awerial has continued to post the highest number of consultations as it has the highest displaced people Figure 2: Number of consultations reported by sites in week 9, South Sudan, 3 25 2 2395 228 15 1 5 176 849 657 461 Awerial Malakal Tongping Un House Melut Bentiu Site Cause specific morbidity for week 9 (n=7466); acute watery diarrhoea contributed about 11.2%, malaria (7.3%), acute bloody diarrhoea (1.5%) and measles (.1%). In week 8 (n=7897), acute watery diarrhoea contributed about 8%, malaria 7.1%, acute bloody diarrhoea 1.8% and measles.15% 4. Epidemic Prone Disease Reported 4.1. Acute Watery Diarrhea (AWD) The trend for acute watery diarrhea is reflected in the figure below. There was a significant increase in cases despite decline in completeness rate in week 9. The total cumulative AWD cases stands at 11666 Figure 3: Trend of Acute Watery Diarrhoea, South Soudan, week 51, 213 - week 9 2 18 16 14 12 1 8 6 4 2 Wk 51-213 159 Wk 52-213 547 WK 1-846 WK 2-1145 WK 3-1557 WK 4-1436 WK 5-1567 WK 6-1884 WK 7-861 WK 8-634 WK 9-837 4.2 Dysentery (ABD) Figure 4 below show a decrease in acute bloody diarrhea cases in week 9 compared with week 8. A total cumulative of 1956 was reported by week 9. 2
Cases and deaths Cases Figure 4: Trend of Acute Bloody Diarrhoea, South Soudan, week 51, 213 - week 9 35 3 25 289 272 25 248 2 189 15 1 5 73 146 88 124 14 114 Wk 51-213 Wk 52-213 WK 1- WK 2- WK 3- WK 4- WK 5- WK 6- WK 7- WK 8- WK 9-4.3 Measles A cumulative total of 79 suspected measles cases with 82 deaths (CFR =1.4%) have been reported from all IDP camps. About 8% of the measles cases were reported by Tomping and Bor. A total of 7 measles cases (UN House 3, Awerial 3, Tomping 1) were reported in week 9 compared to 22 cases in week 8. The last death was reported in week 7. Measles response immunization were done targeting children 6 months to <15 years of age in the various large camps. Most campaigns were done in week 5. Figure 5 below shows measles outbreak at its tail end. Cases reduced significantly from week 5 to week 9. Figure 5: Measles Epidemic Curve in IDP camps, South Soudan, week 51, 213 - week 9 3 25 Cases Deaths 2 15 1 5 51 week 52 week 1 week 2 week 3 week 4 week 5 week 6 week 7 week 8 week 9 Deaths 2 3 21 4 15 1 Cases 3 1 67 114 114 28 175 54 22 7 4.3.1 Measles deaths by site About 5% of all measles deaths were reported from Bor IDP camp. About 27.3% (216/79) of the total cases were from Bor. About 37.8% of measles deaths were reported from Tongpin. A total of 52.3% (413) of all cases were from this camp. 3
Cases Percentage Figure 6: Measles deaths by IDP camps, South Soudan, week 51, 213 - week 9 6 5 4 3 37.8 5 2 1 7.3 3.7 1.2 Malakal Juba III Mingkaman Bentiu Tomping Bor IDP camp 4.3.2 Measles attack rate by IDP camp The highest attack rate was in Bor (396.6/1,), followed by Yida(364.9/1,). Figure 7: Measles attack rate by IDP camps, South Sudan, 4.4 Malaria A decline in malaria cases in last three weeks is observed in figure 8 below. Figure 8: Trend of reported malaria cases in IDP camps, South Soudan, week 51, 213 - week 9 27 24 21 18 15 12 9 6 3 Wk 51-213 26 Wk 52-213 718 77 75 WK 1- WK 2-1479 WK 3- WK 4-1672 WK 5-4 1339 WK 6-2468 WK 7-1197 WK 8-56 547 WK 9-
4. 5 suspected meningitis cases Meningitis outbreak was confirmed in South Sudanese refugee camps in Northern Uganda. As of 27 th Feb 19 cases reported among refugees in Arua (3/34=8.8%) and Adjumani (16/41=39%). Cumulative total of 7 suspected meningitis cases and five deaths (CFR=71.4%) have been reported from Kapoeta North and Budi counties of Eastern Equatoria state. Culture results from AMREF were negative for Neisseria meningitides. No additional cases in week 9 Cumulative total of 8 suspected meningitis cases and 2 deaths (CFR= 25%) have been reported from Kajo Keji county in Central Equatoria State. The latest two cases were reported in week 9 and 1. Cumulative total of 27 suspected cases have been reported from Aweil Civil Hospital in Northern Bahr el ghazal state between week 1 and 8. Two suspected cases were reported from Juba III in week 1. Two samples were collected and sent for culture after initial rapid test (pastorex) turned negative. One suspected meningitis case and death has been reported from Abyei County, Warrap State in week 9 Three suspected cases from Lakien PHCC were reported in week 9 4.6 Other diseases of public health importance No reports of suspected Cholera, VHF, AFP, NNT, AJS and yellow fever in week 9 5. Mortality data 5.1 Under-five mortality rate The under-five mortality rate in all IDP camps have come down below the emergency threshold (U5MR: 2 per 1, per day) as of week 9 (figure 9). Figure 9: Under five mortality rates in IDP camps, South Soudan, week 51, 213 - week 9 18 17 16 15 14 13 12 11 1 9 8 7 6 5 4 3 2 1 Emergency threshold U5MR: 2 per 1, per day Wks 51 Wks 52 Wks 1 Wks 2 Wks 3 Wks 4 Wks 5 Wks 6 7 8 9 Tomping UN House Bor Bentiu Malakal Awerial 5.2 Crude mortality rate The crude mortality rates has remained below the emergency threshold (CMR: 1 per 1, per day) in all IDP camps for the fourth consecutive (week6-week9) as shown in figure 1. 5
Number of deaths Mortality rate/1 Figure 1: Crude mortality rates in IDP camps, South Soudan, week 51, 213 - week 9 4.5 4 3.5 3 2.5 2 1.5 1.5 Crude Mortality rates in IDP Camps Wks 51 Wks 52 Wks 1 Wks 2 Wks 3 Wks 4 Wks 5 Wks 6 7 8 9 Tomping UN House Bor Bentiu Malakal Awerial 5.3 Deaths by Reporting Site Since 15 th December, Tongping reported the highest number of deaths (144) out of the total (371). Tongpin had the highest crude mortality rate 5.2/1. The range was.6-5.2 per 1 Figure 11: Mortality data from IDP camps, South Soudan, week 51, 213 - week 9 16 14 12 1 8 6 4 2 5.1 5.2 4.5 144 2.8 79 51 1. 36.6 45 16 Malakal Bor Bentiu Mingkaman Juba III Tongpin 6. 5. 4. 3. 2. 1.. IDP camp 5.4 Cause-specific deaths A cumulative total of 371 deaths have been reported as of week 9 since December 15 th 213. Deaths attributable to specific causes are shown in figure 12 below. About 22.1% were due measles and related complications; 16.4% were due to diarrhea and related complications; 4% due to Pneumonia; 6.2% due to Malaria and 1.3 % due to Malnutrition. About 19.4% of the deaths were due to unknown cause. The mortality line list from Tongpin had the highest (67) numbers of deaths without any cause indicate. Figure 12 below show the details 6
Percentage Figure 12: Cause specific mortality rate, South Soudan, week 51, 213 - week 9 25. 22.1 2. 16.4 19.4 15. 13.7 1. 5...5.8.8 1.1 1.3 1.3 4. 4.6 6.2 7.5 5.5 Age distribution of mortalities About 56% of the deaths were under 5 years while 39% were over 5 years. Age was not indicated in 5 % of the deaths Figure 13: Age distribution of mortalities, South Soudan, week 51, 213 - week 9 Unknown 5% > 5 years 39% < 5years 56% 7
5.6 Sex distribution of mortalities About 45% of deaths were male and 39% were female. About 16% of the deaths were blank. Figure 14: Sex distribution of mortalities, South Soudan, week 51, 213 - week 9 Unknown 16% Female 39% Male 45% 6. Oral Cholera Vaccination (OCV) The 5 days OCV immunization campaign in Tonping IDP camp (Juba) ended, a total of 14,112 were vaccinated in round one. The 7 days OCV immunization campaign in Mingkoman camp (Awerial) ended on Tuesday 4th March, a total of 52,398 were vaccinated in round one. Round one OCV campaign in Juba III will start on Monday. Social mobilization will be done 2 days prior the campaign. There were disparities between the OCV final tally figures and the used vials MoH/WHO teams are supporting the vaccination monitoring process 7. Conclusions Despite reduction in morbidity in most IDP camps, the trends for diarrhoea diseases and malaria are likely to change due to the onset of rains expected in April. Measles outbreak at its tail end in the IDP camps. A threat of meningitis outbreak is real, local laboratory capacity for confirmation is lacking. The country is currently having stocks of about 9, doses of trivalent (A/C/W135). 8. Recommendations 8.1 Standing recommendations Integrated health services should Improve and expanded in all IDP camps Ensure timely and good quality of morbidity and mortality data from all IDP camps including line listing of all suspected cases of measles using the standard line list. Strengthen disease surveillance system for timely detection, reporting and response to outbreaks and other public health events Fast track importation and distribution of pharmaceutical and none pharmaceuticals to avert a looming crisis in some states. Scale up the use of oral cholera vaccination in other camps (Bor, Malakal and Bentiu) as an additional public health tool to compliment the ongoing WASH activities. Vaccination of new arrivals and routine immunization in camps to prevent future outbreaks. Measles specimens to be analyzed in Juba after the laboratory were re-established. 8
Strengthen capacity for meningitis specimen collection, packaging and transportation in order to improve the isolation rate. Logistical and financial resources should be mobilized to undertake a preventive meningitis mass vaccination in the high risk areas. Improve on cross border surveillance by sharing epidemiological information with neighbouring countries that have received influx of refugees from South Sudan. Use the shared WHO South Sudan crisis response proposal to mobilize funds at all levels. 8.2 Additional recommendations Use lessons learnt after 1 st round OCV campaign in Tongpin and Mingkaman to improve the quality of the planned Juba III campaign which is starting on Monday. Despite the OCV campaigns, laboratory surveillance using cholera RDT kits is required for early detection of cholera cases. The early warning mechanism is critical with the expected rains and floodings. Health Partner Supporting Health Care Services in the IDP camps: MSF- Belgium, MSF-Swiss, MSF-Holland, MSF-Spain, IMC, THESO, CUAM, UNMISS Clinics, UNFPA, UNICEF and WHO. 9