WHO SOUTHERN SUDAN HEALTH UPDATE
Septmber/October2002
HIGHLIGHTS

Field consultation with and feedback from health workers provides inputs
to review EWARN training manual

Suspected outbreaks of whooping cough and an upsurge of Leshimaniasis

Sub-national immunization campaign conducted in southern Sudan
1.0. DISEASE SURVEILLANCE –
AND EARLY WARNING AND
RESPONSE NETWORK (EWARN)
1.1. Field experiences used for manual review
In the last two years, more than 150 Sudanese
health workers participated in training activities
ranging from 1-3 weeks each. The training is
aimed at improving the skills of Sudanese
health workers in surveillance, preparedness,
and early recognition and alerting and prompt
response to suspected outbreak conditions.
The following main recommendations are made
based on inputs from training and orientation
participants, field consultations with health
workers, and supervision on performance of
previous participants to the training;
 Scale-up the ongoing in-service training
to access more health workers and more
areas. Many health workers did not
have the access to such opportunities
due to long years of conflict.
 It is appropriate that emphasis is given
to address the needs of middle level and
primary health care workers. These are
closer to communities where most
outbreaks take place and often there is
delay in early recognition and alerting.
 Involving and delegation of members of
County EWARN team members, local
health workers and participants of
earlier training sessions reinforced skills
and motivated participation, and
 To address these needs and expectations
update the training manual regularly,
with a focus on simplicity for wider use
and flexibility for application to needs.
In-service training needs to be flexible and
address the expectations of health workers
Based on these observations, the training
manual on use was updated. It will be fieldtested in upcoming training sessions.
Reports and training notes from joint training
sessions and field outbreak investigations with
partners, like NGOs, AMREF, CMA, and
KEMRI were used to update the manual so that
it addresses the needs of mid-level and primary
health care workers in southern Sudan.
1
1.2. Field training and supervision
A one-week training focused on strengthening
surveillance and response was conducted to
seven members of Adol/Akot Payam EWARN
team. The participants were selected from
seven PHCUs in the Payam, supported by
ACROSS. Experiences from outbreaks of
Relapsing Fever and measles, which occurred
in the area in the past, and weekly surveillance
data from Adol sentinel site, and video films on
cholera, Ebola Fever, and bacterial diarrhea,
and group exercises on case examples, and
reviews on implementation of Adol EWARN
Team action plans were used to facilitate
training sessions. The training was facilitated
by Adol EWARN Team leader and WHO.
Delegation in training and field activities
motivates participation of health workers
1.3. Supporting training schools
Following consultation of some of the health
workers training schools in southern Sudan,
WHO donated training and reference books for
NPA, IRC, and SCF-USA. These include basic
epidemiology, clinical and laboratory reference
books received with support from WHO/HQ.
NPA is currently implementing training of
different categories health workers (clinical and
laboratory workers) at its Yei Health Training
School. IRC has community health workers
training schools at Ganyiel and Billing. SCFUSA is providing in-service training for its
health workers at Kumo PHCC, the Nuba Mts.
1.4. . Preparedness, Detection and Response
1.4.1. Meningitis preparedness
In the last two years, meningitis outbreak has
occurred in different parts of Sudan. Outbreaks
were detected and responded in Upper Nile and
Bahr Ghazal regions of southern Sudan, the
Nuba Mountains, and Southern Blue Nile.
Based on experiences from these outbreaks,
UNICEF/OLS and WHO, through the EWARN
system, have pre-positioned stock of meningitis
vaccines for use once laboratory confirmation
is received on a suspected meningitis outbreak.
It is also important that health NGOs improve
their stocks of oily chloramphenicol and other
supplies for likely outbreaks in southern Sudan.
Focus: Meningococcal Meningitis
(Epidemic meningitis)
Causative Agent:
Neisseria meningitidis
Clinical manifestations
 Sudden onset headache and high grade fever
 Neck stiffness/rigidity (may be absent-infants)
 Neurological signs (decreased awareness)
 Nausea, vomiting, or even shock may follow
Early warning indicators for possible epidemic:
 Two-three fold increase compared to same month of
in previous years (Ex: Feb 2002 from Feb 2001)
 Doubling of the number of cases from week to the
next for a period of 3 weeks (Ex: 5, then 10, 20)
 An increasing proportion of patients of 5 years of
age and older (Ex: 25 cases, 15 are > +5 years age)
Epidemiological description
 African meningitis belt-including Sudan
 Expand rapidly in dry, windy/dusty seasons


Crowding, like in IDP, cattle, fishing, military
camps, schools with movement facilitate spread
Type: Serogroup A commonly causes epidemics
Interventions
 Monitor trend and forecast seasonality, risk factors
 Pre-position stock of drugs, vaccines and supplies
 Immediately investigate, alert suspected outbreak
 Obtain CSF for lab confirmation (if have the skills
and supplies, if not immediately ask WHO support)
 Active case detection, case management, and
immunization reduce death and contain outbreak
 In epidemics: oily chloramphenicol is good,
inexpensive, easy to comply and use (single dose)
Laboratory Confirmation:
 Important to determine type and initiate vaccination
 Collect CSF before starting antibiotic treatment, and
under aseptic conditions. Skilled people to do LP.
 If your facility does not have the capacity to do
Gram stains, refer CSF to WHO/AMREF
 Start treatment even based on clinical findings and
CSF visual observation (cloudy is usually bacterial)
Remember:
Alert WHO at Papawhisky 3-8015-7002, or radioLima base
2
1.4.2. Outbreaks detection and response
A total of ten suspected outbreak alerts
were received from, verified and
responded as necessary from the
threeegions of southern Sudan, through a
network of 14 partners. The summary of
verified outbreaks is included in Table 1.
Table 1. Summary update of suspected outbreaks alerted and verified, Sept-Oct 2002.
Suspected outbreak
disease/syndrome
Whooping cough
Suspected rabies
Location/Onset
Source and last update
Oriny, Shilluk,
Upper Nile region
FRRA and Tear Fund
Reported cases/deaths/actions
taken
68 recorded cases, 5 deaths
Reported onset:
August/2002
Last Update:
23/09/02
Investigation, case management,
TA, drugs and supplies (TearFund,
UNICEF/OLS, WHO, FRRA)
Rumbek, Twic, and
Ikotos/Torit
Daikonei, ADRA, NCA
Bahr Ghazal and
Equatoria regions
Measles
38 reported unprovoked dog bites, 3
deaths from with manifestations
consistent with rabies among people
Suspected rabid dogs were killed
but no specimen was tested
Reported onset:
August (Rumbek)
October /2002
Labone, Yei,
Eqautoria
Last Update:
29/10/02
Reported onset:
25/09/2002
Last Update:
30/10/02
Rabies vaccines to people, killing of
stray dogs
118 cases with 3 reported deaths
NPA
Case management, health education
Figure 1. Recorded cases and deaths of whooping cough,
Aug-Sept, 2002, Shilluk, Upper Nile
30
Note: All, except 5 were <5 years of age
25
Number
20
Cases
15
Deaths
10
5
0
Atar
Pajor
Ogon
Source: TearFund/FRRA
Omath
Pajoj
Abuman
Dubo
Paroj
Others
Villages
3
1.4.3.Network on the fields
4
2. Polio Eradication Activities
2.1. Polio Eradication Quarterly Review Meeting in Lokichoggio, September 5-7, 2002
Polio eradication field staff from southern Sudan met in Lokichoggio, Kenya for their Quarterly
Review Meeting. EWARN doctors, who are now well integrated into the polio program, also
participated. Regional and national presentations were given along with a review of the findings
of the Technical Advisory Group meeting. The field staff were trained on the use of the new tally
sheet and supervisory and monitoring forms to be used during the sub-national immunization
days (SNIDs). Overall, the meeting was very successful and facilitated the exchange of
information between the different polio program levels and assisted in the preparation for the
next SNID campaign.
2.2. Horn of Africa Polio Partners Meeting, Nairobi, September 25, 2002
WHO and UNICEF convened a Horn of Africa (HOA) Polio Partners Meeting to seek advice on
how to overcome the key challenges to stopping poliovirus transmission in Ethiopia, Somalia,
and Sudan. Those challenges are:
o Ensuring access to all children, including in conflict-affected areas;
o Maintaining political commitment in the face of a disappearing disease; and
o Securing the necessary funding required to implement quality activities through 2005.
The meeting was well attended by high-level participants including Ambassadors from Belgium,
Ethiopia, and the United States, as well as the Deputy Head of Mission from Japan and the First
Secretary from Saudi Arabia. The keynote speaker was the famous photographer and polio
eradication supporter, Mr. Sebastiao Salgado, who spoke to the initiative’s successes, and urged
partners to enhance their efforts.
As a result of the meeting, the polio partnership was called upon to keep the diplomatic
community informed of progress towards polio’s eradication in the HOA and to enhance
collaboration with non-governmental organizations (NGOs). Additionally, G8 member countries
(Canada, France, Germany, Italy, Japan, Russia, United Kingdom, and United States) were urged
to make true their commitment, as outlined in the G8’s Africa Action Plan, to provide funding
for polio eradication activities through 2005. New partners were also urged to learn more about
the polio eradication programme, and to consider supporting the initiative.
2.3. North-South Polio Program Coordination Meeting, Nairobi, September 25, 2002
Sudan Polio Program staff from Khartoum and Nairobi/Lokichoggio convened for their second
meeting of the year to discuss and coordinate program activities. The meeting was attended by
representatives from WHO, UNICEF, Operation Lifeline Sudan (OLS), and Office of
Coordination of Humanitarian Affairs (OCHA). Rotary International and the Centers for
Disease Control and Prevention (CDC) representatives were also present.
The meeting facilitated the coordination of future activities and helped ensure the success of the
goal of polio eradication in Sudan. The group agreed to hold their next meeting in early 2003.
2.4. Expert Review Group Meeting, Nairobi, September 10, 2002
The third Expert Review Group meeting for southern Sudan and Somalia convened on
September 10, 2002 and reviewed three cases for southern Sudan; one was classified as a zeroevidence compatible and two were discarded. The meeting had an increased attendance by
5
national and international experts which contributed to the discussion and review process.
Organizers emphasized the importance of continued attendance and participation at these
meetings.
2.5. Sub-National Immunization Day Campaign
Due to increased insecurity in the region, the 2002 SNID campaign was postponed for several
days. However, the first round of SNIDs was successfully completed during the period of
October 14th to November 7th (including Nuba Mountains). The second round of SNIDs will
start in late November, 2002.
Coming Up:
Second round of Sub-National Immunization Days (SNID) campaign, November 2002.
6