WHO SOUTHERN SUDAN
HEALTH UPDATE
July 2001
HIGHLIGHTS

Integrated clinical and laboratory training for health held in all regions

Training on IMCI takes place in Upper Nile

RBM consultation develops malaria control strategies for s Sudan.

Wild P1 poliovirus isolated from an AFP case from Ruweng County, Upper
Nile
1.0  DISEASE
SURVEILLANCE
Integrated
clinical and–laboratory
AND EWARN
training focusing on surveillance,
response and EWARN covers more areas
further promote the disease Early Warning Alert
1.1. Clinical and laboratory capacity-building
and Response Network (EWARN).
1.1.1.
Training of health
workersencouraging and provides
 Outbreak
response:
response
Specific lessons
topics on for
basicoptimal
clinical and
lab practices,
A ten-day integrated clinical and laboratory-training
standard case definitions and epidemiology of
course
was conducted at Yei Health Workers
epidemic-prone
andworkers
vaccine- preventable diseases,
 AFP surveillance training reaches to front-line
health
Training School, Equatoria. WHO facilitated this
partnership in EWARN and roles and
training, with support from the CHD/Yei, NPA-Yei
responsibilities of stakeholders in disease outbreak
Health Workers Training School and AAH. A total
control were discussed. The training included group
of 8 clinical and laboratory health workers selected
discussions, practical sessions, and presentation of
from PHCCs/hospitals run by SMC, NPA, AAH
group work.
and SRRA were enrolled. Three health coordinators
from SRRA, AAH and WHO Polio program also
Feedback demonstrated that the participants valued
attended the training.
this in-service training as very important and
relevant. Case examples from respective (training)
A similar ten-days training for 8 clinical and
areas were very much appreciated. According to a
laboratory health workers was conducted in Yirol,
participant observation “ the training will help to
Lakes Region. WHO, in collaboration with SRRA
improve practices in outbreak investigation and
CHD/Yirol and DOR facilitated this training.
control in the area”.
Participants were drawn from health facilities and
community-based PHCs and Emergency health
Finally, participants presented follow-up activity
programs of CCM, CRS, DOR, ICRC and SRRA.
plans focusing on strengthening EWARN.
The training aims at strengthening local capacity to
immediately report, investigate and effectively
respond to suspected outbreaks of diseases and
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1.2. EWARN Advocacy
Workshops
and
Surveillance
1.2.1. Community-level workshops continue
WHO, in collaboration with SRRA/Yei and
CHD/SRRA, organized a two-day community-level
sensitization/orientation workshop on EWARN and
disease outbreaks surveillance and response in Yei,
Eastern Equatoria. There were a total of 35
participants from five payams, composed of
teachers, opinion leaders, church and women
groups and local counterparts.
The training focused on epidemic surveillance,
investigation, response and the role of the
community in reporting of suspected/rumors of
outbreaks. Simplified community-level case
definitions on selected diseases/syndromes and
steps to assist the community in reporting of
outbreak were discussed. Guidelines were
distributed to those who could read English.
1.2.2.
NGOs
consultation
to
strengthen
partnership
A one-day follow-up consultation with NGOs on
strengthening outbreak surveillance and EWARN
was conducted in Akobo, Upper Nile. Discussions
were held on the EWARN, and the roles of health
and other development and relief NGOs in outbreak
surveillance and response. MSF-B, VSF-B, PRDA,
RDC and WHO participated.
Similarly, a one-day consultative meeting was held
with 8 NGOs and counterparts in Yei, Eastern
Equatoria. AAH, IAS, Malteser, NPA, SMC,
CHD/Yei, SRRA/Yei and WHO attended. The
participants were briefed on EWARN. Participants
pledged to strengthen partnership among NGOs,
communities and WHO.
1.2.3. Consultation on measles/TT campaign
WHO actively participated in UNICEF/OLS
coordinated
consultations,
planning,
and
community training activities held at Billing,
Yambio and Yei.
The measles coordinator
(UNICEF) and the polio coordinator (WHO) also
traveled as a team through Yambio, Maridi and
Mundri.
1.3. Consultation on Roll-Back Malaria (RBM)
A total of 21 NGOs operating in southern Sudan
participated in a one-day consultation. Loki. The
meeting was organized by WHO EMRO (Drs
Guido Sabatinelli and Atta Hoda) WHO HQ (Dr
Claudio Baltrimello) and WHO s Sudan. Visits
were also made to key partners in Nairobi and Loki
by the team. The consultations identified partners’
activities, challenges and opportunities for the
malaria control effort in southern Sudan.
Partner organizations are ready to actively
participate in RBM efforts
Health service data from southern Sudan show that
malaria is among the leading causes of health
service visits, and seasonal outbreaks occur in
different areas. The four key interventions that can
be effective in the complex emergencies prevailing
in southern Sudan were discussed in detail. These
main interventions are Early detection and adequate
treatment, Presumptive intermittent treatment in
pregnancy (PIT), Use of insecticide treated
materials (ITM), surveillance and epidemic
preparedness and response. Consensus was reached
on roles of WHO, NGOs and local partners in
enhancing RBM.
1.4. IMCI Training Continues
WHO, in collaboration with CCM and MSF-B,
conducted an eight-day training on Integrated
Management of Childhood Illnesses (IMCI) at
Akobo, Upper Nile. This included the training of 2
supervisors/facilitators, followed by the training of
10 CHWs. The training focused on improving skills
on “ Essential Community Child Health Care”. The
training will contribute to reduce the burden of
excess illness and death from common childhood
illnesses (among under-5 children).
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2.0 POLIO ERADICATION
2.1 Wild P1 Poliovirus Isolated from Ruweng
County
available, the nurse had to use a plastic bag that she
found in the vicinity.
2.1.1. Background
2.1.3. Patient Information
The patient is a 2 year old female originally from Akotweng village in Kueldit Payam, Ruweng County,
Western Upper Nile. At the time of onset of paralysis,
the family was living in the toich (wetlands) area
approximately 2-3 hours walk from Padit village
(location of airstrip). The family had moved to the toich
in January 2001 for the dry season (January-May). This
toich area is highly populated during the dry season.
During an upcoming mission to Ruweng County, more
information will be collected concerning the child’s
movement during the months preceding and following
the onset of paralysis.
On Monday, 23 July 2001, the WHO-south Sudan
office received intra-typic differentiation (ITD)
results from the National Institute of Virology
(NIV) laboratory in South Africa on a pending
Acute Flaccid Paralysis (AFP) case. The results,
based upon analysis of a single stool specimen,
confirmed the isolation of a P1 wild poliovirus.
This is the first P1 wild poliovirus that has been
isolated from southern Sudan since the start of the
polio eradication programme in southern Sudan in
1998. P3 wild poliovirus was isolated from stool
specimens from one AFP case from the Bahr el
Ghazal region of southern Sudan in 1999. In 2000,
P1 wild poliovirus was isolated from stool
specimens from 4 AFP cases in north Sudan,
however, it is too early to determine if the recently
isolated P1 from Ruweng County is related to the
viruses isolated from these 4 cases. Geno-typing
of the virus is underway to determine if a
relationship exists.
2.1.2. Case Investigation
The case presented to the medical assistant for Padit,
Ruweng County, who then reported the case to the
MedAir mobile team on 14/05/01. MedAir was to be
on ground in Ruweng County for a total of 6 days in
May 2001 for a seeds and tools distribution—the case
was reported on the day before MedAir was to leave the
area due to insecurity. MedAir immediately contacted
the WHO sub-Office in Lokichokkio, Kenya, to report
that an AFP case had been referred to their team on
ground and that they would require icepacks and a
vaccine carrier in order to collect stool specimens, as
well as a case investigation form. The WHO
Surveillance Medical Officer had just previously
briefed (MedAir in Loki.) The following day,
15/05/01, the cold chain items arrived on a chartered
flight, so MedAir proceeded with the investigation. The
investigation and stool collection was done by a
nurse/mid-wife that was on her first mission into
southern Sudan—this was also her first experience with
investigating a suspected polio case. As it was
necessary for the MedAir team to evacuate the area that
same day, it was only possible to collect one stool
specimen instead of the standard 2 specimens 24 hours
apart. Also, as there was not a stool collection kit
The onset of paralysis date is set at 24/04/01 and
reportedly similar paralysis cases were also existent in
the village/toich of onset. Fever at onset of paralysis
was reported. Paralysis was observed in both the left
and right legs. Although the parents originally reported
that the child had been immunized, upon further
investigation, it was determined that the child had never
received any doses of OPV.
2.1.4. Ruweng County
Ruweng County is located on the northern part of the
Kir/Bahr-El-Arab River. The county is bordered to the
south by Liech (Unity) and Phou States, to the north by
the Nuba Mountains and to the east by Shilluk Kingdom
(Fashoda). The northeast, west and northwest of
Ruweng County are Government of Sudan (GOS) areas.
The community living in the county is Dinka.
Due to ongoing insecurity, Ruweng is the only county
accessible to OLS where WHO has been unable to
establish a polio eradication infrastructure—i.e. there is
no surveillance staffing on ground. One round of NIDs
was conducted in 1999 and two rounds in 2000—due to
large population movement and unreliable population
data, it is difficult to determine exactly how successful
these campaigns were. However, in 2000, according to
the estimated target population, the NIDs coverage was
reported as 111% and 235% for 1st and 2nd rounds
respectively. No immunization has been done in 2001
due to inaccessibility.
Ruweng County has five payams (districts), with an
estimated total population of 64,000 (therefore, an under
5 years population of approximately 12,800).
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There is a lot of population movement in the county
during the dry season due to a shortage of water. Most
people move to the Padit area, which is a place where
they can get fish, water and grazing land for cattle. The
movement to Padit starts in January each year. During
the rainy season, people return to their villages for
cultivation. It is suspected that the family of the
positive case has moved back home by now.
2.1.5.
Plan of Action
A more thorough epidemiological investigation is
immediately required. The primary objectives of the
investigation are to 1) know where the virus has been
circulating without detection for at least 10 months
(particularly if this is the same strain that was the last
isolate from all of Sudan in July 2000 in White Nile
State), and 2) to assess which areas may be presently
infected, and 3) which areas to target in a mopping up
response. This will be accomplished through:
1. Thorough analysis and review of existing AFP
surveillance data, especially in states/areas in and
around Upper Nile (both in OLS and GOS areas).
Focusing on quality of surveillance, silent or gap areas,
areas with clustering of AFP or clinical polio cases.
2. Getting the word out quickly far and wide to
enhance surveillance activities, especially immediate
case reporting, active surveillance, and immediate
investigation of any cases detected.
3. Thorough investigation of the index case, especially
regarding travel and contact history before and after
onset of paralysis and collection of stool.
4. Focusing investigation and surveillance efforts on
areas, particularly relatively densely populated towns or
large villages on travel routes, where the case may have
been and villages located around the village and county
of paralysis onset.
5. Focusing attention to areas that have not been
accessed by immunization teams for many months.
Eight WHO polio staff are presently on ground in
Ruweng County. They will split into 3 teams on
ground and move in different directions on foot. In
addition to the epidemiological investigation detail
above, in all locations the staff will be mobilizing the
communities and developing microplans in preparation
for a 3-round polio immunization campaign for all
children under 5 years of age.
2.2.6 Implications on polio eradication in south Sudan
This case highlights again the importance of surveillance
in ensuring that south Sudan is free from Polio.
The area is one where neither the north nor the south has
full access. The instability in Sudan is currently the most
significant factor affecting eradication activities.
GOOD SURVEILLANCE AND
REACHING ALL CHILDREN IS
CRITICAL FOR POLIO ERADICATION
2.2 Martin Odera recognized as a Polio
Eradication Hero
On 22 October 2000, Mr. Mark Odera from Parajok,
Torit County had breakfast with his family of 2 wives
and 6 children and proceeded to the Payam Headquarters
to present second round SNIDs results to the payam
polio field assistant. That was the last time his family
and friends saw him alive. After submitting the results
at 10.00 am, Mark started walking back to the village
together with the local authority secretary. They heard
the sound of a high flying aircraft, and as they had no
time to run to the nearest bomb shelter, they both
jumped into the nearest foxhole and waited for the worst
to happen. The aircraft dropped 12 bombs in the payam
headquarters, injuring 3 people and killing one person.
Mark Odera was the one killed by a projectile hot
fragment from a bomb that fell a few meters from the
foxhole. His friend sustained serious head injury, and
has not fully recovered even to today.
Mr. Odera died while on duty as polio eradication
volunteer. Since the inception of the polio eradication
program in southern Sudan in 1988, Mr. Odera worked
as a volunteer supervisor. He was dedicated to his work
and performed his duties without reservation under
tough conflict situation and difficult terrain.
It was because of his courageous action and dedication
to duty that the CDC Foundation has recognized his
extraordinary contribution and sacrifice towards
achievement of polio eradication in southern Sudan. Mr.
Miriti Kiruga and Mr. Alfred Geri, Polio Focal Points
presented a certificate and honorarium to his widows for
Eastern Equatoria. May almighty God rest Mr. Odera’s
soul in peace.
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