WHO SOUTHERN SUDAN HEALTH UPDATE
September 2000
HIGHLIGHTS
 Surveillance project review takes place in Cairo
 Modified IMCI and Epidemiology training continues
 Small scale Tuberculosis control strategy adopted for s Sudan
 World Aids Day 2000 planned in Yambio for community sensitization
 Epidemic response to malaria in Bor, measles in Wudier and meningitis in
Akobo.
 Polio AFP surveillance gets a big boost by deployment of 155 Field assistants.
1.0
DISEASE SURVEILLANCE
1.1 Project review team satisfied with s Sudan
Surveillance
A major project review of the S Sudan Surveillance
program took place in Cairo. The review by WHO HQ,
EMRO and Sudan WHO staff was satisfied with the
progress achieved by the project. The second phase of the
project will consolidate the achievements and expand to
the government held areas of the south.
1.2
Capacity Building using modified IMCI
Further training of health workers on a modified Integrated
Management of Childhood Illnesses (IMCI) course, with
an emphasis on outbreak prone childhood illnesses,
continued in Upper Nile. This is a follow-up of the August
WHO/UNICEF/CCM/COSV and WHO/HQ collaborative
IMCI TOT at Adior, Bahr Ghazal. The training was
conducted at Nyal in two phases: a four-day training for
COSV health service supervisors/facilitators and a oneweek training of health workers. A total of 5 supervisors
who will also work as IMCI training facilitators and 13
health workers (12 from COSV-run health facilities and a
WHO field assistant) were enrolled. To foster
understanding and enhance skills, course work, video
shows, practical sessions and presentations were used.
Lessons from this training will also be incorporated in
earlier observations to further improve the quality of IMCI
training. WHO appreciates all those who have collaborated
in this effort and looks to further enhancing disease
surveillance and response.
1.3
Basic Epidemiology training continues
As part of the training activity of the three WHO public
Health Co-ordinators, one of the WHO staff continued to
provide technical backstop to NGOs, another participated
at an Emergency needs assessment mission, while the third
co-ordinator continued with field supervision of health
facilities. As per the schedule, WHO in-house training
with an emphasis on “ Infectious Diseases (IDs)
Epidemiology” continued in September 2000.
1.4
Laboratory support for surveillance
In view of the current malaria outbreaks in Bor, WHO
identified two NGOs; ACROSS and NCA for support with
binocular microscopes as well as training to improve case
management. Once assessments are finalised and
organisations provide official requests, binocular
microscopes will be handed over to local communities to
be used at the NGO health service facilities. WHO
encourages health organisations interested in providing
laboratory services and enhance outbreak investigation and
response to contact the WHO Loki office.
1.5
EWARN Strengthening by community
involvement
WHO held the second round of advocacy meetings with
local partners and community members in Twic county,
Turaliel and Aweng, in northern Bahr El Ghazal. Similar
advocacy meeting were held at Lankein and Udier in
Upper Nile. The discussion identified that malaria
outbreak is frequent and health services’ capacity to
respond to these outbreaks is limited. It was also identified
that there is a need for a community-level sensitization
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about common outbreaks in the area. WHO will continue
its dialogue with the health and education NGOs and local
counterparts on the ground. Similar advocacy discussions
were held with health workers and WHO field polio
assistants. Based on the identified needs, WHO will
conduct community awareness and EWARN strengthening
activities in these areas.
1.6
Utilising the AFP surveillance network
In September, training of AFP/Polio field supervisors and
assistants continued at Lankien and Nyal, in Upper Nile;
Boma and Mapel, in Bahr El Ghazal; and Tambura and
Maridi, in Equatoria. At these sessions, orientation on
enhancing EWARN through community alerting and
response was given for a total of 84 field staff and local
partners. As a result of this integration of AFP
Surveillance to EWARN, WHO is already receiving
outbreak alerts from the polio field staff.
1.7
Outbreak Verification and Response
1.7.1
Malaria at Paluer, Bor, Upper Nile
WHO received a report of a malaria outbreak from
UNICEF and ACROSS on 01/09/00. Bor, like most of
Upper Nile, is known as a highly malaria endemic area
with repeated outbreaks. Following the report, WHO with
ACROSS did a preliminary investigation to assess the
magnitude and identify urgent response needs. It was
identified that eight health facilities in the county have
reported increasing cases starting mid June 2000 which
more than doubled by August. Those severely affected
were children, with more than 95% of all admissions and
deaths occurring among this group. WHO through
UNICEF support provided emergency drugs and supplies.
Radio monitoring, field-visits, and service data and
situation reports were used to track the outbreak. As of
September 2000, the number of cases remains high but
trends in mortality rate among those admitted to health
facilities show a marked decrease (from 1.4% in August
2000 to 0.85% in September). Increase in cases is
attributed to an improving health seeking behaviour
(scaled up health messages and services), continued
transmission (season), and improved reporting from
PHCUs. The marked decrease in death rate is attributed to
improved case management and an early health-seeking
behaviour. A follow-up visit indicated that the outbreak is
fully contained.
1.7.2
Measles at Wudier, Latjur, Upper Nile
On 05/09/00, WHO received an outbreak call from its
Polio/AFP field staff. The cases reported fitted a case
definition of measles. First cases were detected by the
PHCU on the 4th week of July (22/08/00). A preliminary
investigation was done on the date of report. It was
established that this was a measles outbreak with high risk
of further spread to vulnerable host community children in
other villages and among internally displaced population
villages. Immediate needs were identified and WHO
provided technical support on immediate interventions,
including health education, management of complicated
cases and vit A supplementation. Through UNICEF
support, on 10/09/00, WHO deployed a Public Health Coordinator with drugs, vaccines, vit A and supplies.
The WHO Public Health Co-odrinator deployed two local
teams of six PHCU health workers. The teams, lead by
WHO Medical Doctor investigated and managed measles
cases, sensitised communities through health education
and carried out immunisation in adjacent and distant
villages. To enhance outbreak investigation skills of
PHCU health workers, along with promoting effective
management of cases, the MD investigated 20 suspected
cases; of which 19 were proved measles. A total of 856
cases were registered. A total of 30 deaths were reported
(case fatality rate of 3.5%), out of whom 15, i.e. half of all
deaths, are registered. High level of malnutrition believed
to have contributed to severe complications. More lives,
however, were saved as a result of prompt intervention,
including intensive health education, improved health
seeking, and early and effective management of common
and treatable complications. Most of the villages were
crowded. In one location alone, it was reported that there
were 5,276 IDPs and 4,684 returnees. Based on local
population estimates, a total of 5,459 children (6 months to
12 years) from 11 villages, including the three outbreak
villages, were targeted for vaccination and vit A
supplementation. A total of 4,464(84.6% of the target)
were vaccinated; and given vit A supplementation.
This outbreak investigation and response is unique and an
encouraging experience. This is particularly so considering
the fact that there is no health NGO working in the area.
These achievements were by volunteer health workers of a
PHCU supported by the local counterpart. An important
experience from this epidemic was the daily follow-up and
technical backstop through radio, which was very useful in
prompt and effective response. WHO’s proactive
involvement of local staff in investigation, response, and
monitoring was invaluable to build sustainable local
capacity and ensure prompt response.
1.7.3
Rumours of Meningitis at Bunagok; Yerol;
Bahr El Ghazal…cerebral malaria
WHO received rumours of suspected meningitis cases at
Yirol in Bahr Ghazal from ICRC on 09/09/00. Based on
this report, WHO did a follow-up investigation and
verified that there were three cases of reported cerebral
malaria with one reported death at a place called Bangok.
After a follow-up for two weeks after the first reported
cases, no other cases were reported. Conclusion: No
meningitis outbreak.
1.7.4
Meningitis at Akobo; Beih; Upper Nile
On 18/09/00, MSF-Beligium reported to WHO that there
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Figure 1.6.6 Meningitis at Akobo, Beih, Upper Nile;
September 2000
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7
6
5
Number
were three cases of meningitis on week 36, which
increased to six cases on week 36. The disease is reported
to manifest with headache, high fever, and neck stiffness.
The number of cases increased to seven on week 38 and
declined to one case on week 39. A total of 18 cases were
reported (See Figure 1.6.6). Most of these cases were
children, and there was one death. MSF-B had enough
stocks of drugs and supplies and managed all the reported
cases at its PHCC at Akobo. At present, there are no more
cases reported in the area.
Number of Cases
Number of Deaths
4
3
2
1.7.5
Febrile illness- Influenza- in, Maridi;Western
Equatoria
WHO received a report of a febrile outbreak from Maridi
County Health Department on 22/09/00 in the village of
Makke. Onset was beginning of week 11-17/09/00.
Presenting symptoms were mild fever, cough, neck pain,
and malaise. The number of reported cases is not
established. However, it was reported that there are no
deaths. A County Health Department investigation team,
with technical support from WHO, visited the area and
confirmed that this was a self-limiting flue-like outbreak.
The working diagnosis was influenza. Health education on
bed rest and fluid and diet was provided. There are no
reported deaths. WHO maintains very vigorous
surveillance of unexplained fevers in Western Equatoria
because of the high risk of haemorrhagic fevers from
Central African States.
1.7.6
Measles at Kurmouth, Latjor; Upper Nile
An outbreak with fever, skin rash, headache, with reported
childhood deaths, was reported to WHO on 18/09/00 from
RASS. The outbreak is reported to start in the second week
of August at Dualdap village. The descriptions suggest that
it is a measles outbreak. Consultations with RASS revealed
that the area was not cleared for flight. Further discussions
with OLS show that the area is not cleared for flight.
Difficult communication and absence of health NGO are
obstacles to prompt response. WHO has received a special
security clearance to respond to this outbreak.
1.7.7
Measles at Mading, Latjor; Upper Nile
WHO received a report, on 22/09/00, of an outbreak of
fever, skin rash, and running nose and eye problem among
children. This report was from WHO/Polio Surveillance
staff. Following the report, radio contacts were made and
technical support was provided on prevention of further
spread, management of cases, and vit A supplementation.
On 26/09/00, WHO through UNICEF support mobilised
drugs, supplies and vit A. A total of 258 cases and 10
deaths were reported (case fatality of 3.8%). WHO
organised and co-ordinated three vaccination teams of 12
people to respond to the outbreak. The teams were
orientated on EWARN, outbreak alerting, clinical
diagnosis (case definitions), management of measles
complications, safe immunization, and reporting.
Following the orientation, the teams were deployed,
vaccinated and provided vit A capsules to 3,136 (90.6% of
targeted) children in 10 villages, including three outbreak
villages and three IDP settlement villages. Major
challenges of health care in Mading are lack of essential
1
0
Week 36
Source: MSF-B
Week 38
Week 37
Week 39
Report Weeks
drugs and supplies and absence of immunization programs
as there is no NGO in the area.
1.7.8
Rumours of Meningitis at Mading, Latjor;
Upper Nile
On 22/09/00 WHO received a report of two childhood
deaths from a disease with fever and neck stiffness at
Mading. It was rumoured that these cases are meningitis. A
retrospective investigation and a one-week follow-up after
these deaths occurred documented that no other cases were
reported in the area. Moreover, WHO field investigation
verified that the two deaths were from tetanus following
injuries.
1.8
Supervisory Support
In August, WHO provided supervisory support to health
facilities in Twic county in northern Bahar El Ghazal, in
Bor in Upper Nile, Maridi in Equatoria. A total of six
health facilities were visited and discussions were held
with health workers. Identified common and critical
constraints to improve access and quality of basic health
care included inadequate drugs and supplies, little
supervisory support, and poor infrastructure and
communication. Moreover, lack of in-service training,
reference materials, and shortage of personnel were shared
challenges. The team informed the health workers on
outbreaks and the need for reporting data.
1.9
Internal program reviews
From 11-13/09/00, WHO held an in-house process
monitoring exercise at Lokichoggio. A meeting with
WHO-Khartoum, which discussed on the north-south
Sudan activities, followed this review. Based on the
Lokichoggio exercise and feedback from HQ, WHO
developed a WHO information profile, reviewed a draft
and produced a Quarterly Epidemiological Bulletin. WHO
also finalised its quarterly activities performance and
activities plan reports, and drafted an Outbreak specimen
collection and referral format. In addition, WHO did an
IMCI follow-up session with HQ, UNICEF, and CCM in
Nairobi. The reviews provided invaluable lessons for
improving our activities.
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1.10
Program/Activity Development
2.0 POLIO ERADICATION
1.10.1 STI/HIV/AIDS activities
HIV/AIDS is a problem least addressed in southern Sudan.
Despite the fact that there are few data on prevalence of
HIV infection, low level of awareness and increasing
concern among some informed members of communities,
there is no organized and well- defined HIV/AIDS
intervention so far. Worried by this program gap and
aware of the indispensable role of such interventions to
curb the epidemic, WHO developed a proposal aimed at
program advocacy, improving AIDS awareness, and
reducing risky behavior. The proposal has two phases: for
the “World AIDS Day", and based on this advocacy and
consensus building, a one-year community-based and
focused AIDS intervention. This project is shared with
UNICEF, and has become a joint initiative. Moreover,
UNICEF is ready to play an active role in this invaluable
effort. Partial funding is expected from EMRO and
UNICEF.
2.1 Training county supervisors and Field Assistants
Training for County Supervisors and Field Assistants has
been completed in all counties (states) and payams
(districts) accessible to OLS. The Field Assistants are
distributed as shown below. These Field Assistants are
responsible for the implementation of all polio eradication
activities at the district level, including campaigns, AFP
surveillance and social mobilisation.
1.10.2 TB Control and Leprosy support
TB remains a major public health problem that is receiving
no attention in s Sudan. WHO s Sudan in collaboration
with Headquarters is developing small-scale TB treatment
projects using Directly Observed Treatment Short Course
(DOTS). A project with possible funding from Norwegian
government is under development. Support with drugs is
also being provided to Leprosy patients by WHO HQ.
2.3 AFP Surveillance
Although 27 cases of Acute Flaccid Paralysis (AFP) from
2000 have been identified by end September, still no wild
virus has been isolated (5 cases still pending laboratory
analysis). However, we are still faced with the problem of
identifying and investigating AFP cases within 14 days
from the onset of paralysis. Only 6 out of the 27 cases
(22%) can be considered adequate. On a positive note, we
are beginning to see the results of placing field assistants
in each payam/district with the identification of cases from
payams that were previously silent.
1.11
Emergency drugs and supplies
WHO developed a proposal for improving stocks of
emergency drugs and supplies for southern Sudan. This
proposal was developed based on lessons learnt so far in
outbreak response, assessment of the health status and
facilities, and identified urgent needs for basic services.
Moreover, major contributing factors for deterioration of
basic health care and subsequently outbreaks were
considered. The draft proposal is shared with WHO/HQ,
EMRO, WHO/Sudan and an NGO with an interest to
support health needs in African countries for possible
support.
Active AFP Surveillance Reporting sites southern Sudan 2000
2.2 SubNIDS
The campaigns were implemented as planned from 16-22
September in Tambura, Yambio, Juba, Yei, Kajo Keji,
Torit and Kapoeta counties. Only preliminary results are
available at this point from Yambio County where the
number of children immunized in the targeted payams
exceeded all previous campaigns in the county. Detailed
results of the first round in these counties will be available
in the October update.
IMPORTANT EVENTS
23rd - 27th sNIDs 1st round
B/Ghazal
20th-24th 2nd round sNIDs
6-10th Nov 1st round Upper Nile
4-8th December- 2nd round sNIDs
2- 4th December Polio partners
evaluation s Sudan
14 - 15TH December - North South
NID gap areas Coordination
meeting- Fairview Nairobi.
UPPER NILE
BAHR EL GHAZAL
WORLD AIDS DAY 2000
LAKES
JONGLEI
1ST DECEMBER 2000
W. EQUATORIA
E. EQUATORIA
YAMBIO
KEY
Location of each field assistant who is responsible for active
surveillance in his/her district. All districts under OLS have
trained field assistants in place.
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