Southern Sudan. Health Update July Aug lobal Alliance for Vaccine and Immunisation. Strengthening (GAVI HSS) Proposal for Southern

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1 Southern Sudan Health Update July Aug 2008 Contents Health System Development Nursing & Allied Health Primary Health Care Emergency Humanitarian Action 1 & 2 EARN Update 5 Malaria Update HIV/AIDS Programme 6 EPI Update 7 Neglected ropical Diseases orld Health Organization Southern Sudan Office UN OCHA Compound Juba, Southern Sudan Phone: Fax: G Health System Strengthening lobal Alliance for Vaccine and Immunisation Health System Strengthening (GAVI HSS) Proposal for Southern Sudan It is to be recalled that an application for the Global Alliance for Vaccine and Immunisation (GAVI) Health System Strengthening (HSS) in Southern Sudan was submitted to GAVI on March 7, he application was approved subject to clarification of some points. he drafting committee and the technical working group reviewed the document to address the points raised by the GAVI/ IRC and updated the proposal. he review included a teleconference with HO colleagues in EMRO and HO Country Office for Pakistan on August 6, 2008 and a Health Systems Coordinating Committee (HSCC) HSCC meeting to review GAVI HSS revised proposal meeting on August 12, he document was formally endorsed by HSCC and resubmitted by the Ministry of Health to the GAVI secretariat. Support to the MoH, GoSS / Budget Sector orking Group Dr Olivia Lomoro (right) D.G of Research, Planning & Health System Development, with other participants HO was fully engaged in the process of the preparation of the MoH 2009 budget for Health and Nutrition. As the co-chair of the Budget Sector orking group, HO summarized and collated the donor/un projects for the budget and supported the Ministry in the presentation of the draft budget to the Ministry of Finance on August 25, he budget has since been endorsed by the Government. MoH Public Health Library HO is supporting the Ministry of Health to establish a Central Public Health Library. A list of HO publications, text books and other reference materials has been compiled and shared with the MoH for their inputs, with the aim of procuring the same for the Ministry. Human Resources for Health HO co-facilitated two workshops on Human Resource for Health (HRH) held from July 3 to 6, In the first workshop on Human Resource Information System (HRIS), draft data collection tools and procedures for HRIS were presented and discussed. he recommendations and inputs of the participants were incorporated into the draft documents. he second workshop was on the strengthening/restructuring of the Health Personnel Council of Southern Sudan. After lively and constructive discussions, it was Phone: Fax: Page 1

2 Health System Development agreed that the council would be renamed Health Professional Council (HPC) of Southern Sudan and it will be an umbrella council for all health professionals and middle cadre personnel. he different health professionals/personnel will be supported to establish their respective councils and regulate their own professions, under the guidance and support of the Health Professional Council. he HPC will have a consultative linkage with the Sudan Medical Council. HO participated in a stakeholder meeting to present a draft work plan for Japan International Cooperation Agency (JICA) support on Human Resources for Health to the MoH. After a brief discussion the meeting endorsed the draft strategies and work plan. Essential Medicines and Pharmaceutical Policy (EMP) D raft Pharmacy and Poisons Bill for Southern Sudan, 2008 HO provided technical and financial support to the Ministry of Health, GoSS to draft a Pharmacy and Poisons Bill for South ern Sudan a nd r egulations/statutory instruments and conduct a stakeholder workshop on the document. Inputs from the workshop participants and other MoH directorates were incorporated into the document. he final draft documents have been sent for final review by a legal expert on pharmaceutical laws, contracted by HO. he Ministry will then take the necessary follow up for its endorsement, enactment by the Southern Sudan Legislative Assembly and publication, as necessary. Support to Pharmaceutical Regulatory Activities in Southern Sudan Rapid Inspection Activities in Juba and Its Environs As a continuation of its technical and financial support for pharmaceutical regulation in Southern Sudan, HO supported the Directorate of Pharmaceutical Services, GoSS to organize and conduct rapid inspection and clean up of Pharmaceutical trade outlets and clinics in Juba and its environs. he exercise, which was conducted in collaboration with the Pharmaceutical Society of Southern Sudan and the State Ministry of Health of Central Equatoria State, included inspection of formal and informal trade outlets - pharmacies, drug shops and clinics, as well as general market places. In the process various corrective actions were taken, including the following; 12 facilities were closed for operating clinical and/or laboratory service activities and, selling medicines, without the appropriate licences and qualified personnel. A sizable quantity of assorted medicines of dubious identity and quality was seized from illegal trade outlets and hawkers and destroyed. A Juba television crew filmed the inspection exercise in parts of the city and this was aired, with additional public education messages. he inventory of the legal trade outlets and pharmacy personnel of Central Equatoria was updated. Rapid Inspection Activities in orit and Bor and their respective environs Following the successful implementation of the pharmaceutical inspection and clean up exercise in Juba and its environs, the Ministry of Health, GoSS, in collaboration with the Pharmaceutical Society of Southern Sudan and the State directorates for Eastern Equatoria and Jonglei are conducting similar activities in orit, Eastern Equatoria and Bor, Jonglei, and their respective environs. HO Pharmaceutical Store for Emergency Supplies It is to be recalled that HO rehabilitated a section of the Central Medical Stores/GoSS, and converted it to a HO Store for emergency medical kits and laboratory supplies. Steel shelves, furniture and I equipment have now been procured for the store and a programme assistant for Medicines and Pharmaceutical Policy (EMP) has joined the HO team to be responsible for the management of the store. Assessment of the pharmaceutical supply management system in Southern Sudan A consultant has been recruited to conduct an assessment of the pharmaceutical supply management system in Southern Sudan and develop a plan of action to improve the system. he activity will include on-the-job training of the staff of the central medical stores. Donation of I Equipment and 12 Motorcycles HO donated five sets of Information echnology (I) equipment to the Ministry of Health, GoSS, for use by five State directorates of pharmaceutical services. he equipment have been distributed to the following States Lakes, Eastern Equatoria, Central Equatoria, Northern Bahr El Ghazal and Jonglei. welve motorcycles have been procured to support pharmaceutical inspection activities. Each State of the 10 States will receive one motorcycle, while two will be used by the Directorate of Pharmaceutical Services, GoSS. Phone: Fax: Page 2

3 Nursing and Allied Health A ssessment of Nursing Institute in Kajo Keji Director General of Nursing/Midwifery from MoH/GoSS and the HO s technical officer for nursing travelled to Kajo Keji in order to visit and assess a newly e s t a b l i s h e d Medical raining Institute, which started its operation in May 2008 with 50 students in two programs of nursing and c o m m u n i t y m i d w i f e r y. According to the assessment conducted, the school, which is also supported by IMC, has the potential for becoming one of the best centres for training nurses and midwives in Southern Sudan. herefore, the necessity for supporting the school was fully recognized. Following the assessment, technical rec- ommendations for the improvement of school and its training programs, especially on clinical training of students, were provided to the management of the school. Since there were no computers available in the school, HO provided four desktop computers for students to use in the l i b r a r y. HO rec e n t l y e q u i p p ed the library o f t h e school with midwifery and nursing references and textbooks. Midwifery students and teachers in Kajo Keji Medical raining Institute Furthermore, in order to establish a skills lab, which is a necessary component of nurse/midwife training centres, a full set of anatomical models, simulators and charts were provided to the training centre. Other Updates HO has officially requested MoH/GoSS for the nomination of eight nurses for fellowships and one-year midwifery course in Kenya. HO has provided office furniture to the General Directorate of Nursing, computers were provided earlier. ith regard to construction and establishment of Rumbek Nursing Institute, HO has signed a contract with an Italian NGO CISP for the construction of the building. According to the agreement, the construction was meant to be finished by 15th December However, recent communication from CISP states that they might not be able to finish the construction before May Also three candidates for teaching in the institute have been identified and their CVs have been shared with the MoH/GoSS for recruitment. Furthermore, the required teaching aids and furniture for library, skills lab and classrooms have been procured. Primary Health Care raining orkshop he Primary Health Care (PHC) programme officer with a team from MoH/GoSS participated in a 5 day training workshop from August 18 22, 2008 in anzania. his workshop was on integrating quality of care in essential nutrition actions: performance improvement framework approach. he objectives were: 1. o review with participants vulnerability and burden of malnutrition in African countries. 2. o update participants on the Essential Nutrition Actions (ENA) package (designed to prevent and combat malnutrition in communities) and its implementation. Southern Sudan team discussing their action plan during the workshop 3. o coach participants in application of the performance improvement framework as a tool for enhancing the quality of Essential Nutrition Actions (ENA) approach. orld Breastfeeding Day he orld Health Organization (HO) joined the MoH and UNI- Dr Robert giving out a speech CEF in celebrating the orld Breastfeeding eek from August 1 7, his year s celebrations were carried out in all 10 States of Southern Sudan. he PHC programme officer represented HO Southern Sudan office and delivered a speech on behalf of office during the celebration on 6th of August, in Lainya County Central Equatoria State. Phone: Fax: Page 3

4 Emergency EARN Humanitarian Update Action General Situation HO continues to support the Ministry of Health in the area of Emergency and Humanitarian Action. In the months of July and August, most of efforts were directed towards the response to the Internally Displaced Population (IDPs) following the Abyei crisis, response to various diseases epidemics such as Malaria, cholera/ acute watery Diarrhea (AD), measles and suspected Acute Jaundice syndrome. According to the hazard profile in Southern Sudan, the month of July and August are noted to have floods, upsurge of malaria, and AD/ Cholera. Health Sector Coordination HO, health sector lead along side UNICEF sector lead for Nutrition took the lead in developing the UN and Partners ork plan for he health and Nutrition sector has three key objectives which are: to contribute towards better access for vulnerable populations to quality health care services that include a basic health package, nutrition and emergency referral services; to strengthen local capacity to predict, prepare for, respond to, mitigate and manage health and nutri- tion risks that include communicable diseases and seasonal emergencies, with measures such as outbreak control and nutrition surveillance and to contribute to a reduction in maternal and child morbidity and mortality focusing on Safe motherhood intervention. Currently UN and Partners are working toward developing the project sheets for the consolidation of the UN and Partners work plan. he general situation in Abyei has been reported to be calm. In the Month of July, HO received a funding from the Central Emergency Rapid Funds (CERF) to support the emergency responses in areas of Agok and uralei, the most affected areas due to the crisis. hese funds will be used in the provision of an essential package of health services, to IDP s and host populations, including routine immunization, emergency measles immunization campaign, reproductive health, and nutrition; Control of outbreak of communicable diseases; Support to Ministry of Health (MOH), State and County health authorities in coordinating the emergency health response. As the emergency situation is currently phasing out, recovery activities have Abyei Crisis Response been initiated to ensure that IDPs and host communities receive basic health care services. HO is currently consulting with CCM and NGO supporting the uralei hospital, which is one of the main referral hospital providing secondary health care services including emergency obstetrics care and surgical interventions. Nevertheless, capacity building for health workers on malaria treatment policy and Integrated Diseases Surveillance and Response (IDSR) is planned to be conducted in the course of September, Moreover, HO has been participating in the interagency Emergency Preparedness & Response forum at Juba level- to dialogue and shape the recovery phase in Agok and uralei. D Flood Situation ays of torrential rains in last days of July 2008 has brought one of the worst Floods in Peth NBEG State floods in years to the Northern Bahr El Ghazal (NBGS) State, mostly Aweil centre, Aweil East, Aweil est and Aweil North counties. Emergency health conditions continue to be a serious challenge with health service coverage in the flood affected areas being very low before the onset of the flood. Very few health facilities are functioning in the flood affected areas and many others don't have supplies. Similar situation has been reported from Northern part of arrap State. Overview of Hazards in Southern Sudan (Southern Sudan Interagency Emergency Preparedness and Response) Hazard Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Floods Meningitis AD/Cholera, Measles Malaria Inter-Clan/Ethnic conflicts Insecurity LRA attacks* Peak *LRA attacks are determined by political dynamics as they are not limited to seasonal factors Drought is also a major hazard that needs to be planned for in South Sudan. Phone: Fax: Page 4

5 Early arning and Response Network EARN Update (EARN) A Cholera total of four (4) confirmed cholera out breaks were reported in this reporting period: {Malakal, Melut, Nasir (upper Nile state); Aweil north, Aweil Centre and Aweil South (northern Behr el Ghazal state)}. he outbreaks in Upper Nile State were controlled within a few weeks but due to the ongoing floods that started from July 29, 2008, the outbreak in Northern Behr el Ghazal is yet to be contained despite the multi-agency interventions. Aweil town is the worst hit by this outbreak recording cumulative total cases of 1714 and 5 deaths as of August 31, HO led all the initial assessments and outbreak investigation. In addition, HO provided one emergency health kit, one diarrheal kit and technical support through an epidemiologist stationed in Aweil to date. It is worth noting that the out breaks in Juba and orit (184 cases with 4 deaths) were controlled in early July (during this reporting period). M Measles easles outbreak was reported in Udier and Chotbora in Longichuk County and Maban County in Upper Nile State. hese two counties were partly covered by the mass measles campaign of 2006/2007. Because of flooding, accessibility has remained a big challenge to a timely response. MSF Holland conducted an assessment in Udier following the alert in week 32 that indicated a cumulative total of 168 cases with 9 deaths between July 14 to August 17, A multi-agency field team destined to undertake a thorough assessment and carrying along supplies for case management has been stuck in the Upper Nile State capital till Friday September 5, 2008 due to bad weather that has made land route impassable and the airstrip un landable. H Malaria eavy rains in the greater Behr el Ghazal States caused floods and subsequent upsurge of malaria cases. wo agencies (orld relief and MSF Holland) working in Unity State since 2007 reported a 600 fold increase in malaria consultations this July compared to the same period in HO conducted an assessment to verify the situation in Unity State. Another upsurge in malaria was observed in flooded areas of Northern el Bahr Ghazal (NeBGS) State. In response to these potential outbreak situations HO coordinated the shipment of 80,000 doses of ACs to both States (30,000 to Unity and 50,000 to NBeGS) and airlifted 30,000 LLINs to Northern el Bahr Ghazal. In order to monitor the evolution of the malaria situation, the Epidemic Preparedness and Response ask Force in Juba has recommended the inclusion of malaria as a weekly reportable disease. Disease condition GROSS <5 5 CASES DEAHS CASES DEAHS CASES DEAHS AD ABD Measles Meningitis AJS Cases and deaths by disease condition recorded in Southern Sudan between July and August 2008 Acute Jaundice Syndrome leven (11) cases tested positive for E hep E IgM antibodies by ELISA and another 2 were IgG positive from a total of 16 blood samples tested from patients in Magwi County in Eastern Equatoria State. hirty six (36) cases of acute jaundice syndrome have been reported over 6 consecutive weeks (wk 30-35) in Juba town in Central Equatoria State. Concern is being raised about the increasing trend in cases of acute jaundice syndrome, particularly in Eastern Equatoria in view of the ongoing outbreak of hepatitis E in the neighbouring Ugandan districts of Kitgum and Gulu. IDSR/Reporting he average number of Counties that are sending in regular weekly re- ports has improved from 25 in July to 35 in August. One epidemiologist has been recruited to replace the previous one who left last May to resume similar responsibilities in Myamar. He is stationed in au to cover both estern and Northern Behr El Ghazal States. Phone: Fax: Page 5

6 EARN Roll Back Update Malaria os on Malaria Case Management in arrap State R esponding to the request of MoH/GoSS on technical assistance for training on malaria case management, HO/RBM office in collaboration with national malaria control programme unit planned a raining of rainers (O) course for arap State. he training was conducted from July 28 31, 2008 in Kuajok town at omen s training Centre. A total of 23 participants from various partners (VI, GOAL, ADRA and NCA) and County Health Departments of the five Counties in arrap State attended this training course. his training activity was part of the rolling out the new malaria treatment policy for Southern Sudan. However, it was also part of the package, emergency preparedness and response plan activities developed for the flood affected States. he course was organized for the senior health w o r k e r s i n arap State, including doctors, medical assistants, nurses a n d p u b l i c health officers/general Medical Assistants. Participants during the training session he objective of the training was to pro- vide knowledge and skills on malaria case management by using Rapid Participant during the practical session of the training Diagnostic est (RD) and Artemisinin-based Combination herapy (AC) to the senior health workers as raining of rainers. Upsurge of Malaria Cases HO is fully engaged in responding to the upsurge of malaria cases in flood affected States including NBG, arap and Unity States. HO has provided supplementary antimalarial drugs (AS+AQ) and RDs to GOAL, ADRA and COSV to be able to manage the malaria cases at the outpatient departments (OPDs). HIV/AIDS Programme O os on SIs in Juba n July 14 19, 2008; raining of rainers (os) on syndromic management of sexually transmitted infections (SIs) was conducted in Juba under the GFR4 grants. he training was organized by the HIV/AIDS/SI Directorate at the ministry of health GoSS in collaboration with HO, 20 (twenty) participants attended the course from all the ten States of South Sudan. It was facilitated by two national consultants and gynecologist from Juba teaching hospital. One full day was dedicated for a group work to plan for scale-up of training on SI syndromic management. Participants were given the directives to come up with a concrete plan for cascading the SI training sites, how many staff to train per site, presumed costs of training and proposed time for training. Health sector HIV/AIDS plan HO supported the MoH HIV/AIDS SI directorate in the development of national implementation plan for the health sector Participants during the consultative workshop activities. he draft of the two years and five years implementation plan was discussed in a consultative workshop held on July 22 23, State level targets were set and the detailed narrative and costing exercise to be finalized in the coming months. IASC Guidelines new version of the Inter-Agency A Standing Committee s (IASC) Guideline on HIV/AIDS Interventions in Emergency Settings was field tested in South Sudan on August 25 27, 2008; in which HO actively participated the field testing process. During the field testing workshop in Juba, HO as health cluster lead made considerable contribution to the field testing of the IASC guideline, health related sections in particular. M os on SIs oh Central Equatoria State (CES) i n c o l l a b o r a t i o n w i t h H I V / A I D S / S I D i r e c t o r a t e o f MoH/GoSS & HO conducted a os workshop on SIs from Aug 11 15, healthcare workers (nurses, midwives, clinical officers and medical officers) from 5 primary health care centres of CES attended the course. Phone: Fax: Page 6

7 Expanded Program on Immunization (EPI) Update B etween July and August 2008, two AFP cases were confirmed as wild polio type 1 in Jonglei and Upper Nile States. Polio Cases Child suffering from type 1 wild polio virus he first case is a 9 month old male child from au payam of Ayod County in Jonglei State. he child developed fever on June 6, 2008 followed by weakness of both legs and arms on the June 9, He was taken to a private pharmacy in the neighbouring Leer County of Unity State where he was detected as an AFP case and information was relayed to polio field staff. Stool specimens were collected by polio field staff on June 19 21, 2008 from the child and three of his close contacts. he laboratory confirmed wild type 1 virus in one of the three healthy contacts. Genomic sequencing of the virus showed 98.1% similarity with the case from Confirmed Polio Cases of South Sudan year 2008* Name: Nhial Puot EPID: SUD-JON-AYO Date of onset: ild P1 isolated from one contact State Boundary County Boundary Anuak zone of Gambella in Ethiopia. he second child is from Nasir town of Latjor County in Upper Nile State. his is a 14 month old child with date of onset of illness on August 5, he child presented with right leg paralysis and specimens were collected by polio field staff on August 8 9, 2008 from the child and three of his contacts. ild SUD-UNL-LA Months old Male Date of onset 05/08/2008 Right leg paralysis Specimen collected on Aug 8 and 9 2 EPI and 2 NID doses of OPV Confirmed Polio Cases (1*) ype P1 polio type 1 was confirmed by the laboratory in South Africa on the September 3, A Supplementary Immunization Activities s per the recommendation of the 3rd meeting of the echnical Advisory Group for Horn of Africa, Southern Sudan conducted a Sub national Immunisation Days (SNIDs) from Aug 11-14, Following the confirmation of the case in Ayod, the SNIDs were expanded to cover the whole Unity, Upper Nile and Jonglei States and Kapoeta County in Eastern Equatoria State. However as expected, rainy season interfered with some of the activities in few Payams. hree States, namely Northern Bahr el Ghazaal, estern Bahr el Ghazaal and arrap States also conducted SNIDs from September 1 3, 2008 using t-opv as part of the response to the wild P3 isolation in est Darfur. Southern Sudan has conducted NIDs in March, May and June in he next NID is planned for mid- October and is to be synchronized with estern Ethiopia. AFP Surveillance raining R efresher AFP surveillance training for polio field staffs and health workers is currently on going in all ten States of Southern Sudan and is expected to be finished by end of September Phone: Fax: Page 7

8 Neglected ropical Diseases Human African rypanosomiasis (Sleeping Sickness) he HO Laboratory coordinator, Mr Duncan Ochieng, conducted two field visits to supervise the Human African rypanosomiasis (HA) activities in Lui Mundri East County estern Equatoria State. During the supervisory visit, data collection of HA was carried out and it was noted that there is a huge problem with staff attrition, this issue was raised to the MoH for intervention. HO has received 50 DFMO Kits for the treatment of 100 adult patients, 500 vials of Melarsoprol and 300 vials of Pentamidine to support the HA activities in Lui and Juba hospitals. During this visit, national staff were observed when per- forming routine activities, all the records were checked and on-job training was done. HO has continued to work together with all the partners in Sleeping sickness control and to actively involve MoH in all the HA activities. Supervisory visit to Juba eaching Hospital (JH) was also routinely made as part of HO support for the HA activities in the hospital. Relapse patient during admission Juba hospital is yet to comply with the new diagnostic algorithm and HO is supporting the hospital to introduce the diagnostic tests. HO has received most of the medical supplies, therefore JH 3 yr old relapse patient will be assisted in introducing and adopting the protocol in the coming months. he Kala Azar (KA) treatment and laboratory registers were standardized and presented to the MoH for their approval. he registers have been approved by the MoH and printing is in progress. Furthermore, Kala Azar report forms were also standardized and approved by the MoH for printing. hese registers and report forms will be adopted for use in all the KA diagnosis and treatment centres in Southern Sudan raining on Kala Azar awareness, diagnosis and treatment in Bentiu, Unity State has been planned and will be conducted in September Visceral Leishmaniasis (Kala Azar) HO has formally shifted the distribution of all the Kala Azar drugs & supplies to Juba and thus all the partners have been notified. So far 3500 vials of Glucantime and 48 dipstick test kits have been distributed. Phone: Fax: Page 8