1 South Sudan Crisis January 10,2014 Issue # 2 South Sudan Crisis The South Sudan Health Cluster Bulletin provides an overview of the health cluster activities conducted by health cluster partners currently responding to the crisis in South Sudan. This Bulletin will be issued once a week until the end of the crisis. It is a tool used to share information on supplement other information materials. Health cluster partners attend a meeting to discuss the response to the current crisis in South Sudan in Juba Photo: WHO/P Ajello Highlights Since the onset of the conflict on 15 December 2013, UNOCHA estimates that 395,000 people have been displaced due to the ongoing conflict in South Sudan, 352, 000 of these displaced internally. 84,000 others are displaced in Mingkaman and Awerial in Lakes state. Displaced persons have also been reported in neighboring states and countries like Uganda where 32,000 are seeking refuge, 4,800 in Kenya and 6,000 displaced into Ethiopia. A total of 2,633 persons have been wounded across all the conflict-affected states, 176 of them have been medically evacuated to various hospitals since the start of the conflict. Emergency campaigns have been launched following reported suspected cases of measles in internally displaced people's camps in Juba and Bentiu. Vaccination campaigns for measles and polio have been launched in all IDP camps. Vit A and deworming were also included in the vaccination campaigns. Blood specimen for suspected cases of measles were collected from Juba and Bentiu and with the facilitation of WHO, these were sent to Nairobi for further analysis. The main causes of morbidity seen at the primary health care clinics in the IDP camps in Juba, Awerial, Malakal and Bentiu are Malaria (21%), Acute Watery Diarrhea (18%), and Acute Respiratory Infection (20%). There have been no deaths due to diarrhea or malaria. A estimated 11,500 patients have been treated in the last two weeks in clinics offering services in displaced peoples camps. WHO and UNFPA are working to support reproductive health services in IDP camps in Juba and Bentiu, this however remains a major gap in other IDP camps in the five states of Unity, Upper Nile, Jonglei, Central Equatoria, Lakes and Warrap. While IMC has started offering reproductive health services in UN Juba III IDP camp and In UNMISS Tomping camp. 1
2 Health Cluster Bulletin South Sudan Crisis January 10 2014 Affected populations and areas The fighting that first occurred in Juba Central Equatoria State on the 15 December 2013 has continued in parts of Bor in Jonglei and Mayom and Bentiu in Unity States. While in Juba, although the situation is calm, sporadic shooting has continued in parts of the city especially at night time. As a result of continued fighting, the number of people fleeing in to areas of safety has continued to rise. UNOCHA reports that as of 10 January 2014, an estimated 395,000 persons had been displaced as compared to 194,000 reported in the last health cluster bulletin. With the increasing numbers of displaced persons, emergency health needs have equally become enormous thus a need for more humanitarian partners to respond and more medical supplies to ensure that all displaced persons and those wounded are reached. As the fighting continues, the number of casualties is also increasing. Within a period of one week from the last release of the cluster bulletin, 406 cases of gunshot wounds have been reported and treated at 17 treatment centers managing casualties across the country with numbers expected to rise further as fighting continues. An estimated 2,633 gunshot wounds have been treated and managed at all health facilities across five states of South Sudan with many more expected to be wounded and not able to access the hospitals for surgical care. Of those injured, 176 have been medically evacuated to Juba for further treatment. Between 2 and 10 January 2014, 109 new cases of gunshot wounds have been evacuated as compared to fifty seven evacuations conducted by 2 January 2014. Those evacuated have been receiving medical care in UNMISS hospitals in Bor, Malakal, Bentiu and Juba and in government and NGO health facilities in Renk, Mayom, Bentiu, Malakal, Agok, Leer, Kuajok, Gogrial, Juba Military hospital and Juba Teaching Hospital located in the six states of South Sudan. UNMISS hospitals together with ICRC and MSF with support from the WHO are the major actors in managing trauma cases across the conflict zones and neighboring states where wounded patients are referred. UNMISS clinics in Juba and Bor are however full and there is need to support the relocation of some patients to other, safer health facilities where they can continue to receive specialized care. The delivery of humanitarian medical assistance however continues to be greatly hampered, especially in Bor due to the high insecurity as the hospital in Bor is currently non-functional. Some agencies have therefore set up bases within the UNMISS compounds in Juba, Malakal and Bentiu while others stayed at the hospitals in Bentiu and Malakal. Although many agencies have started returning, not many are on 2 ground to provide the much needed services. This however is expected to change in the next coming weeks.
3 Health facilities reporting patients with gunshot wounds in South Number of surgery cases per facility Total surgeries 2,623 Juba Teaching Hospital 465 Malakal Hospital 291 Beintu hospital 10 UNMIS Bor 168 Rumbek 15 Juba Military Hospital 1024 Gograil hospital 7 Turalei Hospital 4 Agok hospital 74 Public Health Risks, Needs and Gaps As the number of persons being displaced rises, public health risks are also increasing. For instance in all the areas where displaced persons are currently seeking refugee, overcrowding is a key concern. Due to this diseases of public health concerns like measles, are more likely to be reported and spread if overcrowding is not addressed. In addition the likelihood of Tuberculosis and other airborne diseases spread in settings like this becomes a key concern for all health partners. Kuajok hospital 59 Yirol 33 Rubkona 134 Ajoung Thok 7 Gumuruk 20 Nasir 68 Leer 9 YUAI 31 Water and sanitation conditions in many camps also raise a lot of Lankein 94 concern and fears of a potential cholera and other water borne Pibor 30 diseases outbreaks. Although the water, sanitation and hygiene conditions in the camp are improving compared to the pervious MSF RUMBEK 15 weeks when people had just moved in, the risk of cholera and Juba Level II UNMISS 90 other water borne diseases still remains a public health concern. In this reporting period, acute watery diarrhoea was reported as the number three cause of morbidity in all internally displaced people s camps. There is therefore a need for improved water and sanitation conditions, coupled with health education and promotion to ensure that the risk of cholera outbreak is minimized further. Given that most displaced persons are sleeping in areas without shelter with those having shelter, having poor conditions, the risk of respiratory tract infections and malaria remain of public importance. For instance in this reporting period, Respiratory tract infections was reported as the leading cause of morbidity in all Internally displaced persons camps while malaria cases were reported at the number two cause of morbidity. If the people continue sheltering in the open spaces and be without shelter, the risk of more RTI will shoot higher. Health Cluster coordination At the national level, WHO and IMC are supporting the coordination of the health cluster partners, as such three health cluster meetings have been convened, a 3 Ws of who is doing what and where matrix has been updated and shared with UNOCHA so that maps are developed and shared widely with partners. The Health cluster also sits in the inter cluster working group that meets daily to for strategic discussions to guide partners response and in some instances conduct joint planning and response activities. For instance the health cluster lead is closely working with the logistics cluster to ensure that all medical supplies going to the states of emergency are transported on time so that the displaced and wounded persons are able to have access to the much needed health care services. 3
4 Special Bulletin: South Sudan Crisis January 2014 The health cluster has actively supported the coordination and made it possible for hundreds of persons wounded to be medically evacuated in to areas where they can get specialized health care services. For instance in this reporting period, the health cluster coordinated the evacuation of one 109 patients from various health facilities in to either Juba, Malakal, Gogrial, Agok, Kuajok or Leer hospitals. Assessments Health cluster partners together with WASH cluster assess the potential risk factor for cholera in UNMISS Tomping camp Photo: WHO/P. Ajello Following displacements of thousands of persons in internally displaced camps in various states of conflicts and in to neighbouring states, conducting rapid assessments is necessary in order to establish the needs, gaps and interventions for those in need of health care interventions. In regard, health cluster partners participated in various interagency assessments. In Malakal and Bentiu, the health cluster participated in an interagency rapid assessment. In Malakal, the teams visited the UNMISS IDP camp and the Malakla Teaching hospital. The team established that all the six Primary Health Care Centers (PHCCs) in Malakal city are currently closed and non-functional, while Malakal hospital the only operational hospital n the city is focusing on only managing trauma cases. Trauma management in Malakal is being done by ICRC and MSF Spain. This therefore leaves a big population outside the camps with no access to primary health care services. Those displaced and those wounded and living within the camps currently access primary health care services within the UNMISS Protection of Civilians (POC) level I and II clinics. MSF is supporting to provide this service at the UMISS base with medical supplies from WHO and the State Ministry of Health. There is however a gap in service delivery for the huge population in the city who have no facilities for primary health care services. In UNMISS protection of civilian Malakal, there is shortage of supplies particularly antibiotics and blood bags. Reproductive health supplies at level 2 UNMISS hospital also remains a gap. Although the health facility has adequate human resources. At Malakal hospital, a backlog of 192 patients are awaiting surgery due to blood and workload on the two surgeons at the hospital from the ICRC who are working round the clock to reduce this backlog. Absence of key partners including Cordaid, IMA and GOAL. There is need for all actors to scale up their presence in terms of staffing and supplies. 4
5 Health Cluster Bulletin South Sudan Crisis 10 January 2014 Bentiu hospital is currently providing limited surgical capacity with support of ICRC and MSF. Primary health care and reproductive health services are however not being provided due to the absence of health personnel. Other primary health care facilities within Bentiu and other nearby counties are not operational due insecurity and lack of personnel. With the support of WHO and UNICEF, displaced health personnel currently living inside UNMISS camps are providing primary health services, however MSF plans to support with additional mobile clinics. The number of IDPs living in the UNMISS compound in Bentiu has drastically increased in the last two days as the security situation deteriorates. An emergency measles vaccination campaign together with polio and vit A has just been completed. Sanitation and hygiene needs among the displaced people living in UNMISS camp is very poor and need to be urgently addressed. In Juba, Medair conducted an assessment in Mahad Primary School Juba, near Konyo Konyo Market, Central Equatoria states currently housing IDPS from Jonglei state. As of 2 January 2014, a total of 3,000 people were reported by the Relief and Rehabilitation Commission as being displaced in this area. Medair assessment team established that acute watery diahorrea and respiratory tract infection were the main causes of morbidity. Although there is no PHCU, Juba Teaching hospital and Al Shabah hospitals are close to the population. There are private clinics in the area, but these may require funds that the displaced people may not have. There is therefore a need to conduct a mobile clinic on this area and need to conduct a mass measles campaign as the number of children in this over crowded area puts them at risk of measles outbreak. Health service delivery In most of the affected areas, service delivery has been limited to a few health facilities. In Malakal town, all Primary Health Care facilities have been closed with only Malakal hospital providing trauma management, while UNMISS Level I hospital and MSF Spain are providing trauma and primary health care services to the IDPs inside the UNMISS compound. In Bor Jonglei state, the hospital is non functional and all those displaced in to the camps are receiving health services in UNMISS camp. In Bentiu Unity state, Bentiu hospital continued providing health services to the communities not displaced. ICRC and MSF are on ground providing management of trauma patients while inside the UNMISS base, UNICEF and WHO are supporting to provide primary health services in the camps. In Juba, MSF, IMC and UNMISS are providing primary health care and treatment for the wounded inside the UN bases while those not in camps are accessing medical services from different hospitals in Juba. Other health facilities that are currently supporting with health service delivery for the displaced include; Agok, Kuajok and Turalei in Warrap state, Juba Military at Hospital, Juba Teaching hospital in Central Equatoria state, Yirol and MSF- Rumbek in lakes state, Leer, Lankien, Yuai and Nasir. The issue of referral of patients and access to areas where patients are being referred to remains a challenge due to the air asset to transport to areas where they have been referred to. In Awerial where over 84,000 people are displaced, CCM/CUAMM and MSF are providing primary health care services while WHO is providing drugs and other medical supplies, UNICEF is providing vaccines to support the vaccination of children and, In Baliet County, Upper Nile state three health facilities are believed to have been demolished during the latest fighting in Baliet. The facilities are: Adong PHCC, Galachol PHCU and Banglai PHCU. All the people have moved to Baliet town and more are still coming from their hiding places. Baliet PHCC is however fully operational but is currently experiencing shortages of essential supplies. GOAL has supplies in Lokichoggio that were due to be trucked through Juba before the fighting started, options are being weighed of how the supplies can be sent there. The other three facilities in Baliet are also believed to be functional at the moment. As soon as access to Baliet and Ulang is possible GOAL supplies will be delivered and more staff to support the team currently there. Vaccination campaigns There is a significant risk of a measles outbreak occurring in the overcrowded IDP camps. Measles virus is endemic in South Sudan and over recent years numerous measles outbreaks have been documented in many parts of the country. The routine EPI coverage is very low. Children of South Sudan are also at risk from polio virus, especially from imported virus coming from the recent Horn of Africa outbreak. For these reasons an integrated immunization campaign was planned with both measles and polio antigens to be administered to children living in the IDP camps. In addition, children were also considered to be at potential risk for malnutrition so administration of Vitamin A supplement was planned as part of the intervention. 5
6 Health Cluster Bulletin South Sudan Crisis 10 January 2014 Suspected measles cases have been reported from Bentiu and Juba IDP camps, vaccination is a key component in preventing a potential disease outbreak arising from the displaced persons. Over the past week 11 suspected cases of measles were reported from Juba alone and three new suspected cases were reported from Bentiu IDP camp. Samples were collected and with the support of WHO were sent them to Nairobi for further analysis. In this regards, UNICEF and WHO in close collaboration with health authorities and partners on ground like MSF and CCM/CUAMM started conducting vaccination campaigns in all the internally displaced peoples camps with the exception of Bor. In order to reduce the risk of disease outbreak, the Ministry of Health with partners planned for an integrated intervention to administer measles antigens, oral polio vaccine, vitamin A and deworming for children seeking refuge in IDP camps. The intervention was first planned to be implemented in the 2 IDP camps in Juba located at UNMISS compounds; at Tomping IDP camp on December 29-31 and in UN House IDP camp on December 30-January 1. Similar interventions were also planned for Bentiu, Malakal, Bor, Awerial and other IDP camps in Turalei. The campaigns aimed to vaccinate children aged 6 months 15 years against measles, children from birth 15 years against polio and to administer Vitamin A supplement to children aged 6 months 5 years. In Turalei, GOAL supported vaccination of the displaced people is on going in three locations where there are IDPs (Aweng, Turalie and Man Angui). As of this reporting period, a total of 368 children under 5 had been vaccinated against measles and OPV. Once the campaign is over a comprehensive report will be shared Results from Juba Campaign At the end of the activity the state EPI team compiled the data and reported coverage to partners. The table below summarizes the administrative coverage achieved in the immunization activity in Juba IDP camps. Antigen/Intervention Number of children receiving intervention Juba IDP camps UNMISS Tong- UNMISS UN Ping House Total Oral Polio Vaccine (0-15 years) 13,555 7,433 20,988 Measles (6 months - 15 years) 12,857 6,996 19,871 Vitamin A supplement (6 months - 5 years) 12,857 5,111 17,968 Results from Bentiu and Awerial Campaign The immunization activity was implemented in Bentiu UNMISS IDP and Awerial IDP camp from Jan 6 to 8 in Bentiu and from 4 to 6 in Awerial. In Bentiu the target population was 3,380. Antigen/Intervention As other results became available, the cluster with share the results of the campaigns. In Bor the campaigns will be conducted once the security situation gets better. In Awerial IDPs camp (Mingkaman) malnutrition was also reported as a concern. Data from the Primary Health Care Centre in Awerial managed by CCM/CUAMM showed that 14 severely malnourished children were admitted and 24 moderate malnutrition under treatment in PHCC. Reproductive Health Number of children receiving intervention in Bentiu IDP camp Deworming 1,114 Partial results of no of children receiving intervention in Aweial IDP camp Oral Polio Vaccine (0-15 years) 2,333 3,898 Measles (6 months - 15 years) 2,272 4,629 Vitamin A supplement (6 months - 5 years) 1,235 In Juba, many partners are working to improve the maternal and neonatal health of women. IMC started antenatal care services in UN house Juba III, and plans are on-going to collaborate with UNFPA and WHO to start similar services at Tomping alongside MSF s clinic. IMC is increasing its capacity in Juba III to be able to conduct deliveries soon. The UNMISS Level II Cambodian Hospital continues to conduct deliveries for IDPs in Tomping IDP camp and UN Juba III. WHO has developed five protocols for emergency obstetric care services and supplied them to Cambodian Hospital that are being used for standard care. 6
7 Health Cluster Bulletin South Sudan Crisis 10 January 2014 Reproductive Health kits being loaded from the UNFPA stores fto be taken to UNMISS Level II hospital In Malakal, the RH services continue to be offered by the UNMISS clinics with those who require obstetric services referred to Malakal teaching Hospital. MSF Spain has started primary health care services in the IDP camp and are expected to increase capacity soon to start ANC. In Bentiu MSF Holland offers ANC and will soon start to conduct deliveries. Since the start of the conflict on 15 December 2014, a total of 67 deliveries have been recorded to date in UNMISS Level II hospital in Juba, 12 of these deliveries happened within a period of one week (2 to 9 January 2013). Five of these deliveries were breech deliveries. And five pregnant women were treated for postpartum hemorrhage and nine others treated for complications of abortion. Surveillance and communicable disease control WHO South Sudan supports the Ministry of Health to strengthen early waning and disease surveillance in all areas affected by the ongoing conflict. Routine surveillance in conflict affected areas has been interrupted due to the closure of many health facilities and displacement of health personnel. Early warning surveillance was set up in all IDP camps (except Bor) and partners have been submitting weekly surveillance data to the Epidemic Preparedness and Response department in order to monitor the disease trend. Respiratory tract infection, malaria and diarrhea are still the leading causes of morbidity in week one, the majority of cases being children below five years of age. In week one, (29 Dec 13-5 Jan 14) the total number of consultations reported from Juba, Awerial and Malakal was 3,084. Of these cases, 25% were suspected malaria 19% acute watery diarrhea and 6% bloody diarrhea. Thirty three percent (33%) of malaria cases, 70% of acute watery diarrhea cases and 15% of bloody diarrhea cases were in children below five years of age. The majority of diarrhea cases were recorded from Juba and Awerial IDP camps, where the sanitation conditions are very poor. Twenty eight suspected measles cases with no death were recorded from displaced camps in Juba and Bentiu since December 15 2014. Of these cases, seventeen were below five years of age and 11 above 5 years. Blood specimens were collected and sent to KEMRI/CDC for analysis. Epidemiological and laboratory investigation are undertaken by surveillance teams with the support of WHO and partners once outbreak alerts were reported in high risk areas. Health cluster partners have intensified preventive and control measures against epidemic prone diseases in the affected areas. Enhanced surveillance, case management and social mobilization activities have been put in place in all camps. 7
8 Health Cluster Bulletin South Sudan Crisis 10 January 2014 Table showing who is doing what where in areas of conflict in South Sudan 8
9 Special Bulletin: South Sudan Crisis January 2014 Gaps and Needs Provision of primary health services in IDP camps at Bor UNMISS compound needs to be addressed. Timely referral for wounded patients from Bor to other referral hospitals due to insecurity in Bor. Lack information in many areas where there is ongoing conflict like in Mayom, Pariang, Akoko, Balliat, and other areas. Referral of Severe Acute Malnutrition cases with complications for medical management is a challenge as access to the only children referral care hospital (Al Sabbah Children s Hospital in Juba) supported by UNICEF is not feasible due to security reason as community would not agree to take their children out of the UNMISS base. Concerns There are still few health cluster partners on ground. Medical evacuations to various areas is challenging due to the dynamics of the conflict, thus the choice of evacuation of those wounded has to be carefully made. Reproductive health remains a major challenge here requiring more partners to fill in this gaps. At this stage, determining the number of fatalities is challenging and unknown. Plans for future response In Malakal plans are also under way by MSF Spain to conduct mass measles campaigns among the displaced persons camp inside the UNMIS base. All partners involved in the response need to constantly monitor surgical capacity across the country. Develop and improve the capacity of Minkiman Primary Health Care Centre currently run by CUAMM. Health Cluster partners Partners working towards the response include: Ministry of Health, State Ministries of Health, WHO, UNICEF, MSF Spain, MSF Belgium, MSF France, MSF Swiss, MSF Holland, ICRC, CCM, THESO, HEALTH LINK, UNFPA, UNMIS,S CUAAM, GOAL, IMC and Save the Children. Donor observers: ECHO, OFDA, CIDA, DFID, EU, Currently the national Health Cluster is Chaired by MOH and Co- WHO. Contacts For more information please contact: Dr Julius Wekesa Health Cluster Coordinator WHO South Sudan wekesaj@who.int Ms Pauline Ajello Communication and Advocacy Officer WHO South Sudan ajellop@who.int +211 955 873 055 +211 954805966 Ines Morgan Co-Cluster Lead International Medical Corps (IMC) South Sudan sshealthclustercolead@gmail.com +211 954309962 9