Southern Sudan Health Update Jan Feb 2008

Southern Sudan Health Update Jan Feb 2008 Contents Health System Development Emergency Humanitarian Action 2 3 & 4 EWARN Update 5 & 6 Malaria Update 6 EPI Update 7 HIV/AIDS Programme 8 Neglected Tropical Diseases Nursing & Allied Health 10 World Health Organization Southern Sudan Office UN OCHA Compound Juba, Southern Sudan Phone: +249 811 820077 Fax: +249 811 232333 www.who.int www.emro.who.int/sudan 9 WHO Sudan Retreat in Khartoum W HO Southern Sudan Head of office Dr A b d u l l a h i Ahmed together with six technical staff visited Khartoum from 5 6 February, 2008 to participate in a WHO Sudan retreat. The objective of the retreat was to review and look back at the 2006-07 biennium and draw lessons; and to strategise for the efficient implementation of 2008-09 biennium. The first day of the retreat was dedicated to the review of 2006-07 biennium. After brief introductions and an opening speech by the WHO Representative Sudan Dr Mohamed Abdurrab, various key staff from WHO Country Office in Khartoum and WHO Southern Sudan made presentations to update participants on the activities in their respective regions/areas of work. Background information and progress report on the UNDAF planning process was also made. The participants then worked in five small groups and reviewed the last biennium to develop matrices on the Strengths Weaknesses Opportunities- Threats (SWOT) analysis in four aspects of the work plan, namely; implementation, coordination monitoring & evaluation, and documentation & information sharing. The SWOT analyses were then presented and discussed in a plenary session that followed the group work. On the second day participants worked in four small groups to review the SWOT analyses developed on the first day to come up with recommendations for 2008-09 biennium, along the lines of the SWOT analyses themes. Following recommendations were made: North-South coordination meetings (MOH & WHO) to be held every three months; all sub-offices to be involved in this meeting North and South program coordinators/officers to exchange regular updates on achievements and plans Heads of offices and units to strengthen the M&E system in their respective programmes, with the assistance of the WR s office C o n d u c t w o r k p r o - gramme review meetings at WHO Country office twice a y e a r. S u b - offices and units to conduct review meetings more frequently Head of office Southern Sudan Dr Abdullahi Ahmed during a retreat with WHO Sudan colleagues WHO to help establish and/or strengthen M&E within MOH Prioritized WHO documents to be stored in digitalized form for electronic retrieval and easy sharing Phone: +249 811 820077 Fax: +249 811 2323331 Page 1

Health System Development Update story continued from page 1 Essential Medicines and Pharmaceutical Policy Taking photographs by technical and support staff, as a means of documentation to be encouraged and facilitated Good documentation by counterparts to be encouraged and the capacity for it developed Future Directions Group photo of participants at retreat A task force was set up to prepare for the first quarterly review meeting between FMOH and MOH/GOSS and WHO offices in the North and South Sudan. The next WHO Sudan retreat to be held after one year in Juba Southern Sudan. S outhern Sudan Pharmacy Policy and related guidelines WHO provided financial support to the Ministry of Health, GOSS to print the Pharmacy Policy of Southern Sudan (later renamed Southern Sudan Pharmacy Protocol), Guidelines for the Donation of Medicines, Medical Supplies and Equipment for Southern Sudan, the Southern Sudan Essential Medicine List, and the Standard Treatment Guidelines of Southern Sudan. It is to be recalled that WHO provided the technical support for the development of the above-mentioned documents and the Ministry of Health formally launched these documents as sub-sector policies and guidelines to the Southern Sudan National Health Policy in December 2007. D onation of GPHF Mini-Lab Kits to MOH As part of the efforts to support the Southern Sudan pharmaceutical regulatory activities, WHO procured five GPHF (German Pharma Health Fund) Mini Laboratory Kits to the Directorate of Pharmaceutical Services, Ministry of Health. GPHF mini-lab kits are sets of essential laboratory equipment and reagents in two suitcases and additional laboratory supplies to perform rapid tests on medicines at ports of entry, hospitals and medical stores. This is expected to enable the Southern Sudan regulatory authorities in detecting counterfeit and substandard pharmaceuticals. R ehabilitation of a Pharmaceutical Store WHO finalised plans and announced bids for the renovation / rehabilitation of a section of the Central Medical Stores /GOSS, to be converted to WHO Store for emergency medical kits and laboratory supplies. The Ministry of Health assigned the section of the store to WHO in December 2007. Health System Strengthening W HO continued working with the Ministry of Health and other partners on the draft Application for the Global Alliance for Vaccine and Immunisation (GAVI) Health System Strengthening. It is to be recalled that WHO has been providing the lead technical assistance and coordination for the development of the application. The first draft application, which was completed in December 2007, has been circulated among the key stakeholders in Southern Sudan, in WHO EMRO and WHO HQ and other partners and comments received. The WHO International technical assistance worked with the drafting committee and the national Technical assistance, to incorporate the comments and fill in additional data as required in finalising the draft. During this period a meeting with the director generals of the State Ministries of Health was organized and the document endorsed, with additional inputs from Some of the participants of the above-mentioned meeting with Director Generals of the State Ministries of Health the participants. A consensus/finetuning workshop for the application is planned for early first week of March 2008, after which it will be submitted to GAVI. Phone: +249 811 820077 Fax: +249 811 2323332 Page 2

Emergency Humanitarian Action B y 1 March, 2008 repatriation of Sudanese refugees to Southern Sudan and Blue Nile State has reached a cumulative total of 181,804. Of this number 89,793 were under the organized and assisted self-repatriation programme. Since 1 January to 1 March, 2008 the repatriation figure reached 12,838, out of whom 12,675 persons (99 %) were organized, 163 persons (1%) were assisted self-repatriation. (Source: UNHCR) Population Movement and Repatriation WHO is working closely with the Ministry of Health and other partners, to ensure that immediate health assistance to the returnees (internally displaced population and refugees) and host communities is addressed. Moreover, WHO is periodically providing Maps to returnees working group; depicting counties in which meningitis cases have been reported, classifying them in: Outbreak/epidemic level - RED, Alert level - YELLOW, Cases registered but below alert threshold BLUE. This information have proved to be very instrumental when planning convoys and prioritizing areas. S Refresher Trainings tate Polio team led by WHO-Polio Focal point had organized series of refresher trainings in all Counties for the purpose of preparing the first NIDs campaign in early March, 2008. The aim of these r e f r e s h e r trainings was to maximize the effectiveness of the polio campaign, while i m p r o v i n g the participation of the Participants during the refresher training local communities. Training participants pledged to actively participate in the immunization activity, to ensure all children can benefit from the polio campaign. I Measles Acceleration Campaign in Yambio n order to respond to limited measles outbreak in Yambio County, measles acceleration campaign was successfully conducted from 18 20 February, 2008 in Bangasu Payam. T Improved Surveillance Response in Western Equatoria o improve surveillance response at State level, Western Equatoria State surveillance team combined their resources with Polio programme which lead to dramatic increase (80%) in reporting rate. This collaborated effort has helped surveillance team to investigate the outbreak rumour more efficiently and it also helped in the process of transmitting weekly data through different communication channels. Efforts are on going to implement the same strategy in other States so that overall response of surveillance can be elevated. Vaccinators administering vaccine to a child W Donor s Support HO s activities in Southern Sudan are supported by CERF for flooding response, CHF for (health sector coordination, HIV/Aids & neglected tropical diseases), ECHO for strengthening EWARN, Italian Corporation for strengthening health systems, Finish Government for scaling up humanitarian interventions and Irish Government for Malaria program activities. Phone: +249 811 820077 Fax: +249 811 2323333 Page 3

Emergency Humanitarian Action Health Situation Analysis O ver the period of January to February, 2008, the general health situation across Southern Sudan remained to be calm in terms of diseases outbreak. Epidemiological trend indicates a significant change in the Meningitis situation; Last year 5,292 cases were reported from Jan Feb, 2007 on the contrary this year only 42 cases were reported for same months. However, situation is slightly different for Acute Watery Diarrhoea (AWD) and Measles, where records show cumulative cases of 2632 and 65 for AWD and Measles respectively. Compared to last year from January to February, AWD cumulative recorded 1132 and 30 cases for Measles. Elevated cases of both diseases are thought to be due to current reported outbreak of Measles in Eastern Equatoria and AWD in Central and Western Equa- toria States. During the month of February, cases of hepatitis E were confirmed from Eastern Equatoria State. More efforts including the emphasis of the Early Warning and Response network have been improved. WHO Public Health Specialists stationed in five strategic States across Southern Sudan have continued to work closely with the Ministry of Health and partners to ensure that diseases outbreak rumours are thoroughly verified and investigated in a timely manner. CHF First Allocation 2008 C HF first allocation 2008 was awarded in the month of January. Total amount allocated to Southern Sudan was $ 44.7 million of which Health & Sector received $ 12.1 million (27 %) of total budget. WHO Southern Sudan have been allocated funds for the following projects: 1. Health Sector Coordination, Emergency Preparedness and Humanitarian Action 2. Diseases Control, Prevention and Epidemic Preparedness 3. Training of Juba Teaching hospital Nurses and Midwives, on nursing, midwifery and Management skills 4. HIV/AIDS for PoHC 5. Neglected Tropical Diseases 6. Routine Immunization and vaccine preventable diseases surveillance The implementation action plans are currently being developed to accelerate the implementation process. Southern Sudan CHF Allocation 2008 by Sectors (Source: UN Work-Plan 2008) Phone: +249 811 820077 Fax: +249 811 2323334 Page 4

Early Warning and Response Network (EWARN) EWARN Update Update Highlights Eight reports/rumours of outbreaks received by WHO were investigated. Reports of animal deaths in Melut, Upper Nile in early January were thought to be due to drought by Veterinary Experts. No human cases of Rift Valley Fever (confirmed in the state by PCR in Dec 2007) were found. Animal samples are being investigated. WHO coordinated the development of the Preparedness and Response plan for Meningitis and the preparation of a draft for cholera for the 2008 seasons for both outbreak conditions. Coordinated the stockpiling of about 500,000 doses of A/C meningitis vaccine for the 2008 season. Pre-positioned 6000 vials of oily chloramphenicol for the treatment of 100 cases of meningitis in each of the 10 states of Southern Sudan. Lab reagents pre-positioned in high risk areas for the preservation of blood, cerebro spinal fluid and stool samples and facilitated their transportation to ref labs in Kenya. Coordinated the investigation of reported/rumoured outbreaks of suspected Rift Valley Fever, Cholera, Meningitis and measles. Hands on training on observance of Standard Precautions provided to staff and Personal Protective Equipment (PPE) donated to hospitals managing suspected cases of viral haemorrhagic fevers. Coordinated the review of Integrated Disease Surveillance and Response (IDSR) training materials in view of planned roll out TOT workshops in Upper Nile, Unity, Lakes, Warap and Eastern Equatoria states in March and April of 2008. Western Equatoria State where an IDSR TOT was conducted last year launched its second edition of weekly epidemiological bulletin which demonstrated 80% completeness and timeliness of reporting in Counties (8 out of 10 counties) of the State. Acute watery Diarrhoea (AWD)/Chlra Acute bloody Diarrhoea (ABD) Measles Meningitis CASES DEATHS CASES DEATHS CASES DEATHS CASES DEATHS 2667 12 1654 4 65 1 43 9 CFR 0.45 % CFR 0.24 % CFR 1.54 % CFR 20.9 % Cumulative total cases and deaths in Southern Sudan of the four outbreak disease conditions from 1 Jan - 29 Feb, 2008 B Emergency Preparedness and Response to Disease Outbreaks y the 9th (26 Feb 4 March) epidemiological week in 2007, a cumulative total of 2811 cases and 204 deaths of meningitis had been recorded. A large number of CSF samples tested positive for Neisseria Meningitidis by culture. This compares to 46 cumulative cases and 10 deaths for the end of the 9th Epidemiological week (25 Feb - 2nd March) in 2008. None of the CSF samples tested so far have had Nm isolated by culture. While many cases of Acute Watery diarrhoea (2678 cases) had been recorded by end of the 9th week, a significant proportion of the cases occurred among the under fives and only in one location (Owinkibul) was V cholerae confirmed in the small scale outbreak that was rapidly controlled. However the situation remains challenging for scattered measles outbreaks and the advent of Hepatitis E in large parts of Eastern Equatoria with relatively high case fatality rates. O Meningitis utbreaks of meningitis were reported in Eastern Equatoria, Western Equatoria and Jonglei States. In two occasions, (Bor and Yambio) samples tested positive for Nm A, Y, W135 by Investigation of suspected meningitis outbreak in Tabur village in EES rapid tests in the field but tested negative by culture at reference lab. Few rapid tests were positive for Strep Pneumonia. Phone: +249 811 820077 Fax: +249 811 2323335 Page 5

Early Warning and Response Network (EWARN) EWARN Update Update M Acute Watery Diarrhea ost of the Acute Watery Diarrhea (AWD) cases 2678 recorded by end of week 9 are among under-fives. Seven stool samples tested for the most affected area (Tambura) were negative for V Cholerae. The short-lived outbreak in Owinkibul that originated in a military barracks affected 227 persons (111 military personnel) and caused 16 deaths (8 military). Five samples tested positive for V Cholerae in this outbreak. No cases reported in epidemiological weeks 8 and 9. A Measles Outbreak n outbreak of measles in Kapoeta in 3rd week of February was investigated. Twenty six cases were recorded and five blood samples were collected. At the Juba Teaching Hospital 24 cases were line listed of which Thirteen were newly admitted cases in week 9. A Suspected RVF suspected outbreak of Rift Valley Fever (RVF) in Eastern Equatoria (Kapoeta) in February was confirmed to be due to Hepatitis. Other cases diagnosed as Acute Jaundice Syndrome in Ikotos County were also confirmed as Hep E. Five samples tested positive out of 14 samples. Roll Back Malaria Update Malaria Technical Working Group meeting D r. Othwonh Thabo, MoH/GoSS Malaria focal point called for a malaria technical working group meeting on 3 February, 2008 in which following points were discussed: 1. National ITN plan and allocation of MDTF nets 2. ITNs to be distributed by other partners in 2008 3. Plan of action for distribution of MDTF nets and chronogram Dr Thabo made the presentation on the national ITN plan and allocation of MDTF nets. The presentation outlined the rationale for the national ITN plan, which is based on the national malaria strategic plan and explained the distribution of MDTF nets between the different States. During this meeting, PSI draft plan of action for distribution of MDTF nets and associated chronogram were also discussed. Furthermore, ToR for three working groups (Technical committee, Communications committee & Logistics committee) were drafted. T Training Course on Communicable Disease Control in Emergencies he technical officer of Malaria program in WHO Southern Sudan, Dr Jeylani Mohamoud attended the five day training course on Communicable Disease Control in Emergencies, which was held at the WHO headquarters, Geneva, Switzerland from 10 14 December, 2007. This training course was organized by the Disease Control in Humanitarian Emergencies (DCE) unit. 25 participants were drawn from WHO offices, MoHs, UN Agencies, NGOs and International Organizations working in humanitarian emergencies mainly in African continent. The course was offi- cially opened by Dr. David Heymann, the Director of DCE Unit with remarks on the rationale of the training and the way forward to make it a yearly regular course in the future. The aim of this course was to provide participants with the necessary technical skills to develop and implement communicable disease surveillance and control activities in collaboration with other partners. Phone: +249 811 820077 Fax: +249 811 2323336 Page 6

Expanded Program on Immunization (EPI) Update N Preparations for NIDs IDs 1st round for the year 2008 is scheduled to be conducted in the 1st week of Mach 2008. Funds have been distributed to the States and all the logistic preparations for vaccine storage and transport have been put in place. Moreover, training has been conducted for all volunteer vaccinators and field staffs by State focal points. A 2007 AFP Surveillance Performance t the end 2007, a total of 133 AFP cases were identified and investigated. The chart on the right shows the performance of AFP surveillance in Southern Sudan through the years indicating achievement of certification standard targets in 2007. Target 4 3.5 3 2.5 2 1.5 1 0.5 0 AFP Surveillance Performance 2002 2003 2004 2005 2006 2007* Non-polio AFP Rate % Adequate Specimens 100 90 80 Target 70 60 50 40 30 20 10 0 M Routine Immunization oh/goss in collaboration with WHO and Unicef conducted a 4 day workshop in Juba (18 22 Feb, 2008) to develop micro plans to scale up the routine immunization in Southern Sudan. All the Director Generals and the state EPI operation officers from the ten State ministries of Health participated in the workshop. In addition WHO polio field staffs, Unicef Zonal EPI officers and NGOs actively participated and facilitated the meeting. At the end of the workshop all Ten States produced their micro-plans on revitalizing and establishing EPI services. The MoH/GoSS is to avail the GAVISS funds for the scaling up of EPI activities. Cases with adequate specimens Specimens in good condition Cases with NPEV detected Cases with inadequate specimen receiving a 60 day f/up Quality of specimens 2003 82% 100% 10% 100% 2004 87% 100% 15% 85% 2005 76% 98% 16% 84% 2006 82.4% 100% 33.8% 77.8% 2007 88% 99% 15.6% 81.3% The table above shows the details of quality of AFP specimen in 2007. As in the previous years, the performance again achieved the global expectations and standards. Phone: +249 811 820077 Fax: +249 811 2323337 Page 7

Integrated Management of Childhood Illness HIV/Aids Programme Update Neglected Tropical Diseases W Site Supportive Supervision to Kajokeji, Yambio and Nzara Hospitals HO conducted site assessment and site supportive supervision to Kajokeji (15 17 January, 2008), Nzara & Yambio hospitals (3 February 1 March, 2008). Kajokeji Civil hospital is located in Eastern Equatoria Kajokeji County. Land route takes two days from Juba. The nearest hospital with ART service is Moyo hospital in Uganda 20kms from Kajokeji on public transport. The VCT, PMTCT, ART, STI, blood safety and universal precaution services were assessed in detail. As of January 16, 2008 there are 36 patients on ART, 19 patients enrolled in care and on cotrimoxazole prophylaxis. Discussion and feedback was given on the spot to the h o s p i t a l m a n a g e - ment and a Meeting with PLHIV in Nzara Hospital during initiation of ART services meeting was held with the county health office on the introduction and scale-up of the available HIV services in the hospital and agreement was reached to strengthen the county health forum. The constraints in the supply of test kits, cotrimoxazole, guidelines and the need for training of additional staff on counseling, syndromic management of STIs, renovation of the building dedicated for laboratory and HIV services, allocation of dedic a t e d staff to run the H I V clinical c a r e w e r e some of Meeting at Kajo-Keji County Health department Orientation of ART services in Kajo-Keji Hospital the act i o n points agreed to be solved by IMC and WHO in the near future. Scale Up of Antiretroviral Therapy and Management of Opportunistic Infections N zara hospital is the only hospitals in Western Equatoria in Nzara County 15 miles from Yambio. The hospital was selected to start ART in December 2007 by the joint mission of ministry of health GoSS, state AIDS commission, state ministry of health, WHO, UNDP and UNICEF who assessed both Yambio and Nzara sites. The hospital has prepared a block to be used for both out patient consultation and admission of patients in HIV AIDS related services (agreed to be used for general admissions too). Moreover, staff has been identified awaiting recruitment, to run the counselling and ART services in addition to existing ones. Agreement was reached with the Comboni sisters Nzara who run the hospital to fill the human resource, furniture and medical supplies gap with the Global fund round four resources. WHO Staff provided on the job orientation of the ART services, start the pre-art and ART services in collaboration with existing trained staff and worked on practice set up for comprehensive HIV AIDS services. Furthermore, 150 PLHIV were enrolled in HIV care of which 59 were initiated on ART after preparation and adherence counselling in the week February 13 March 1, 2008 using WHO clinical staging. Finalization of National HIV AIDS Strategic Framework F irst National Strategic Frame work (NSF) for HIV AIDS was circulated for comments by South Sudan AIDS Commission and WHO staff have participated in the consultative workshop to finalize the preparation of the NSF. WHO has contributed in the finalization of the strategic framework. Preparation of Normative Guides T The final versions of the guidelines of antiretroviral therapy and opportunistic infections, HIV testing and counselling, national blood safety strategy, guidelines on the syndromic management of sexually transmitted diseases have been developed and currently waiting for final endorsement. New Staff - HIV AIDS Team Dr Wilma Juma has joined WHO HIV AIDS team on 26 February, 2008 as national professional officer on STIs, Blood safety and Universal precautions. Phone: +249 811 820077 Fax: +249 811 2323338 Page 8

Neglected Tropical Diseases GUINEA WORM ERADICATION PROGRAM S outhern Sudan Guinea Worm Eradication Program (SSGWEP) 2007 Review meeting took place in Juba from 30 31 January, 2008. It appeared that there is a significant decrease in morbidity (69%) comparing to the previous year. One of the major outcomes of the meeting was the absolute need for the SSGWEP to stay focused on improving surveillance; case detection & containment; and supervision & monitoring of all interventions so that 80% real containment of transmission during 2008 and complete halt by the end of 2009, can be achieved. I Human African Trypanosomiasis (Sleeping Sickness) n year 2007; 362 new cases were reported and 24,267 people were screened (see map below). In view of the incompleteness in reporting, the data available shows that only 1.3% of the population at risk has been screened. Schistosomiasis and Soil Transmitted Helminths (STH) A prevalence survey on S. haematobium, S. mansoni and STH was conducted among school children in Nyal, Unity State from 4 15 February. A total of 205 stool samples collected from primary school children were examined using the Kato Katz technique. The prevalence of schistosomiasis was found to be 47% (97/205) for S. mansoni, 0.5% (1/205) for Ascaris lumbricoides and 0.5% (1/205) for Enterobius vermicularis. A total of 209 urine samples were also examined and the prevalence of S. haematobium was found to be 86% (180/209). The findings indicate that schistosomiasis prevalence is very high in Nyal and mass treatment is recommended Aerial view of Nyal. The swamp is conducive for the transmission of Schistosomiasis Phone: +249 811 820077 Fax: +249 811 2323339 Page 9

Nursing and Allied Health Health Science Institute in Rumbek A ctivities for the establishment of a health science institute in Rumbek are in progress. WHO has requested Ministry of Health for nominations of potential trainers, who will be given a 3- month refresher course on nursing and teaching skills abroad; WHO will facilitate this process. MOH has already made a radio announcement to call for candidates and is currently in the process of selection of trainers. In order to have all required equipment for the training center ready by the initiation of the academic year, lists of required books, teaching aids, anatomical models, computers, photocopier, furniture and other required items have been prepared, and are in the process of procurement. With regard to the construction of the educational building, WHO technical officer for nursing and architect travelled to Rumbek and have had negotiations with an NGO on the ground, CISP, who are willing to participate in the construction of the educational building and some other parts of the school. The idea has been initially agreed by the WHO office in Southern Sudan and it has been communicated to the regional office for approval. If approved, the construction shall start immediately and is expected to be completed by October 2008, to allow initiation of the nurse training program this year. M Directorate of Nursing inistry of Health in Southern Sudan has recognized the important role of nurses and midwives in health systems, and therefore have recently endorsed the establishment of a General Directorate of Nursing/Midwifery in the Ministry of Health/ GOSS. WHO is committed to support the general directorate and has been closely working with the ministry to develop the organogram, detailed functions of its four subordinate directorates, and job descriptions of staff. Several activities, including capacity building of the staff of general directorate, are planned in JPRM for the current biennium. WHO has re- quested MOH to nominate its directors so that capacity building activities can take place. Furthermore, as the first step to resource the general directorate, two desktop computers have been provided for the directorate. I Mental Health n January, the Regional Advisor for Mental Health, Dr. M. Taghi Yasami visited Southern Sudan. During this trip the main places for taking care of mentally ill patients including psychiatric ward of Juba Teaching Hospital, and Juba prison were visited. Meetings were also held with key officials in MOH on the subject of mental health to discuss the current situation and plan for the future activities. Subsequently, an urgent plan of action for the conduction of an assessment of mental health situation in Southern Sudan and some rapid interventions including implementation of Chain Free Initiative and training of nurses and technical officers on mental health, was developed by the regional advisor. Phone: +249 811 820077 Fax: +249 811 23233310 Page 10