ACUTE WATERY DIARREHA AND OTHER POTENTIAL

UNCLAS SECTION 01 OF 03 KHARTOUM 000700

SIPDIS

AIDAC
SIPDIS

STATE FOR AF/SPG, PRM, AND ALSO PASS USAID/W
USAID FOR DCHA SUDAN TEAM, AF/EA, DCHA
NAIROBI FOR USAID/DCHA/OFDA, USAID/REDSO, AND FAS
USMISSION UN ROME
GENEVA FOR NKYLOH
NAIROBI FOR SFO
NSC FOR JMELINE, TSHORTLEY
USUN FOR TMALY
BRUSSELS FOR PLERNER

E.O. 12958: N/A
TAGS: EAID PREF PGOV PHUM SOCI KAWC SU
SUBJECT: ACUTE WATERY DIARREHA AND OTHER POTENTIAL
OUTBREAKS IN SOUTHERN SUDAN

REF: Khartoum 0478

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Summary and Comment
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1. From February 18 to March 3, 2006, a USAID Office of
U.S. Foreign Disaster Assistance (USAID/OFDA) Public
Health Advisor traveled to Juba, Southern Sudan, to meet
with USAID/OFDA health partners and assess the response
to the Acute Watery Diarrhea (AWD) outbreak in Juba and
surrounding areas. Between January 28 and March 7, 2006,
a total of 5,924 cases of AWD and 132 deaths, with an
overall case fatality rate of 2.23 percent, were reported
in Yei and Juba. The outbreak spread, with cases
reported in Malakal, Torit, and Bor towns. In Juba, the
response has been adequate with excellent coordination
among the technical working group, the water and
sanitation working group, and local authorities. The
number of new cases in Juba is now declining, but the
outbreak is spreading to other areas. Humanitarian and
health agencies remain concerned about the possibility of
a meningitis outbreak. End summary and comment.

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Introduction
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2. The first case of AWD occurred in Juba on February 6,
2006, and the AWD outbreak has since been linked to
vibrio cholera inaba. According to WHO, the Government
of National Unity Ministry of Health (GNU MOH),and the
Government of Southern Sudan Ministry of Health (GoSS
MOH),the last cholera outbreak in Juba was in 1976.
Cholera causes AWD in 20 percent of those infected.
According to WHO, approximately 10 percent to 20 percent
of those infected develop severe watery diarrhea with
vomiting, leading to dehydration and death if untreated.
Approximately 80 percent of cases can be successfully
treated with oral rehydration salts. Prompt and
appropriate medical management of cases can significantly
decrease mortality. According to WHO and non-
governmental organizations (NGOs),most deaths during
this outbreak are due to late presentation of cases for
treatment at health facilities.


3. According to WHO, as of March 7, 2006, the cumulative
number of reported AWD cases in Juba was 4,158 and the
cumulative number of reported deaths due to AWD was 79,
indicating a case fatality rate of 1.9 percent. In Yei,
the cumulative number of AWD cases reported through March
5, 2006 was 1,766 and the cumulative number of reported
deaths from AWD was 53, indicating a case fatality rate
of 3 percent.


4. The number of new cases from Juba and Yei has
declined, but the outbreak is now spreading to other
locations in Southern Sudan. Laboratory tests have
confirmed cases in Kajo Keji (2 cases),Pibor (40 cases
with 1 death),Lekuongole (1 case),and Terekeka (51
cases with 3 deaths). Cases of AWD pending laboratory
confirmation have also been reported from Torit (422
cases with 24 deaths) and Mongalla (14 cases with 5
deaths),but laboratory tests have not yet confirmed
these as linked to cholera. In addition, 21 new cases
and 1 death from AWD were reported in Malakal on March 7.
In Bor there have been 31 reported cases of AWD with one
death as of March 7. In Koboko, Uganda, across the
border from Yei, 31 cases of AWD with 1 death have been
reported since February 3, 2006.

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Coordination
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5. The Under Secretary of the GoSS MOH chairs a task
force responsible for the overall public health response
to the outbreak in Juba. This task force meets daily and
has representation from different working groups involved
in the response. The working groups include a technical
group dealing with the case management and surveillance,

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and a working group on environmental control in the
sectors of water, sanitation, and hygiene. The task
force and working groups appear to be well coordinated
and efficient. For example, the technical working group
mapped the data on cases of AWD and shared this
information with the water and sanitation experts, who
then focused the chlorination and hygiene promotion
activities in high-risk areas.

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Environmental Control
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6. Efforts are underway to improve the water supply in
Juba. Access to clean water is expected to remain a
major concern given the anticipated high rate of
population return into this area.


7. The U.N. Children's Fund (UNICEF) will provide spare
parts needed to fix broken boreholes. Water chlorination
is taking place at the river, boreholes, and households.
As of March 2, 238 volunteers had been trained to
disinfect wells and boreholes, chlorinate water at 11
sites along the riverbank, and inject chlorine into
individual water containers. Nevertheless, some women
refused to have their water containers chlorinated due to
the unpleasant taste of the chlorinated water and
misunderstanding of the need for the chlorination. The
water and sanitation working group is implementing
community health education activities and increasing
awareness on cholera prevention methods, but continued
work is needed to educate the population. UNICEF has
trained monitors and provided them with testing kits to
ensure that water sources are properly chlorinated.


8. Health and hygiene education campaigns have been
underway since the start of the outbreak. Health
messages are broadcast on the radio, as well as question
and answer sessions with Sudanese health professionals,
water and sanitation experts, and NGOs. These broadcasts
focus on the causes and prevention of the illness, and
where to seek treatment for AWD. Health education
messages are also disseminated from a yellow taxi that
drives around town with a public address system,
broadcasting messages on AWD prevention and the location
of treatment centers.


9. Volunteers have been sent to marketplaces and
households for sanitation and hygiene promotion, case
finding, and referral to the cholera treatment centers.
Marketplaces have been cleaned up and new latrines are
being constructed. The government declared March 3 and
March 6 as public cleaning days during which the
population in Juba town cleaned their homes and areas in
town. These cleaning efforts need to be sustained in
order to consolidate the hygiene and sanitation gains
achieved in response to the current crisis.

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Case Management and Surveillance
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10. There are three cholera treatment centers and two
local hospitals providing treatment in Juba. Health
partners are following WHO case management guidelines and
protocol for treating bodies of those who have died. In
addition, all health agencies are using the same case
definition for AWD, making surveillance more systematic
and reliable from the nine fixed surveillance sites in
Juba. Additional sites will be set up to cover new
outbreak areas. The working group analyzes and monitors
the epidemiological pattern and transmissions trends
daily to respond to the changing patterns of the
outbreak. The surveillance system collects
systematically stool samples for laboratory testing in
order to monitor any change in the pathogen causing this
outbreak.


11. Currently the technical group has enough cholera
supplies to deal with the outbreak. However, if the
outbreak continues or expands to several highly populated

KHARTOUM 00000700 003 OF 003


areas, WHO would need assistance with additional cholera
kits, and health partners would need additional resources
to respond. WHO has identified a possible need for an
epidemiologist to provide technical assistance to the
current response.

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Meningitis
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12. Another emerging concern is meningitis. According
to WHO, more than 100 cases of suspected meningitis have
been identified in six states of Sudan to date in 2006.
One death due to meningitis was confirmed at the Juba
Teaching Hospital. The GoSS MOH, GNU MOH, WHO, and NGOs
have begun preparing for a possible meningitis outbreak
by working on the case definition and management
guidelines and setting up disease surveillance systems.
WHO has testing kits and 90,000 vaccine doses ready for
dispatch from Kenya. WHO has one million doses of
vaccines specifically for the Neisseria meningitis W135
strand ready to dispatch from Geneva.

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USG response
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13. The USAID Sudan Field Office (USAID/SFO) and partner
agencies have continued maintaining sensitivity and
support to the GoSS MOH regarding its reluctance to
announce a cholera outbreak, calling it instead AWD in
accordance with GoSS Ministry of Information preference.
International organizations and foreign government
advisors will support a decision by the GoSS MoH to
announce the cholera outbreak, provide modern emergency
management protocols and guidelines, and assist in public
relations damage control if necessary.


14. USAID partner John Snow Institute (JSI) has produced
20,000 copies of information materials for distribution
this week. The first round of posters is scheduled for
distribution in coordination with the GoSS MOH task force
in the towns of Juba, Yei, Terekeka, Kajo Keji, Nimule,
Bor, and Pibor, and the counties of Panyagor, Tambura,
Mvolo, Mundri East and West, Tonj South, and Panyijar.
JSI has also hired an outbreak specialist to provide
recommendations on a technically sound response to the
outbreak and an assessment of current efforts.


15. The Centers for Disease Control and Prevention (CDC)
has suggested that an applied epidemiology resident
expert assist efforts in Juba. A CDC expert from Atlanta
may be in country soon to assist the UNICEF-led effort to
send water and sanitation teams to areas of reported
cases of AWD.


16. USAID and USAID health partners have formed an AWD
outbreak group to share information. The group
understands that the GoSS MOH, GNU MOH, and WHO are the
lead agencies and has agreed that no USG-funded
interventions, publications, or other activities are to
take place without prior knowledge and approval of the
lead agencies. USAID/OFDA partners working in the health
and water and sanitation sectors are using existing funds
to assist in this response through sanitation and
chlorination activities.


17. USAID/OFDA, in close collaboration with USAID/SFO
health specialists, will continue to monitor the outbreak
and provide support should the outbreak spread to new
areas and exceed the capacity of NGOs and WHO. Support
could include funding to purchase new cholera kits,
implement water and sanitation or hygiene activities, and
establish cholera treatment centers. USAID/OFDA, in
collaboration with USAID/SFO health staff, will monitor
preparations for a possible meningitis outbreak and
support NGO partners in case a response is needed.

STEINFELD