1

Rift Valley Fever (RVF) outbreak – Yirol East, Eastern Lakes State,

Republic of South Sudan

Situation Report (Sitrep No. 9) as at 17.00 Hours; 24 February 2018

Summary Statistics

No. Summary of cases Total 1 New suspect cases (deaths) – week ending 25th February 2018 1(01) 2 Cumulative suspect cases (deaths) in

• Health Facilities • Community

03(01) 29(03)

3 Total number of suspect cases on admission 00 4 Cumulative suspect cases discharged 08 5 Epidemiological classification of human cases

• Suspect (pending lab results) • Confirmed by IgG + IgM • Confirmed by IgG • Confirmed – total • Probable • Non-cases (RVF lab test negative) • Deaths (CFR%) – excluding non-cases

12 01 04 05 03 12

04(20%)

6 Number of domestic animal events I. Abortion in goats

II. Abortion in sheep III. Domestic animal abortions IV. Dead goats (with bleeding into tissues) V. Disease in cattle

01 01 02 08 01

7 Wild bird deaths 01 8 Specimens collected

Human – new since last update Human – cumulative Animal – new since last update Animal – cumulative

01 27

00 28

9 Total samples shipped to WHO/FAO collaborating laboratories Human Animal

18 28

10 Cumulative specimens (blood) collected Human Animal

27 28

11 Number of cases with laboratory confirmation Human samples - PCR negative for Ebola, Marburg, CCHF, RVF, Sosuga Human samples - RVF serology – IgM and IgG positive (high titres) Human samples - RVF serology – IgG positive (high titres) Animal samples - RVF serology – IgG positive (high titres)

26 01 04

01

2

Situation update • Since the last update (of 16 February 2018), one new suspect human RVF case has been reported in Yirol East. The

suspect case involved a 17-year-old male from Adior payam that presented to Yirol East hospital on 19 Feb 2018 with history of fever, headache, and joint pains that started the same day. On 21 Feb 2018, he vomited coffee grounds and frank blood and passed melena stools and thereafter lost consciousness and died the same day. RDT was positive for malaria and a blood sample was obtained for RVF testing. A cow is reported to have died after giving birth in the neighbourhood of the case residence. In same way, goat deaths have been reported in the neighbourhood.

• There are currently no suspect human cases on admission in Yirol East. • During the week, eight human samples shipped earlier to Uganda Virus Research Institute (UVRI) in Entebbe, Uganda

tested PCR negative for Ebola, Marburg, CCHF, RVF, and SOSUGA viruses. Serology for RVF is currently underway. • Overall, out of the 26 human samples tested for RVF (since the onset of the current event – 7 Dec 2017), five have been

RVF positive with one sample being RVF IgM and IgG positive while the other four samples were RVF IgG positive. • Test results from the 21 animal (Livestock) samples shipped to South Africa for laboratory testing are still pending.

Initial reports on the event • On 28 December 2017, the Eastern Lakes Ministry of Health reported a suspect viral hemorrhagic fever cluster to the

National Ministry of Health and WHO. The initial cluster involved three deaths in Thonabutkok village, Yali Payam, Yirol East county with 7 December 2017 as the earliest date of onset.

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• Preliminary investigations conducted by the County Health Department, State and National MoH, CUAMM, and WHO showed that the three deaths had a severe hemorrhagic illness and were epidemiologically linked by place (Thonabutkok village) and time (with 49 and 51 as the respective epidemiological weeks of illness onset). However, there was no history of close physical contact between the cases, and travel history was not significant. Also, the symptoms were not reported in the respective close case contacts during the clinical illness or even after death.

• These initial investigations showed significant history suggestive of a zoonotic hemorrhagic illness as abortions in goats and sheep; deaths/disease in goats and cows; wild bird die-offs were reported in association with this event cluster.

Brief Case Clinical and Epidemiological Findings

• The putative initial case was a 30-year-old female Gravida 5 Para 4+0; housewife from Thonabutkok village in Yirol East county. Her illness started on 7th December 2017 with fever, headache, neck pain and sudden nose, gum, and injection site bleeding. She reported to a health facility the same day where she was admitted to maternity ward since she was pregnant. After 8days of treatment with no improvement, she moved to a private clinic for 4days where she was treated for malaria and typhoid fever. The illness worsened on 19th December 2017 and requested to return home. She died at home the same day. No supervised burial was done, and no symptomatic cases have been reported among the close contacts during the clinical illness and after death.

• The second case was a 13-year-old female from Thonabutkok village (approximately 150 meters from the putative initial case). Her illness started on 20th December 2017 with a headache, joint pain, neck pain, fever, generalized swelling at the joints which were painful (ecchymosis), bleeding from the nose and gums. She died at home on 26th December 2017 after she developed bleeding from the skin blisters. Goat and sheep abortions were reported in association with this case. No supervised burial was done, and no symptomatic cases have been reported among the close contacts during the clinical illness and after death.

• The third case was a 15-year-old male from Thonabutkok village. His illness started on 24th December 2017 with a headache, fever, sweating, and neck pain, nose bleeding, vomiting of blood and gum bleeding, convulsions and loss of consciousness. He died at home on 27th December 2017 after failing to improve on treatment in a private clinic. Eight goat deaths with extensive hemorrhage were reported in the case neighborhood (the goats were skinned, cooked and eaten). No supervised burial was done, and no symptomatic cases have been reported among the close contacts during the clinical illness and after death.

Timeline of the Rift Valley Fever outbreak in Yirol East, week 49, 2017 to week 5, 2018

• In the period 7 December 2017 to 24 February 2018, a total of 32 suspect RVF cases were reported in Eastern Lakes state. These were reclassified based on epidemiological investigations and laboratory test results, such that as of 24th

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February 2018, there were a total of five (5) RVF confirmed cases,1 three (3) probable, and twelve (12) suspect RVF cases (laboratory results are pending). Twelve (12) cases were discarded as non-cases following negative laboratory results for RVF and other common causes of viral haemorrhagic fever.

• The case fatality rate among suspect, probable and confirmed cases (excluding non-cases) is 20% (4/20). More cases have been reported among females 12 (60%) than males 8 (40%) (Figure 1).

• Most of the cases have been reported in the 20-29-year and 30-39-year age-groups with most cases occurring the 10-19-year and 20-29-year age-groups in the males while in the females, most cases are reported in the 20-29-year and 30-39-year age-groups (Figure 2). The deaths occurred in the 10-19-year and 30-39-year age-groups (Figure 3).

• Figures 4 and 5 show the distribution of cases by time and outcome/epi-classification. The initial probable cases occurred between week 49-52, 2017. Most suspect cases have been reported in week four though only two have been confirmed as RVF IgG.

• Figure 6 shows the distribution of clinical symptoms among suspect, probable, and confirmed cases (excluding none-cases). The most frequent symptoms are non-specific and include fever, headache, neck pains, and joint pains. Bleeding has been reported in 70% of suspect cases, but none of the five confirmed cases had bleeding.

• All the 20 probable, confirmed, and suspect cases (excluding the non-cases) have been reported from Yirol East county in Eastern Lakes state (Figure 7). In Yirol East county, cases have been reported from five payams with most 10 (50%) cases and all the three deaths reported from Yali payam.

• All the probable and confirmed cases are clustered in Yali Payam, Thonabutkok village (Figures 8 and 9).

1Subject to change as the RVF laboratory case classification algorithm is currently being reviewed.

0 0.1 0.20.05Decimal Degrees

4

White N

ile

R. A

tem

R. M

och

R. Lou (Dok/Dhok)

White Nile

Yirol East

Twic East

Yirol West

Panyijiar

Awerial

Rumbek East

Bor South

Lake Yirol

Rift Valley Fever by Epi classification , Yirol East County, Week 49 of 2017 to Week 8 of 2018South Sudan:

Disclaimer: The boundaries and names shown and the designations used on this map do not imply official endorsement by the United Nations

Map creation date: 24.02.2018

Payam Confirmed ProbableSuspected Total Cases

Case classification by Payam

Mangar 1 0 0 1

2

4

0 0

0 01 1

Total cases

Pagarau 0 0 2

Yali 3 3 10

Wonthou 4 4

Moger

Khap

Adior

1 10 0

0 01 1

5 12 3 20

5

Response updates

Overall coordination of investigation and response activities

• Investigation and response activities are currently coordinated by a multi-sectoral task force that is meeting weekly at the national level and sub-national (Yirol East) level.

• During the week, the RVF taskforce meeting was held at the national level to review the situation and follow up on the implementation of investigation and response activities. In Yirol East, the RVF coordination meeting was held on 23 Feb 2018.

• The WHO technical officer verified the suspect case admitted in Yirol East hospital and supported the collection of samples to facilitate confirmatory laboratory testing.

• Community mobilisation, engagement, and sensitisation activities are ongoing with support from Unicef, CHADO, the County Health Department and the state Ministry of Health.

Surveillance and case management • During the week, one alert was reported, verified, and investigated by the WHO technical officer from the Rumbek hub. A

sample was obtained to facilitate confirmatory laboratory testing. • There are currently no suspect cases on admission. • Surveillance for human and animal alerts by community health workers (CHWs) and community animal health workers

(CAHWs) is ongoing. Weekly update on UNICEF support to the ongoing RVF outbreak (16th – 22nd February 2018) • UNICEF partner, CHADO community mobilizers continued with social mobilization activities such as household

interactive sessions, community meetings, water point and market sessions and church announcement in response to RVF outbreak in Yirol East, Yirol West and Awerial county.

• The83communitymobilisersandPayamsupervisorswereorientedonInterpersonalcommunicationskillsandRVFsymptomsandsigns.Sofar,theyhavereached9,947households(47,762peoples)withkeymessagesonRVFinEasternLakesstate,824communityinteractivemeetingsconducted,5,733peopleparticipated.Inaddition,theairingoutofRVFRadiospotsonMingkamanFM100continuedfour(4)timesaday.BelowaresomeofpicturesduringcommunitymeetingsandhouseholdsessionsonRFVpreventiveandcontrolmeasuresinEasternLakesstate.

Pending actions, gaps, and challenges

• The development of a multisectoral RVF preparedness and response framework that will facilitate readiness activities to enhance resilience capacities to avert or minimize the impact of future rift valley fever outbreaks is ongoing.

• Overall, there is need to strengthen national capacities for viral hemorrhagic fever preparedness, surveillance and response. These capacities will allow the country to respond to emerging threats of other viral hemorrhagic fevers effectively.

• Technical support for developing a rift valley fever communication strategy that will be used for continued community engagement, social mobilization, and risk communication during the inter-epidemic and pre-epidemic period.

• Review and updating of RVF messages and IEC materials by the communications working group is currently ongoing.

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Planned activities and Way forward

• Conclude testing of the pending human and animal samples. • Conduct weekly meetings of the national and state-level RVF taskforce. • Active surveillance and response to emerging human and/or animal alerts in the affected and at-risk counties. • Community engagement and risk communication in the affected and at-risk counties. • Conduct extended public health, animal health, and entomological investigations into the event by – Ministry of Health;

Ministry of Animal Health Resources and Fisheries, WHO, FAO, and partners. • Disseminate regular updates by way of situation reports and/or press statements/releases as the situation evolves.

0 0.1 0.20.05Decimal Degrees

4

White N

ile

R. A

tem

R. M

och

R. Lou (Dok/Dhok)

White Nile

Yirol East

Twic East

Yirol West

Panyijiar

Awerial

Rumbek East

Bor South

Lake Yirol

Rift Valley Fever by outcome, Yirol East County, Week 49 of 2017 to Week 8 of 2018South Sudan:

Disclaimer: The boundaries and names shown and the designations used on this map do not imply official endorsement by the United Nations

Map creation date: 24.02.2018

Payam Alive Died Total CasesMangarPagarau 2

1

Yali

1

Total Cases

Case classification by Payam

1 12

7 3 10Wonthou 4 4MogerKhap 1 1Adior 1

16 4

1

20

7

Tables and Figures

Figure 1: RVF case distribution by sex in Yirol East, wk 49, 2017 to wk 8, 2018

Figure 2: RVF case distribution by age and sex in Yirol East, week 49, 2017 - week 8, 2018

Female60%

Male40%

RVFcasedistributionbysexinYirolEast,wk49,2017towk8,2018

5.00

5.00

25.00

20.00

0.00

5.00

5.00

10.00

10.00

5.00

5.00

5.00

30 25 20 15 10 5 0 5 10 15

0-9

10-19

20-29

30-39

40-49

50-59

Percentage%

Ageinyears

RVFcasedistributionbyageandsex,week49,2017- Feb2018

8

Figure 3: RVF case distribution by outcome in Yirol East, week 49, 2017 - week 8, 2018

Figure 4: RVF case distribution by time and outcome in Yirol East, week 49, 2017 - week 8, 2018

2

7

4

12

3

1

0

1

2

3

4

5

6

7

8

0-9yrs 10-19yrs 20-29yrs 30-39yrs 40-49yrs. 50-59yrs

Num

berofcases/deaths

RVFcasedistributionbyoutcome,YirolEastn=20(exludingnone-cases)

Alive Died

0123456789

47 48 49 50 51 52 1 2 3 4 5 6 7 8

Num

berofcases

Epidemiologicalweekofonsetin2017and2018

RFVcasedistributionbytimeandoutcomeinYirolEast,wk49,2017toweek8,2018

Alive Died

9

Figure 5: RVF case distribution by time and epi-classification in Yirol East, week 49, 2017 - week 8, 2018

Figure 6: Clinical symptoms among suspect, probable, and confirmed cases, Yirol East, wk 49, 2017 to wk 8, 2018

0

1

2

3

4

5

6

7

8

9

47 48 49 50 51 52 1 2 3 4 5 6 7 8

Num

berofcases

Epidemiologicalweekofonsetin2017and2018

RFVcasedistributionbyclassificationinYirolEast,wk49,2017toweek8,2018

confirmed probable suspected

75%

80%

10%

70%

70%

0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Fever

Headache

Neckpains

Jointpains

Bleeding

Convulsions

Clinicalsymptomsamongsuspect,probable,andconfirmedcases,YirolEast,wk49,2017towk8,2018

10

Figure 7: RVF cases by County and Payam, outcome, Eastern Lakes wk 49, 2017 to wk 8, 2018

Figure 8: RVF cases by County and Payam, classification, Eastern Lakes wk 49, 2017 to wk 8, 2018

12

7

4

1 1

3

10

2

4

6

8

10

12

Mangar Pagarau Yali Wonthou Moger Khap Adior

Yiroleast

Num

bercases/death

RVFcasesbyCountyandPayam,outcome,EasternLakeswk49,2017towk8,2018

Alive Died

1

4

3

2

3

4

1 1 10

2

4

6

8

10

12

Mangar Pagarau Yali Wonthou Moger Khap Adior

Yiroleast

Num

bercases/death

RVFcasesbyCountyandPayam,classification,EasternLakeswk49,2017towk8,2018

confirmed probable suspected

11

Figure 9: RVF cases by County, Payam, village, and classification, Eastern Lakes wk 49, 2017 to wk 8, 2018

0

1

2

3

4

5

6

7

Aruau

Agal

jamith

Amethic

koiwic

Pagarau

Agal

Amethic

jamith

Thonabutkok

Wunthou

Yecliet

nyang

jamith

Wunthou

Athoibak

koiwic

Abang Agal Mangar Pagarau Yali lekakodu Wonthou Moger Khap

Yiroleast

Num

bercases/death

RVFcasesbyCounty,Payam,village,andclassification,EasternLakeswk49,2017towk5,2018

confirmed suspected probable