Cross Sectional Survey

Rubkona Payam Unity State, Republic of South Sudan

Prepared by:  Emmanuel Timothy THWOL

PhD candidate, University of Juba

Executive Summary

A tribal conflict of December 2013 has seriously devastating South Sudan and its people. According to recent data, 4.2 million people are in need of assistance; 5,993 were injured, and 705,800 were displaced. 202, 500 are in refugee. Unity State is one of conflict affected region where significant numbers of people injured, displaced from their areas and live under protection in UNMISS compound. Currently more than 7,000 IDPs live under UN peace keeper protection.

The cross sectional study was designed  to assess the prevalence of malaria and diarrhea in Internal Displaced Persons (IDPs) in Burkina Payam of Unity State, Republic of South Sudan.

About 40 subjects were interviewed with structured questions during the survey. SPSS data software was used for data entering and analysis.

In addition, four Epi-weeks IDSR morbidity reports from primary health care units: PoC1, PoC2 and IOM Clinic were analyzed to see burden/trend of malaria, diarrheal and other diseases in IDPs under five children.

Finding: Among 40 study population, 17 (43.5%) and, 20 (51%) of under five children were found to have diarrhea and malaria diseases respectively in the last two weeks of the study. Male children experienced more illness of malaria and diarrhea in this study finding. Among those, who have reported the presence of disease during interview, 63.6% and 50% of male children caught malaria and diarrhea respectively while only 35.5% of female children experienced the illness in both malaria and diarrheal diseases.

The analysis of weekly IDSR morbidity report also showed that the burden of malaria ranked first and followed by diarrheal disease in under five children. Malaria accounted for 45%, while acute watery diarrhea was accounted for 21 % in the last 4 weeks of health care morbidity report.

Conclusion:

  1. This study can be used as baseline information on current health condition of Rubkona IDPs to draw area of attention for public health interventions to improve their health.

  2. Provide health promotion activities to enable the IDPs community control over potential risk factors associated with diarrhea and malaria

  3. Moreover, additional assessment with strong methodology is encouraged to answer why high prevalent of the disease and why male children more affected than females?

Introduction

The Republic of South Sudan is newly emerging country from prolonged civil conflict and faces immense social, economic and political challenges; Inter and intra-tribal tension over resource and political space are common challenges - experiencedin different pockets of the administration units.  High mortality and morbidity form preventable diseases are another facet of challenge.

The country is situated adjacent to Kenya, Uganda and Democratic Republic of Congo in the Southern, Ethiopia in the East, Central African Republic and Chad in the West and Northern Sudan in the North. It has a surface area of 383,537 Sq. Kms. It consists of 10 States and 80 Counties administrative units with an estimated population of 10.8million (2008 Censes).

South Sudan is one of the most undeveloped countries with little infrastructure and highest maternal mortality and female literacy rate in the world.  More than 90% of population lives on less than $1 a day. South Sudan has the worst health indicators in the world. The life expectancy at birth is 54 years; the under-five infant mortality rate is 135.5 per 1000 live birth. The maternal mortality is the highest in the world at 2053.9per 100,000 live births. The prevalence of HIV among adult age 15-49years is estimated to 3.1% (WHO Global Health observatory data, 2011)

Current Crisis in South Sudan

The Republic of South Sudan is falling into new crisis since 15 Dec 2013 after two years of independency. It celebrated independency as of 9 July 2011. An armed confrontation between Ethnic supporters; Dinka and Neuer are blamed for the crisis and thousands reportedly killed, thousands displaced along the ethnic lines. The situation has begun to deteriorate in to a civil war. Over millions of south Sudan forced from their home due to conflict. Seven of ten states are affected by current wave of armed violence with most affected being Jonglei, Unity and Uper Nile States. 4.2 million People are in need of assistance, 5,993 were injured, and 705,800 were displaced. 202, 500 are in refugee. More than 68,000 IDPs are sheltering in the UN peace keeping base (UNMISS) of which 32,000 in Juba ( Tomping and UN house), 21, 500 in Malakal, Upper Nile state, 5,694 in Bor, Jongle state, and 7407 in Bentu, Unity state, The Number of people who need lifesaving assistance such as health care and protection is deemed to continue to increase.

Priority population set: children under five years of age, women who are pregnant or of child bearing age, people vulnerable to violence or gender based violence

Principal health issues

  1. Injuries as direct result of violence,

  2. high burden of communicable diseases, such as pneumonia, diarrhea and malaria - the leading causes of childhood death

  3. Risk of disease outbreaks related to lack of safe water, poor sanitation and hygiene, overcrowding and low vaccination coverage

  4. Malnutrition; especially of infant and young children, reproductive health, sexual and GBV, sexually transmitted disease and mental health.

  5. Poor access to health services due to attack on patient and health assets and severe shortage of health staff

  6. Major disruption in medicine supply chain

  7. Poor infection prevention and control in health facility

Literature Review  

Water born / Sanitation/Hygiene related diseases

According to recent WHO/UNICEF estimates, only 9.9% have an access to treated water in South Sudan. About 15.5% have access to improved sanitation and the large majorities (64.4%) of the population are practicing open defecation. With this low access to water, sanitation, and hygiene (WASH)the reeks of epidemic disease is predictable to occur.

The risk of cholera outbreak is also high because of population movement, overcrowding, inadequate hygiene and toilet facilities, and limited access to sufficient and safe water. Similarly, the risk of other water born diseases such as hepatitis A or E, shigellosis and typhoid fever outbreak is high, particularly in IDPs settings.

Malaria in high complex emergency

A complex emergency is a situation that affects large civilian population with war or civil strife, food shortages and population displacement resulting in excess mortality and morbidity. For instance, war between states, internal conflict, and political persecution of ethnic group. This situation may cause large-scale population displacement or commonly leave community stranded and isolated in their homes unable to access assistance. These settings are often characterized by breakdown of social and physical infrastructure including health care system.

Malaria is common and life threatening diseases in such kind of settings and in many tropical and sub-tropical areas. It is currently endemic in over 100 countries. Each year an estimate of 300 million people fall in with malaria and there are more than one million deaths.

In South Sudan, high malaria risk due predominantly to plasmodium falciparum exists throughout the year especially during rainy season in the whole country including the capital Juba. Wide spread resistance to chloroquine and sulfadoxine-pyramethamine makes these drugs obsolete for treatment of malaria in the country.

Diarrhea

In the year 2000, diarrhea claimed an estimated 1.4 to 2.5 million lives. It is among one of the leading causes of death in developing countries. Both the incidence and risk of mortality from diarrheal disease are greatest among children younger than 1 year of age and thereafter rate decline incrementally. Other consequence of diarrhea in children includes malnutrition, diminished growth, and impaired cognitive development in resource limited countries. Estimated episode of diarrhea per year is estimated at 1.5 Billion. In developing countries, children under 3 years of age have 3 episodes per year. The morbidity from diarrhea has remained relatively constant during the past two decades, with each child under five years of age experiencing an average of three annual episodes. Interventions such as breastfeeding and improved sanitation are expected to affect mortality and morbidity simultaneously.

Causative Agent and Pathogenic Mechanism of Diarrhea


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Other Diseases Associated with Displacement and Crowding

Population displacement can result in overcrowding in resettlement area -raising the risk of transmission of many communicable diseases including vaccine preventable diseases. Acute respiratory tract infections, measles, diphtheria, meningitis and pertussis are transmitted from person to person through respiratory droplets generating during coughing and sneezing and the risks are increased when shelters are overcrowded and inadequately ventilated.

Measles

The risk of measles outbreak is high because of the low vaccination coverage in population movement and the overcrowding in IDPs setting. Measles is highly contagious disease and substantially affects all susceptible hosts in IDPs setting. The case fatality rate can reach 30% due to complex risk factors in crises

Integrated Disease Surveillance and Response (IDSR)

The Integrated disease surveillance system was launched in South Sudan in 2006. It was launched in the country to integrate multiple surveillance systems and vertical programs like AFP surveillance. The intention was to help the country to use available little resources in efficient way and to improve the use of information for decision making. Currently, IDSR is well promoted and technically supported by country WHO office. The integrated surveillance system monitors nearly 27 diseases. The epidemic prone diseases are reported on weekly bases. These diseases are: Cholera, Acute Watery Diarrhea, Diarrhea with Blood, Measles, meningitis, Viral Hemorrhagic fever (VHF), Relapsing fever, Acute Jaundice Syndrome (AJS), malaria, Neonatal Tetanus, Guinea-worm disease suspect, and Acute Flaccid Paralysis (AFP)

 

Objectives of the study

General Objective

The general objective of this study is to assess the health Condition of under five children in IDPs

Specific Objectives

  • To estimate IDPs access to safe drinking water and toilet

  • To determine the prevalence of diarrhea and malaria on under five children in last two weeks of the assessment

  • To determine proportion of household members access to toilet and mosquito bed net

  • To see the trend/burden of malaria and diarrheal illness in the last 4 epidemiologic weeks of the cross sectional study

Methodology

A cross-sectional survey was conducted in selected cluster of the study areas in the IDPs compound. Structured questionnaires were prepared to interview subjects of interest. In addition, Patient consultation book was assessed for four epidemiologic weeks back to see the burden of cases in IDPs  

Sample Size

A total of 40 subjects were interviewed from all clusters. The mother who has under five years of child was interviewed in the cluster as the under-five child could not be interviewed for his/her age.    

Sampling

WHO cluster methodology was used to determine desired clusters for study. Names of clusters were listed out in the camp.  Five clusters were selected randomly. Then, lottery method or random sampling technique was used to select the study subject in the study cluster. All 40 subjects were reached with interview questionnaires as per random selection outcomes

Sample Size

A total of 40 subjects were interviewed from all clusters. The interview was conducted with the mother who has under-five years of children in the cluster. One mother was interviewed in every household as per random sample captured the study subject from study population

Data Analysis

SPPS data software was used for data entering and analysis. The data was carefully organized and entered to run frequency to see desired variables distributions and may be further analysis if needed

Result

Characteristics of the study population

A total of 40 mothers who have under-five children were interviewed on their children health condition during the study. The minimum age of the study sample was 2 months and the maximum was 48 months. The mean age was 24.7 with 13.27 of standard deviation.

Figure 1: Distribution of age of study population

Age (in month)

Frequency

Percent

0-11

6

15

12-59

34

85

Total

40

100

 

 

Distribution of study population by sex

About 23 (57.5%) male children and 17 (42.5%) of female children were included in the study. See the following pie gram.

 

Household size per shelter

The study population were homogenous that derived from the same community who were victims of crisis during the war. In this study, large members of the family were found to live together in small emergency shelter. About 6 (15%) sample live with at least 5 people, 15 (35.7%) lives with 5-7 people and the rest 19(47.5%)lives with 7 or more people in one shelter or household.

Diarrheal Disease

Considerable prevalence of diarrhea was identified during this study. Among 40 studied population, 17 (43.6%) of under five children were found to have diarrhea in the last two weeks of the study. This study did not specify types of diarrhea. But asked for those who experienced diarrhea by definition (those who pass loose stool three times or more within a day or 24 hours.

Figure 4: Distribution of diarrheal case by age, sex, and size of household

Variables

Got diarrhea in the last two weeks

Total

 

yes

No

 

Age of child (months)

     

0-11

16.7

83.3

100.0

12-59

48.5

51.5

100.0

Total

43.6

56.4

100.0

Sex of the child

     

Male

50.0

50.0

100.0

Female

35.3

64.7

100.0

Total

43.6

56.4

100.0

Household size per shelter

     

<5

83.3

16.7

100.0

5-7

53.3

46.7

100.0

7+

22.2

77.8

100.0

Total

43.6

56.4

100.0

 

Hygiene and Sanitation

The IDPs have access to treated source of drinking water from pillow or bladder tanker. This study revealed 97% of study population gets drinking water from tanker. From this source, about 28(70%) of the study population consume more than 60 liters per day. 11(27%) consumes 41-60 liters of water per day. The tanker had never been seen cleaned or flashed with water. 39(97.5%) subjects reported it was not cleaned since they had begun to use a tanker as source of water in IDPs. See figure 5 for daily water consumption

Among the study population, 20 (50%) have hand washing facilities to clean their hand after toilet use while 19 (47.5%) of the study population do not have hand washing facilities to practice hand washing after toilet use. Only 22(55%) of the study population have soap to wash their hand with soap while 18(45%) of the study population do not have soap to wash their hand with soap. Unfortunately, this study did not assess how many of the study populations who have an access to hand washing facilities are used to washing their hand after toilet use.

Toilet and its utilization

If not all, almost 38(95%) of the study population were accessible to pit latrine for human excreta disposal, but a single toilet is shared by many household members. An average number of users per toilet were found to be minimum 20 people and maximum 100 people or more. See the following table

Figure 3: Average number of users per functional toile

 Number  of users

Frequency

Percent

<20

3

7.5

21-25

9

22.5

51-100

16

40

>100

12

30

Total

40

100

 

Malaria

Malaria was found to be high prevalent in this study finding. Among 40 studied population, 20 (51%) of under five children reported got malaria in the last two weeks of the study. See figure 4tables below. Availability of mosquito bed net in the household and use were also assessed to see the utilization rate among studied population. About 16 (40%) household members were found to use when they are in bed. 16 (40%) of the household members reported some uses and some of household members do not use mosquito bed net. About 8 (20%) of the study population had never used mosquito bed nets to protect mosquito bite when they sleep.

Figure 4: Distribution of malaria in the study population

 Got Malaria

Frequency

Percent

Yes

20

51.3

No

19

48.7

Total

39

100.0

 

Figure 5: Distribution of Malaria by age, sex, and size of household

 Variables

Yes

No

 

Age of child (months)

     

0-11

33.3

66.7

100.0

12-59

54.5

45.5

100.0

Total

51.3

48.7

100.0

Sex of the child

     

Male

63.6

36.4

100.0

Female

35.3

64.7

100.0

Total

51.3

48.7

100.0

Household size per shelter

     

<5

66.7

33.3

100.0

5-7

57.1

42.9

100.0

7+

42.1

57.9

100.0

Total

51.3

48.7

100.0

 

IDSR Morbidity Report Analysis

The morbidity report analysis is limited to weekly notifiable diseases. Among notifiable diseases, cases of acute watery diarrhea (AWD), Diarrhea with Blood (BD) and malaria were analyzed roughly to see their prevalence along with cross sectional survey finding.The  Epi-week 10-13 morbidity report were captured from health facility record and analyzed to see the burden of these cases among under-five children living in the study area.

The morbidity report analysis also revealed high prevalence of malaria among under-five children who visited the health facilities in the last 4 weeks of the study. The prevalence of malaria, acute water diarrhea and Bloody diarrhea were found to be 45%, 21% and 3.6% respectively. As you see from line graph, malaria peaks high in week 12 (59.9%). The prevalence of diarrhea with blood looks constant ranged from 2.8% to 6%.  For details see Figure 5 &table below

 

 

 

Limitation of the study

This is a small descriptive study to establish a kind of base line information for those in need to use this information to improve IDPs health condition. The sample size is too small to do further analysis and to generalize the observed findings to the general population.

It might be advisable to observe subject’s household hygiene practice and mosquito bed net use during survey, but this could not be done due to time and other resource constraints.

Anyhow, this study is not a big research. It is a capstone that may pave a way for me to a big research that I wish to do in the next move.

 

Discussion

It is well known that unhygienic food and drinking water are risk factors to develop diarrheal disease. In this survey, household hygiene and sanitation assessment were not included to see risk factors for possible association with diarrhea. According to this study result, 39 (97.5%) subjects were accessible to safe sources of drinking water and relatively have good amount of water distribution. Among the study subjects, 11 (27.5%) uses 41-60 liters of water, 28 (70%) of subjects use 61 or more liters of water for drinking, cooking and cleaning purpose daily. This may not be far from WHO recommendation which is 20 liters of water per person to use for all purpose. But his could not be enough to reduce risk of getting diarrhea. Because water may be contaminated from the container when the member of the family fetches it, or can be contaminated in the process when they are using it. In addition, the hygiene of the household members may not be good in particular mothers when they prepare the food for the family and feed the small children. These all may be contributing factors to develop diarrheal disease.

Malaria is stable disease in South Sudan; it is always there. It is difficult to avoid the incidence of malaria in the IDPs. However, it’s possible to reduce the risk of getting malaria and death due to malaria. The incidence of malaria can be reduced by reducing mosquito population in resident areas through different approaches that is interfering with mosquito breeding sites via chemical, biological or drainage of stagnant water. The use of treated mosquito bed nets to protect families from mosquito bite is cheap and doable exercise if the family understood why the uses of mosquito bed nets are promoted in malaria region. In this study, 16 (40%) subjects  use mosquito bed net when they sleep while 16 (40%) subject’s family partially use; some of the household members use while other members of  the family do not use mosquito bed net when they sleep. The presence of mosquito bed net in the household will not prevent mosquito bite unless they use whenever they sleep. The whole household members should use mosquito bed net all nights when they sleep. There is no person immune to malaria disease. Malaria is deadly disease. But it is possible to prevent or reduce death by early detection of the disease and provision of treatment. So it is possible to provide IDPs community with health information to improve their care seeking behavior for early detection and treatment of the diseases

Conclusion

This study can be used as baseline information on current health condition of Rubkona IDPs;

(1) To draw area of attention for public health interventions to improve their health condition.

(2) Provide health promotion activities to enable the IDPs community to control over potential risk factors associated with diarrhea and malaria.

(3) Moreover, additional assessment with strong methodology is encouraged to answer why high prevalence of the disease and why male children are more affected than females?  

Reference Materials

  1. United nation Mission in South Sudan, (UNMISS), Communication and Public Information Office,26 March 2014

  2. Communication Strategy for prevention and control of malaria during pregnancy,

  3. World Gastroenterology organization practice (Acute Diarrhea), March 2008

  4. Malaria control in complex emergency. An integrated field hand book, WHO 2005

  5. Surviving Malaria decision guide, October 2003

  6. WHO South Sudan emergency Response. Situation report #15

  7. Conflict and Human crisis in South Sudan. WHO, 03 Jan 2013

  8. Assessment of Needs of IDPS in Colombia, Dec 2002

  9. (WHO-South Sudan Emergency response situation report #15 (13-19March 2013).

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