Prepared by:

Emmanuel Timothy THWOL

PhD candidate, University of Juba  

 

  1. Executive summary

 

Kala-azar is endemic in this country especially at Upper Nile state. From last couple of months, there were unusual high number of cases treated in Malakal Teaching Hospital; primarily defined by the attending clinician as an outbreak. So, this reporter started investigating it with objectives of (i). Understanding the epidemiology of the suspected outbreak for immediate response and (ii) planning to minimize future risk of such outbreaks.

 

This investigator has to depend on hospital records only. According to the records, 50% of total cases (n=164) are from Malakal county, 25% from Baliet and 20% from Fashoda county. The outbreak seemed started from August and then sharply rose on September and October especially in Malakal County. Two-third of total cases is below 15 years age group: 34% under 5 years and 32% “5 to <15” year’s age group; uncommon in ≥35 years age (10% only). Most of the cases were malnourished (under-nutrition); about 14% (23) of total cases died mainly due to severe anaemia. Though it is not clear in the hospital records yet it is understood that Kala-azar patients are coming to the hospital late: 41% after one month of onset, 34% after 2 months and 13% after three months.

 

As the outbreak is still in upward trend and mainly in Malakal county among <15 years old children, an immediate outbreak response is critical. It includes: (i) uninterrupted supply of medicine for Kala-azar management (ii) equipping peripheral primary health care facility staffs especially in Makal county with knowledge and logistics for rapid diagnosis and referral and also (iii) establishing a community network for Kala-azar awareness, case identification and immediate referral in addition to  Providing nets to the high risk community also important.

 

    1. Introduction and background information

 

Kala-azar in this region occurs in 2 foci and is caused by L. donovani. In the one focus (Upper Nile, Jonglei, and Unity states), Phlebotomus orientalis is the vector. Epidemiologic modelling of data from Upper Nile state estimated that those who visited healthcare facilities from October 1998 through May 2002 represented only 55% of cases and that 91% of kala-azar deaths were undetected. Health coverage is so minimal that some patients must walk for several days to access even the most basic healthcare services. So, the cases detected at the Malakal Teaching Hospital in 2013 outbreak and number of known deaths might be tip of the iceberg especially in this rainy season of this highly inaccessible state.

 

  1. Objective of the investigation

    1. General objective

 

  1. Conduct of an epidemiological investigation, situation analysis of the Kala-Azar outbreak and identifying the risks factors in the State in Upper Nile Sate.

    1. Specific objectives

 

  • Understand the epidemiology (pick time, most affected place and person) of current Kala-azar outbreak in Upper Nile and response accordingly

  • Provide technical guidance to the State Ministry of Health (SMOH) and the relevant institutions  on the magnetite of the outbreak

  • Future plan to minimize risk of Kala-azar outbreaks in Upper Nile state

 

  1. Methodologies  used in data collection

The study established an outbreak hypothesis and verifies all possibilities of Kala-azar  occurrence through analysing all hazard factors and options, conducting assessment exercise in Malakal Teaching Hospital (MTH) , in addition filed visits to Health Facilities, Market place and residential areas were carried out to create clear scenario, accordingly the  following  details methods where  conducted ;

 

    1. Health facility visits and collection of epidemiological data

    2. Community visits and assessment of   environmental conditions

    3. Key informant interview of key SMOH officials, stakeholders, community members and leaders

    4. Collection of relevant samples for testing

 

  1. Limitation of this investigating exercise

 

This investigation was conducted based on hospital record which is inadequate, not unique and not much specific to prepare a complete report. Even after cleaning data obtained from the hospital records, this investigator has to compromise with the quality of information/data and its analysis.

  1. Epidemiology of the Kala Azar outbreak

    1. Place

 

Kala-azar cases of Upper Nile outbreaks are mainly from 4 counties and also huge number (69) from a neighboring county, Pigi of Jonglei state. In Upper Nile state (n=164) about half of the cases are from Malakal (86), one fourth from Baliet (40), one fifth from Fashioda (32) and few (6) from Akoka county. Traditionally houses in these areas are made of soil without windows and most of these areas are bushy.

 

Map: Kala-azar case distribution by counties

map1

 

About ²/3rd of total cases (n=164) are below 15 years old:34% from under 5 years age group and 32% from “5 to <15 years” group. Only 10% are from ≥ 35 years age group.


Two third of total cases are male and remaining female; None pregnant.


Almost all the adult patients (97%) were in <93% of “weight for height” range and none of the children with >18.2 BMI

Weight for height %      

<25%

25 to <50%

50 to <75%

75 to <93%

≥93%

Kala-azar patients in %  

38%

0%

30%

30%

2%

 

    1. Time                                                    Chart 2: Kala-azar cases by month of onset

 

There were 2 to 11 cases in each month from January to July 2013; seemed normal as the disease is endemic in this state.


But there was a sharp rise in September and pick in October especially in Malakal (28 & 36 cases respectively).

 

    1. Complication                   Chart 3: Status of anaemia (Hb gm/dl) in Kala-azar patients

About three fourth of total cases got moderate to severe anaemia as

mentioned below (per dl)-


  • <5 gm        : 14%

  • 5 to <7 gm : 30%

  • 7 to <9 gm  : 32%

 

About 2% of the cases got

Hepatic failure

 

4.5. Case fatality rate

About 14% of the total detected cases (23 out of 164 cases) died; 20 of them due to severe anaemia, 1 due to anaemia with jaundice and 2 due to hepatic failure.

 

  1. Discussion

It is assumed that about half of total Kala-azar cases are not seeking medical care from the hospital and about 90% of total death cases remained undetected. As all the cases are from neighbouring counties of Malakal Teaching Hospital, so there might be many more Kala-azar patients especially in the remote communities and significant number of those cases are dying home without proper medical care.

 

Two third of total cases are children and significant (34%) percentage are under 5 years age group; indicates lack of awareness about Kala-azar among parents to protect their children from sand fly bites.

 

Kala-azar patients especially from the distant places coming late (1 to 8 months after onset) for hospital care that indicates inadequate or absent social awareness program in Upper Nile state as well as poor screening facility at the primary health care facilities. The outbreak is at the pick in October and may continue unless community level intervention given.

 

  1. Conclusion

 

Some shortage of drugs to manage Kala-azar patients in Malakal Teaching Hospital noticed. Interventions to save Kala-azar patients means saving children of Upper Nile as two thirds are under 15 years age.

 

8.Challenges

 

  • Inaccessibility of some areas (HFs) for an aim of getting broader picture, information gathering and evaluation of preparedness level at PHCUs due to lack of mobility means.

  • Inadequate multi-sector representation in the State.

  • Cross-border movements heighten the risk of communicable diseases

 

9.Lessons learned

  • Necessity for SMOH staff capacity building, surveillance system reform and emergency stockpiles preposition at State, County level is highly due to remoteness of health facilities and inaccessibility of roads.

  • Potentially need to extend support to counties hospitals to equip to response to any reported case.

  • Strengthening an area of sample collection ,shipment and examination

 

 

 

10. Recommendations

10.1. For immediate response:

  • Ensure uninterrupted supply of medicine for Kala-azar management at Malakal Teaching Hospital

 

  • Equip peripheral primary health care facility staffs especially in Malakla County with knowledge and logistics for rapid diagnosis and referral. Supplying nets for high risk community also critical

  • Provision of supplies: The provision of supplies required for outbreaks response activities; supplies should available in state or county.

  • Human resource development and training: Service quality in HFs should be maintained and improved by counting refresher trainings.

10.2. For late response: Establish a community network for Kala-azar awareness, case identification and immediate referral. A comprehensive plan for community level AFP surveillance, EmOC awareness and “Kala-azar awareness-identification-referral” system might be developed with the support of local partners.

 

References

  • SMOH IDSR /HIMS data base 2013

  • WHO Malak Sub office  weekly bulletins (2013 )

  • WHO Malakal sub office Kalzar’s outbreak line -listing (2013)

  • WHO South Sudan emergency Response. Situation report epidemiological weeks  #(13-43)

  • WHO-South Sudan Emergency response situation report Wpi Wks #1(3-452013).

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