VZCZCXRO4532
PP RUEHROV
DE RUEHKH #0700/01 0790732
ZNR UUUUU ZZH
P 200732Z MAR 06
FM AMEMBASSY KHARTOUM
TO RUEHC/SECSTATE WASHDC PRIORITY 1955
INFO RUCNIAD/IGAD COLLECTIVE

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 
 
------------------- 
Summary and Comment 
------------------- 
 
¶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. 
 
------------ 
Introduction 
------------ 
 
¶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. 
 
------------ 
Coordination 
------------ 
 
¶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, 
 
KHARTOUM 00000700  002 OF 003 
 
 
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. 
 
--------------------- 
Environmental Control 
--------------------- 
 
¶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. 
 
-------------------------------- 
Case Management and Surveillance 
-------------------------------- 
 
¶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. 
 
---------- 
Meningitis 
---------- 
 
¶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. 
 
------------ 
USG response 
------------ 
 
¶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