Chikungunya in Sudan · Chikungunya Fever • Chikungunya Fever is an emerging disease caused by Chikungunya virus (CHIKV) • An arbovirus transmitted by the bite of infected female

Chikungunya Fever in Sudan 2018-2019

3-2 October2019

AlMATY -Kazikhstan

Dr.Nassma Altayeb

Health Emergency and Epidemic Control Federal Ministry Of Health Sudan

Introduction • Sudan is a sub-Saharan African country

that borders the Red Sea and seven countries. E

• The total population of Sudan estimated to be 43,120,843 (July 2018 est.).

• Administratively, Sudan is divided into 18 States.

• Eastern Sudan includes three States; namely, Red Sea, Kassala, and Gedaref States.

• Eastern Sudan has the coastline with the Red Sea and shares borders with Egypt ,Eritrea and Ethiopia

• The climate in Sudan is hot and dry.

Introduction • In November 2018 over 200,000 people in 15 of

Sudan’s 18 States have been affected by heavy rains and flash floods between June and early November

• This is almost double the number of people affected by floods the same time last year.

• Over 19,640 homes were destroyed, according to • The situation created favorable ground for

mosquitoes breeding.

• People in eastern Sudan, including Kassala and Port Sudan Cities, suffer from periodic shortage of potable water.

• The people tend to store water in Jerricans and other containers.

• Usually these containers do not have cover and turned to be breeding sites for mosquitoes.

Chikungunya Fever

• Chikungunya Fever is an emerging disease caused by Chikungunya virus (CHIKV)

• An arbovirus transmitted by the bite of infected female mosquitoes, Aedes aegypti and Aedes albopictus

• Chikungunya Fever occurs in sub-Saharan Africa, Southeast Asia and tropical areas of the Indian subcontinent, as well as islands in the south-western Indian Ocean.

Chikungunya, countries or areas at risk in 2015.

Clinical Presentation of Chikungunya Fever

• In July 2018 many people of Kassala city in the east of Sudan were complaining of sudden high fever and un ability to walk and the majority of patient requiring assistance to walk

The disease is characterized

• Fever • Headache • Myalgia • Rash • Both acute and persistent arthralgia. Other symptoms may include joint swelling or rash. • Symptoms usually begin 4 - 8 days after being

bitten by an infected mosquito. • Most patients will feel better within a week and

recover fully. • The disease can cause severe morbidity and, since

2005, some fatal cases were reported

History of Chikungunya Fever in Sudan

• There are reports of the sporadic cases of CHKV in Sudan since 2007

• co-infection with Yellow Fever and Dengue • There were no records of occurrence of a major

outbreak of Chikungunya Fever in Sudan. • Nevertheless, Aedes aegypti has been detected

in all States of Sudan except Khartoum and Northern States

Beginning of the Outbreak • On 31 May 2018, the State Ministry of Health (SMOH) of Red Sea

State reported four suspected cases of Chikungunya Fever from Sawakin locality; diagnosis was coined based on clinical grounds.

• On 27 July 2018, the sentinel disease surveillance system in Kassala State detected unusual increase of cases of Undifferentiated Febrile Illness (UFI) associated with arthralgia and other symptoms.

• On 8 August 2018, Kassala State reported the first suspected case of Chikungunya Fever in a male traveller from the Red Sea State.

• The diagnosis of Chikungunya Fever was laboratory confirmed by the National Public Health Laboratory (NPHL), Khartoum

• Afterwards, more cases were reported from Kassala city. • Later, some cases of Chikungunya Fever were reported from rural

areas in Kassala State

Case Definition

• The FMOH and WHO developed case definitions for Chikungunya Fever because Chikungunya Fever has never been in the list of notifiable diseases in Sudan.

• A suspected case : a person presented with acute onset of fever (greater than 38.5°C) and severe arthralgia with travel history to areas affected by Chikungunya Fever transmission within 15 days prior to the onset of symptoms and his/her illness that could not be explained by other medical conditions

Case Definition

• A confirmed case :a suspected case with laboratory confirmation by one of the following two tests in the acute phase.

• Serological tests: Enzyme-Linked Immunosorbent Assays (ELISA), to confirm the presence of IgM and IgG anti-chikungunya antibodies .

• presence of viral RNA by Reverse Transcriptase–Polymerase Chain Reaction (RT–PCR) as recommended by WHO

Laboratory Investigation • More than 150 blood samples were collected

from patients presented with UFIs in Kassala city and Port Sudan were transferred to the NPHL

• for testing by RT-PCR and or ELISA and confirm the CIKV

• Additional laboratory tests were made to exclude malaria and Dengue Fever.

• The sequencing of the virus was conducted at UK to identify the strain of the outbreak

Laboratory Investigation

• Indicated that the Chikungunya virus was of South East Asian origin

• It is most likely that the virus

entered the Sudan through a ship that harbored in Sawakin seaport.

Entomological Data • Data on activity of mosquitoes were collected from fixed

sentinel sites used for routine monitoring of malaria control program.

• The Entomology Survey Team of the vector control divided the quarters of Kassala city (more than 47 quarters) into six sectors.

• Each week the Entomology Team predefined the number of households to be covered that particular week.

• About 1,167 Health Care Workers (HCWs) including 782 volunteers participated in inspecting households and instituting corrective measures as necessary.

Entomological Data

• The inspection team checked for larvae in water-storing containers as well as for potential breeding sites within and around the houses. e.g. broken water pipelines, discarded tins, tires, plastic bottles, etc

• Every water-holding container is inspected and categorized as positive (contains larvae/pupae) or negative (no larvae or pupae).

• Entomological surveys conducted in Kassala, Red Sea and Gedaref during the outbreak

• At the beginning of the outbreak, the entomological assessment reports found that about one third of all inspected houses in Kassala City were infested with larvae of Aedes aegypti.

• In Red Sea State Aedes aegypti were found in 1,955 (21.9%) of 8,906 inspected containers in government and private institutions.

Tools used to remove Larvae In water containers) in Kassala, 2018

Control Measures during the Outbreak

• The key interventions instituted by FMOH/SMOH to contain the spread of the outbreak focus on four areas.

(1) Enhancing disease surveillance (2) Improving case management (3) Implementing Integrated Vector Control (IVC) (4) Intensifying social mobilization.

Enhancing disease surveillance

• FMOH& WHO Developed working case definitions for suspected and confirmed to enhance early detection

• Health Care Workers (HCWs) were trained on the case definitions and the case definitions were printed in posters and distributed to all public and private health facilities in the affected States

• The SMOH instructed all health facilities and private practitioners to report suspected on daily basis including zero reports

Improving Case Management • The FMOH and WHO

adopted case management protocols for Chikungunya Fever.

• conducted series of training on appropriate case management for HCWs in the affected States in Sudan

• Medical supplies (e.g. Intravenous (IV) fluids and anti-pyretic drugs) needed for case management were made available. Chikungunya patients in

Kassala, 2018

Improving Case Management • In Port Sudan, some

traditional healers posted advertisement as having traditional medications for Chikungunya.

• The picture shows an advertising flyer for tradition treatment of Chikungunya Fever with telephone number of the traditional healer.

Implementing Integrated Vector Control (IVC)

• In Kassala State only an average of 270 IVC teams were deployed.

• 1st team : made house-to-house visits to inspect, demonstrate and eliminate positive or potential breeding sites for Aedes aegypti at the household level

• 2nd Team were deployed to inspect and manage mosquito breeding sites in the institutions such as mosques, schools, health facilities, and market places

• To complement the above vector control strategy, knockdown space spraying (fogging) was conducted in selected areas in Kassala City to rapidly reduce the adult vector density.

Health promotion and social mobilization

• The FMOH developed and distributed health promotion materials in the affected States.

• The Information, Education and Communication (IEC) materials (with pictures and illustrative diagrams) were used to educate the public on how to avoid infection with Chikungunya virus.and raising awareness on preventive measures at household and community levels

• The health promoters joined the IVC teams during the house-to-house visits where face-to-face health educational messages and demonstrations took place

• messages were passed to the public using printed materials

• All The messages were adapted to the local context and language

Epidemiologic Description of the Outbreak

• The outbreak of Chikungunya Fever occurred in Sudan during the period between 31 May 2018 and 30 March 2019.

• A total of 48,193 cases of Chikungunya Fever were reported by disease sentinel surveillance system.

• Almost all cases (99.7%) occurred in Kassala and Red Sea States of eastern Sudan alone.

• Smaller outbreaks and laboratory-confirmed sporadic cases of Chikungunya Fever were also reported from seven other States; namely, Gedaref, River Nile, Gezira, Sennar, West Darfur, South Darfur and North Kordofan

Map showing spread of Chikungunya Fever in Sudan, 2018-2019

Epidemiologic Description of the Outbreak

• All the reported sporadic cases were epidemiologically linked to the outbreak in eastern Sudan.

• The sporadic cases did not result in outbreaks with locally acquired cases, except in West Darfur and North Kordofan States.

• In West Darfur 39 locally acquired cases of Chikungunya Fever were documented.

• In North Kordofan a small outbreak (113 cases) occurred in small village during the period between 26 February 2019 and 16 March 2019.

• The outbreak was successfully contained and no more cases of Chikungunya Fever were reported from neighboring towns or villages.

Epidemiologic Description of the Outbreak

• In eastern Sudan, the outbreak occurred in four waves. • First wave of the outbreak that occurred in Sawakin town,

Red Sea State (736cases) was on 31 May 2018. The outbreak in Sawakin town continued for nine weeks

• The second wave of the outbreak occurred in Kassala State where the sentinel disease surveillance system reported a total of 19,902 cases of Chikungunya Fever.

• Almost all cases (19,015 cases, 95.5% of all cases in Kassala State) occurred in Kassala City alone.

• The daily caseload reached as high as 1,100 cases during the peak of the outbreak.

• The epidemic curve of Chikungunya Fever in Kassala was bimodal (with two peaks)

• the outbreak continued for 11

Epidemiologic Description of the Outbreak

• The third wave started on 16 September 2018 in Port Sudan, Red Sea State.

• The outbreak in Port Sudan continued for 20 weeks in single long wave. A total of 28,861 cases were reported

• The fourth wave of the outbreak occurred in Sawakin town (1,129 cases, 3.9% of all cases in Red Sea State

• during the period between 09 December 2018 to 24 March 2019.

• The outbreak occurred for the second time in Sawakin town in concurrence with the third wave in Port Sudan City.

Epidemic curve of Chikungunya Fever cases in Sudan by State and date of onset, 2018-2019

Chikungunya Fever :Pattern of spread in Kassala City, 2018

D

B

C

A

Age-sex distribution

• More Chikungunya Fever cases were reported among females (51.2%) compared to males (48.8%).

• All age groups were affected. • More than 60% of cases occurred among

population aged 20-60 years. • About 30.9% of all cases occurred among

population aged less than 20 years • Only 8.7% of the cases occurred among the elderly

(60 years of age and more)

Age-sex distribution

• This probably be explained by the fact that females tend to stay at home during the day close to household mosquito breeding sites.

• Aedes aegypti bites primarily during the day as it is most active for approximately two hours after sunrise and several hours before sunset when people are unlikely to put on protective clothes, use repellent or bed nets

Cost of the Outbreak • The direct cost of the outbreak amounted to SDG

34,349,511. • The indirect that relate to loss in productivity and days

of healthy life lost (DALY) were not estimated. • local cost of labour and staff and volunteer time was

not included. • In addition, the cost of smaller outbreak and sporadic

cases in different States were not included. • Hence the above documented cost of the outbreak

could be underestimated. • This may warrant further study to better estimate the

cost and burden of the outbreak.

Magnitude of the outbreak • This outbreak was the largest outbreak of Chikungunya

Fever ever occurred in Africa and the Eastern Mediterranean Region (EMR)

• The disease surveillance system in Sudan reported a total of 48,763 cases of Chikungunya Fever that occurred within 10 months

• There are indicators suggest that the actual number of cases of Chikungunya Fever may have been grossly underestimated indicate that the number of Chikungunya Fever cases during this outbreak may be four or five fold larger than the reported casesThe number of actual cases may range between 200,000 to 250,000 cases in the two most affected States, Kassala and Red Sea

What can support this

• Sentinel disease surveillance system • Private clinics were not initially reporting

suspected cases of Chikungunya • It has been observed that people opted

home and self-treatment because they knew that there is no specific medication to cure for viral diseases and that Chikungunya Fever is not fatal

• Patients served as reservoir for Chikungunya virus

• Failure of infected persons to use bed nets at

home and in health facilities as part of case management protocol could have amplified the transmission among co-patient, health workers, household contacts and people living in neighboring houses.

• The feeding behavior of Aedes aegypti which requires multiple human bites increases the likelihood of infecting more people and that would further escalate transmission of the virus.