Sudan del Sur: Guerra, Hambre y Cólera… Otra vez! Dra Lucy Anne Parker [email protected] Epidemióloga Médicos sin Fronteras Directora Master de Cooperación al Desarrollo ‐ Especialidad Salud en Países en Desarrollo (UMH)
Sudan del Sur: Guerra, Hambre y Cólera… Otra
vez!
Dra Lucy Anne Parker [email protected] Epidemióloga Médicos sin Fronteras Directora Master de Cooperación al Desarrollo ‐ Especialidad Salud en Países en Desarrollo (UMH)
Plan • Sudan del Sur • Conflicto, hambruna, desplazamiento de población • Epidemias de Cólera • Vacuna Oral de Cólera – invesIgación operacional
South Sudan • Population 12,5 million
• Independence from Sudan in July, 2011
• Civil war broke out in 2013
• 4.9 million people (40% of the population) are in need of food
• More than 3 million people have been forced to leave there homes IDPS
Refugees
Image : https://www.cia.gov/library/publications/the-world-factbook/geos/od.html
Literacy South Sudan (est. 2009)
0
5
10
15
20
25
30
35
40
45
Male Female
% aged 15yrs+ who can read and write
27% total both males and females
Population: 12,042,910 (July 2015 est.) Ethnic groups: Dinka 35.8%, Nuer 15.6%, Shilluk, Azande, Bari, Kakwa, Kuku, Murle, Mandari, Didinga, Ndogo, Bviri, Lndi, Anuak, Bongo, Lango, Dungotona, Acholi (2011 est.) Languages: English (official), Arabic (includes Juba and Sudanese variants), regional languages include Dinka, Nuer, Bari, Zande, Shilluk
Maternal and Infant mortality
Maternal mortality rate: • 789 deaths/100,000 live births (2015 est.) • country comparison to the world: 1
Infant mortality rate: • total: 66.39 deaths/1,000 live births • male: 71.05 deaths/1,000 live births • female: 61.49 deaths/1,000 live births (2015 est.) • country comparison to the world: 16
Plan • Sudan del Sur • Conflicto, hambruna, desplazamiento de población • Epidemias de Cólera • Vacuna Oral de Cólera – invesIgación operacional
AcOvidades dificultada por: • Conflicto acIvo
• Ataques dirigidas a personal y centros médicos
• Infraestructura deficiente, transporte etc.
• Rupturas en la cadena de suministro (medicamentos, herramientas …)
Photos: Nicolas Peissel/MSF
Pensamos en las condiciones de vida de las personas desplazadas …. Forcibly displaced people Refugees Stateless people
65.3 million (2016) 21.3 million (2016) 10 million (2016)
Photo: UNHCR (accessed 8 October 2016)
Improved sanitation
• Only 6.7% of the population have access to Improved sanitation (7lush or pour‐7lush to a piped sewer system, septic tank or pit latrine; ventilated improved pit latrine; pit latrine with slab; or a composting toilet)
• Over 7,500 medically attended cholera cases in 2014 and 2015
Sensibilización y WATSAN
Vigilancia epidemiológica y respuesta rápida
NoIficación de nuevos casos Ambulancia Desinfección de la vivienda si necesario Enterramientos seguros Búsqueda acIva de casos
Plan • Sudan del Sur • Conflicto, hambruna, desplazamiento de población • Epidemias de Cólera • Vacuna Oral de Cólera – invesIgación operacional
Oral Cholera Vaccine • 3 vaccines prequalified by WHO • OCV Shanchol® (2011) • Semi-affordable (<2USD/vial) • 2 doses proven feasible and
effective • Preventative • Reactive (response to outbreaks)
• Vaccine shortage is a major obstacle
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Photo: Jacob Kuehn, MSF
Rational: Single-dose OCV Juba
• Juba appears to serve as a hub of transmission for the country
• Limited number of vaccines available • Single dose of OCV has potential to save more lives
• Herd protection, immunological studies, preliminary trial data, mathematical modelling
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Juba appears to serve as a hub of transmission for the country
Rational for the dosing regimen proposed
• Limited number of vaccines in stockpile
• Potential for greater public health impact
• Reduced logistical complexity
Average one and two dose effectiveness from previously published studies
Figure 2. Average One and Two Dose Effec8veness from Previously Published Studies1‐6
Population Impact Single dose
OCV Double dose
OCV Vaccines 100,000 100,000
Number of people vaccinated 100,000 50,000
EfCicacy 50% 75%
Immunity 50,000 persons 37,500 persons
Cholera cases averted 1000 750
Cholera Timeline, Juba, 2015
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Northern Bari‐ 2009
Northern Bari ‐ 2015
OCV campaign (31 July-5 Aug 2015) • Single-dose Shanchol®
offered to individuals aged ≥1 year
• targeted areas of Juba • high risk groups
• Large fixed sites and mobile teams
• Limited social mobilisation • Vaccination coverage survey
using spatial random sampling
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Aim
• To evaluate the feasibility, coverage, and vaccine effectiveness of this first ever use of single-dose OCV as an outbreak response
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
• Vaccination status ascertained by interview and inspection of vaccination card
• Unadjusted and adjusted vaccine effectiveness estimates were derived from proportional hazard regression models.
• Ethics: Approved by the John Hopkins Bloomberg School of Public Health IRB and the Ethical Committee of the Ministry of Health, Republic of South Sudan.
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Methods: Case-cohort study Suspected cholera cases
confirmed through multiple diagnostic tests
Cohort of a spatially representative sample from
across Juba
Results: Feasibility
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
• ~143,000 persons • main campaign 31 July-5 Aug 2015
• ~ 22,000 persons • comprehensive package • immediate neighbourhoods of suspected
cases • Vaccine coverage in targeted
areas • 68.8% (95%CI: 63.9 – 73.6%)
• Vaccine coverage in targeted areas 68.8% (95%CI: 63.9 – 73.6%)
Results: Vaccine effectiveness (VE)
Direct and Indirect protection offered by the vaccine: • Unadjusted single-dose VE: 79.5% (95%CI 59.9-100)
• Adjusted single-dose VE: 89.6% (95%CI 75.3-100.0)
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Limitations • Observational study in challenging field conditions • Confirmed cholera cases in Juba ceased within 2-weeks of
vaccination campaign • limited sample size, high uncertainty
• Nearly 50% of participants did not have their vaccination cards • Potential for natural immunity in the study population due to
cholera history in Juba
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Discussion
• Important evidence for deciding on vaccine strategy in light of limited OVC supply
• A single-dose of OCV offers high levels of protection against severe cholera
• both direct and indirect herd protection
• A single dose also logistically simpler and less expensive to deploy in emergencies
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Conclusions • Until sufficient doses of OCV are available, flexible alternative
vaccination strategies are needed • including highly targeted vaccination campaigns • and single-dose regimens.
• Our results from an outbreak in an urban context show that both are feasible and effective.
Lucy A Parker ‐ MSF ‐ First mass vaccinaIon with single‐dose oral cholera vaccine in response to an outbreak in Juba, South Sudan
Parker LA Lancet Inf Dis. 2017 Azman AS Lancet Glob Health. 2016
Gracias
hjps://seguirconvida.msf.es/es 23 marzo a 9 abril en Valencia