Sudan del Sur:  Guerra, Hambre y Cólera… Otra 

vez! 

Dra Lucy Anne Parker lparker@umh.es  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