Visceral Leishmaniasis Outbreak in South Sudan 2009–2012: Epidemiological Assessment and Impact of a Multisectoral Response

The humanitarian situation in South Sudan is dire, with over two million returnees since 2005 and another 300,000 expected to return by the end of 2013. In 2012, 170,000 refugees settled in five camps in Unity and Upper Nile states, endemic areas of visceral leishmaniasis (VL) (Office for the Coordination of Humanitarian Affairs Sudan Humanitarian Update 1st Quarter 2012). VL in South Sudan is endemic in four states, namely Upper Nile, Unity, Jonglei, and Eastern Equatoria, where 2.7 million people in 28 counties are considered to be at risk. It is an anthroponosis caused by Leishmania donovani, and the vectors are Phlebotomus orientalis and P. martini. South Sudan is suffering from recurrent epidemics in areas previously considered to be nonendemic [1]. VL in South Sudan was first described in a child from Bahr-el-Ghazal in 1904 [2]. Since then, outbreaks have been reported in several different areas, namely Jonglei state in the 1930s and 60s [3,4], the former Blue Nile province in the 50s [5], and Unity state (formerly Western Upper Nile) in the 80s, until by the 90s it was claimed that almost one-third of the population had been affected between 1984 and 1994 [6– 8]. In 1994 and in 2002 there were two further outbreaks in northern Jonglei and Eastern Upper Nile states, resulting in 17,000 cases reported. Since 2002, the number of cases reported has progressively decreased to reach 582 in 2008. From 2004 to 2008, an average of 1,756 cases were reported annually, although the actual number of cases was estimated to be between 7,400 and 14,200 cases [9]. Until 2004, VL treatment services were provided almost exclusively by Médecins Sans Frontières-Holland (MSF-H), after which time part of the VL-treatment activities were handed over to the Southern Sudan Secretariat of Health. In addition to this, the World Health Organization (WHO) supported eight health facilities run by nongovernmental organizations (NGOs), and in 2009, that network was expanded to 12. Another VL outbreak was declared in 2009 and it is still ongoing. This publication provides a detailed report on the epidemiology of and the response to this outbreak.