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Background First Few “X” (FFX) studies provide evidence to guide public health decision making and resource allocation. The adapted WHO Unity FFX protocol for COVID-19 was implemented to gain an understanding of the clinical, epidemiological, virological, and household transmission dynamics of the first cases of COVID-19 infection detected in Juba, South Sudan. Methods Laboratory-confirmed COVID-19 cases were identified through the national surveillance system, and an initial visit was conducted with eligible cases to identify all close contacts. Consenting cases and close contacts were enrolled between June 2020 and December 2020. Demographic, clinical information and biological samples were taken at enrolment and 14–21 days post-enrolment for all participants. Results Twenty-nine primary cases and 82 contacts were included in analyses. Most primary cases (n=23/29, 79.3%) and contacts (n=61/82, 74.4%) were male. Many primary cases (n=18/29, 62.1%) and contacts (n=51/82, 62.2%) were seropositive for SARS-CoV-2 at baseline. The secondary attack rate among susceptible contacts was 12.9% (4/31; 95% CI: 4.9%–29.7%). All secondary cases and most (72%) primary cases were asymptomatic. Reported symptoms included coughing (n=6/29, 20.7%), fever or history of fever (n=4/29, 13.8%), headache (n=3/29, 10.3%) and shortness of breath (n=3/29, 10.3%). Of 38 cases, two were hospitalised (5.3%) and one died (2.6%). Conclusions These findings were used to develop the South Sudanese Ministry of Health surveillance and contract tracing protocols, informing local COVID-19 case definitions, follow-up protocols and data management systems. This investigation demonstrates that rapid FFX implementation is critical in understanding the emerging disease and informing response priorities.

As the coronavirus pandemic continues, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequence data are required to inform vaccine efforts. We provide SARS-CoV-2 sequence data from South Sudan and document the dominance of SARS-CoV-2 lineage B.1.525 (Eta variant) during the country's second wave of infection.

Relatively few COVID-19 cases and deaths have been reported through much of sub-Saharan Africa, including South Sudan, although the extent of SARS-CoV-2 spread remains unclear due to weak surveillance systems and few population-representative serosurveys.We conducted a representative household-based cross-sectional serosurvey in Juba, South Sudan. We quantified IgG antibody responses to SARS-CoV-2 spike protein receptor-binding domain and estimated seroprevalence using a Bayesian regression model accounting for test performance.We recruited 2,214 participants from August 10 to September 11, 2020 and 22.3% had anti-SARS-CoV-2 IgG titers above levels in pre-pandemic samples. After accounting for waning antibody levels, age, and sex, we estimated that 38.5% (32.1 - 46.8) of the population had been infected with SARS-CoV-2. For each RT-PCR confirmed COVID-19 case, 104 (87-126) infections were unreported. Background antibody reactivity was higher in pre-pandemic samples from Juba compared to Boston, where the serological test was validated. The estimated proportion of the population infected ranged from 30.1% to 60.6% depending on assumptions about test performance and prevalence of clinically severe infections.SARS-CoV-2 has spread extensively within Juba. Validation of serological tests in sub-Saharan African populations is critical to improve our ability to use serosurveillance to understand and mitigate transmission.

Nodding syndrome (NS) is a catastrophic and enigmatic childhood epilepsy, accompanied by multiple neurological impairments and neuroinflammation. Of all the infectious, environmental and psychological factors associated with NS, the major culprit is Onchocerca Volvulus (Ov)–a parasitic worm transmitted to human by blackflies. NS seems to be an ’Autoimmune Epilepsy’ in light of the recent findings of deleterious autoimmune antibodies to Glutamate receptors and to Leiomodin-I in NS patients. Moreover, we recently found immunogenetic fingerprints in HLA peptide-binding grooves associate with protection or susceptibility to NS. Macrophage migration inhibitory factor (MIF) is an immune-regulatory cytokine playing a central role in modulating innate and adaptive immunity. MIF is also involved in various pathologies: infectious, autoimmune and neurodegenerative diseases, epilepsy and others. Herein, two functional polymorphisms in the MIF gene, a −794 CATT5–8 microsatellite repeat and a −173 G/C single-nucleotide polymorphism, were assessed in 49 NS patients and 51 healthy controls from South Sudan. We also measured MIF plasma levels in established NS patients and healthy controls. We discovered that the frequency of the high-expression MIF -173C containing genotype was significantly lower in NS patients compared to healthy controls. Interestingly however, MIF plasma levels were significantly elevated in NS patients than in healthy controls. We further demonstrated that the HLA protective and susceptibility associations are dominant over the MIF association with NS. Our findings suggest that MIF might have a dual role in NS. Genetically controlled high-expression MIF genotype is associated with disease protection. However, elevated MIF in the plasma may contribute to the detrimental autoimmunity, neuroinflammation and epilepsy., Author summary Nodding syndrome (NS) is a devastating and enigmatic childhood disease, accompanied by multiple neurological impairments and neuroinflammation. NS is associated with the parasite Onchocerca volvulus (Ov) and other environmental factors. It was shown that NS seems to be an "Autoimmune-Epilepsy". However, it is still not clear why only some children, within the same family, tribe and district, develop this malady in South-Sudan. Recently, we hypothesized that immunogenetic factors might address this question, and indeed demonstrated that few amino acids in human leukocyte antigen (HLA) peptide-binding grooves associate with either protection or susceptibility to NS. In the current study, we evaluate the contribution of macrophage migration inhibitory factor (MIF) to NS pathology. MIF is an immune-regulatory cytokine that is involved in numerous pathologies, which vary from infectious diseases, autoimmunity to neurodegenerative diseases. Immunogenetic analysis of MIF in South-Sudanese NS patients and healthy controls shed new light on the epidemiology of this disease. Our findings suggest that MIF promoter genotypes that are linked with high-protein expression are associated with disease protection. However, in affected patients, with established NS, MIF plasma levels are elevated compared to control subjects and might be involved with autoimmunity and neuroinflammation.

On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; however, historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. Discordance in case definitions among countries might reduce the effectiveness of cross-border initiatives during outbreaks with high risk for regional spread. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries. Changes in MOH-approved Ebola case definitions were analyzed, referencing the WHO standard case definition, and concordance among the four countries for Ebola case categories (i.e., community alert, suspected, probable, confirmed, and case contact) was assessed at three dates (2). The number of country-level revisions ranged from two to four, with all countries revising Ebola definitions by February 2019 after a December 2018 peak in incidence in DRC. Case definition complexity increased over time; all countries included more criteria per category than the WHO standard definition did, except for the "case contact" and "confirmed" categories. Low case definition concordance and lack of awareness of regional differences by national-level health officials could reduce effectiveness of cross-border communication and collaboration. Working toward regional harmonization or considering systematic approaches to addressing country-level differences might increase efficiency in cross-border information sharing.

Health systems resilience (HSR) is defined as the ability of a health system to continue providing normal services in response to a crisis, making it a critical concept for analysis of health systems in fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan to develop a data-driven understanding of resilience. We used 14 maternal, newborn and child health (MNCH) coverage indicators from household surveys in South Sudan collected at independence (2011) and following 2 years of protracted conflict (2015), to construct a resilience index (RI) for 9 of the former 10 states and nationally. We also assessed health system stress using conflict-related indicators and developed a stress index. We cross tabulated the two indices to assess the relationship of resilience and stress. For maintaining function for 80% of MNCH indicators, seven state health systems were resilient, compared with improving function for 50% of the indicators (two states were resilient). Achieving the health system national target of 50% coverage in half of the MNCH indicators displayed no resilience. MNCH coverage levels were low, with state averages ranging between 15% and 44%. Central Equatoria State displayed high resilience and high system stress. Lakes and Northern Bahr el Ghazal displayed high resilience and low stress. Jonglei and Upper Nile States had low resilience and high stress. This study is the first to investigate HSR definitions using a resilience metric and to simultaneously measure health system stress in FCAS. Improving function is the HSR definition detecting the greatest variation in the RI. HSR and health system stress are not consistently negatively associated. HSR is highly complex warranting more in-depth analyses in FCAS.

Background The world’s second largest Ebola outbreak occurred in the Democratic Republic of Congo from 2018 to 2020. At the time, risk of cross-border spread into South Sudan was very high. Thus, the South Sudan Ministry of Health scaled up Ebola preparedness activities in August 2018, including implementation of a 24-h, toll-free Ebola virus disease (EVD) hotline. The primary purpose was the hotline was to receive EVD alerts and the secondary goal was to provide evidence-based EVD messages to the public. Methods To assess whether the hotline augmented Ebola preparedness activities in a protracted humanitarian emergency context, we reviewed 22 weeks of call logs from January to June 2019. Counts and percentages were calculated for all available data. Results The hotline received 2114 calls during the analysis period, and an additional 1835 missed calls were documented. Callers used the hotline throughout 24-h of the day and were most often men and individuals living in Jubek state, where the national capital is located. The leading reasons for calling were to learn more about EVD (68%) or to report clinical signs or symptoms (16%). Common EVD-related questions included EVD signs and symptoms, transmission, and prevention. Only one call was documented as an EVD alert, and there was no documentation of reported symptoms or whether the person met the EVD case definition. Conclusions Basic surveillance information was not collected from callers. To trigger effective outbreak investigation from hotline calls, the hotline should capture who is reporting and from where, symptoms and travel history, and whether this information should be further investigated. Electronic data capture will enhance data quality and availability of information for review. Additionally, the magnitude of missed calls presents a major challenge. When calls are answered, there is potential to provide health communication, so risk communication needs should be considered. However, prior to hotline implementation, governments should critically assess whether their hotline would yield actionable data and if other data sources for surveillance or community concerns are available.

HIV prevalence is estimated to be 2.7% in South Sudan; however, little is known about the young country's epidemic. We conducted a respondent-driven sampling biobehavioral survey in Juba of female sex workers (FSW) aged ≥15 years who sold or exchanged sex in the last 6 months to learn more about this population. We enrolled 838 FSW from November 2015 to March 2016 and estimated HIV prevalence to be 37.8%. Prevalence of active syphilis was 7.3%. FSW were from South Sudan and most neighboring countries. Comprehensive knowledge of HIV was 11.1% and 64.2% of FSW had never spoken with an outreach worker. In multivariable analysis, HIV was associated with being from Uganda (aOR: 3.3, 95% CI: 1.7-6.1) or Kenya (aOR: 4.3, 95% CI: 1.5-13.0) versus from South Sudan. Our survey suggests that FSW may play a critical role in South Sudan's HIV epidemic and highlights the importance of tailoring services to the unique needs of FSW of all nationalities in Juba.

Nodding Syndrome (NS) is a fatal pediatric epilepsy of unknown etiology, accompanied by multiple neurological impairments, and associated with Onchocerca volvulus (Ov), malnutrition, war-induced trauma, and other insults. NS patients have neuroinflammation, and ~50% have cross-reactive Ov/Leiomodin-1 neurotoxic autoimmune antibodies. RESULTS: Studying 30 South Sudanese NS patients and a similar number of healthy subjects from the same geographical region, revealed autoimmune antibodies to 3 extracellular peptides of ionotropic glutamate receptors in NS patients: AMPA-GluR3B peptide antibodies (86%), NMDA-NR1 peptide antibodies (77%) and NMDA-NR2 peptide antibodies (87%) (in either 1:10, 1:100 or 1:1000 serum dilution). In contrast, NS patients did not have 26 other well-known autoantibodies that target the nervous system in several autoimmune-mediated neurological diseases. We demonstrated high expression of both AMPA-GluR3 and NMDA-NR1 in human neural cells, and also in normal human CD3+ T cells of both helper CD4+ and cytotoxic CD8+ types. Patient's GluR3B peptide antibodies were affinity-purified, and by themselves precipitated short 70 kDa neuronal GluR3. NS patient's affinity-purified GluR3B peptide antibodies also bound to, induced Reactive Oxygen Species (ROS) in, and killed both human neural cells and T cells within 1-2 hours only. NS patient's purified IgGs, or serum (1:10 or 1:30), induced similar effects. In vivo video EEG experiments in normal mice, revealed that when NS patient's purified IgGs were released continuously (24/7 for 1 week) in normal mouse brain, they induced all the following: 1.Seizures, 2. Cerebellar Purkinje cell loss, 3. Degeneration in the hippocampus and cerebral cortex, and 4. Elevation of CD3+ T cells, and of activated Mac-2+microglia and GFAP+astrocytes in both the gray and white matter of the cerebral cortex, hippocampus, corpus calossum and cerebellum of mice. NS patient's serum cytokines: IL-1β, IL-2, IL-6, IL-8, TNFα, IFNγ, are reduced by 85-99% compared to healthy subjects, suggesting severe immunodeficiency in NS patients. This suspected immunodeficiency could be caused by combined effects of the: 1. Chronic Ov infection, 2. Malnutrition, 3. Killing of NS patient's T cells by patient's own GluR3B peptide autoimmune antibodies (alike the killing of normal human T cells by the NS patient's GluR3B peptide antibodies found herein in vitro). CONCLUSIONS: Regardless of NS etiology, NS patients suffer from 'Dual-targeted Autoimmune Sword': autoimmune AMPA GluR3B peptide antibodies that bind, induce ROS in, and kill both neural cells and T cells. These neurotoxic and immunotoxic GluR3B peptide autoimmune antibodies, and also NS patient's NMDA-NR1/NR2A and Ov/Leiomodin-1 autoimmune antibodies, must be silenced or removed. Moreover, the findings of this study are relevant not only to NS, but also to many more patients with other types of epilepsy, which have GluR3B peptide antibodies in serum and/or CSF. This claim is based on the following facts: 1. The GluR3 subunit is expressed in neural cells in crucial brains regions, in motor neurons in the spinal cord, and also in other cells in the body, among them T cells of the immune system, 2. The GluR3 subunit has diverse neurophysiological role, and its deletion or abnormal function can: disrupt oscillatory networks of both sleep and breathing, impair motor coordination and exploratory activity, and increase the susceptibility to generate seizures, 3. GluR3B peptide antibodies were found so far in ~27% of >300 epilepsy patients worldwide, which suffer from various other types of severe, intractable and enigmatic epilepsy, and which turned out to be 'Autoimmune Epilepsy'. Furthermore, the findings of this study could be relevant to different neurological diseases besides epilepsy, since other neurotransmitter-receptors autoantibodies are present in other neurological and psychiatric diseases, e.g. autoimmune antibodies against other GluRs, Dopamine receptors, GABA receptors, Acetylcholine receptors and others. These neurotransmitter-receptors autoimmune autoantibodies might also act as 'Dual-targeted Autoimmune Sword' and damage both neural cells and T cells (as the AMPA-GluR3B peptide antibodies induced in the present study), since T cells, alike neural cells, express most if not all these neurotransmitter receptors, and respond functionally to the respective neurotransmitters - a scientific and clinical topic we coined 'Nerve-Driven Immunity'.

Background High numbers of persons with nodding syndrome and other forms of epilepsy were reported to occur in onchocerciasis endemic regions of South Sudan but an epilepsy prevalence survey was never performed. Methods In May 2018, a door-to-door household survey was conducted in 8 study sites, including 44 villages in an onchocerciasis endemic area in Maridi County. Onchocerciasis-associated epilepsy (OAE) was defined as ≥2 seizures without any obvious cause, starting between the ages of 3-18 years in previously healthy persons who had resided for at least 3 years in the onchocerciasis endemic area. Findings A total of 2,511 households agreed to participate in the study, corresponding to 17,652 individuals. An epilepsy screening questionnaire of 5 questions identified 799 persons suspected to have epilepsy (4.5%); in 736 (96.1%) of the 766 seen by a clinical officer or medical doctor the diagnosis of epilepsy was confirmed. Adding 38 persons not seen, but with a positive answer to a combination of screening questions to have epilepsy, 774 (4.4%) persons had epilepsy. Epilepsy prevalence was highest in the 11-20 age group (10.5%). The median age at first seizure was 10 years (IQR: 7-14); 66 persons with epilepsy (PWE) developed their first seizures in the year preceding the survey (annual incidence=373.9/100.000). OAE criteria were met by 85.2% of PWE. In 45.4% there was a history of nodding seizures. Neurocysticercosis cannot explain the high epilepsy prevalence because there are no pigs kept in the area. Independent risk factors for epilepsy included male gender, belonging to a "permanent household", belonging to a farming family, and living in a village bordering the Maridi River. Only 7209 (40.8%) of the total population took ivermectin in 2017. Interpretation Urgent action is needed to prevent children in Maridi County from developing OAE by strengthening the onchocerciasis elimination program. Funding: European Research Council (ERC) grant 671055 Declaration of Interest: No conflict of interest declared. Ethical Approval: Ethical approval was obtained from the ethics committee of the Ministry of Health of the Republic of South Sudan and from the ethics committee of the University of Antwerp, Belgium. The study aims and procedures were explained to all participants in the language of their choice, and signed or finger-printed informed consent was obtained from participants, parents or carers, and assent obtained from adolescents (age 12–18 years). All personal information was encoded and treated confidentially.

Highlights • An epilepsy prevalence of 4.4% was observed in villages in Maridi. • Living close to the Maridi river is a major risk factor for epilepsy. • Persons with nodding seizures and with other forms of epilepsy live in the same areas. • Ivermectin coverage needs to increase to prevent onchocerciasis associated epilepsy., Purpose To determine the prevalence and incidence of epilepsy in an onchocerciasis endemic region of South Sudan. Methods In May 2018, a door-to-door household survey was conducted in 8 study sites in an onchocerciasis endemic area in Maridi County. Results A total of 2511 households agreed to participate in the study, corresponding to 17,652 individuals. An epilepsy screening questionnaire identified 799 persons suspected to have epilepsy (4.5%); in 736 of the 766 persons (96.1%) seen by a clinical officer the diagnosis of epilepsy was confirmed. Adding 38 persons who were not seen but with a positive answer to a combination of screening questions, 774 persons (4.4%) had epilepsy. Epilepsy prevalence was highest in the 11–20 age group (10.5%); 66 persons with epilepsy (PWE) developed their first seizures in the year preceding the survey (annual incidence = 373.9/100.000). Neurocysticercosis cannot explain the high epilepsy prevalence since no pigs are kept in the area. Independent risk factors for epilepsy included male gender, belonging to a “permanent household” and a farming family, and living in a village bordering the Maridi River. Only 7209 (40.8%) of the population took ivermectin in 2017. Conclusion A very high prevalence and incidence of epilepsy was observed in several villages in Maridi County located close to the Maridi River and the Maridi dam. Urgent action is needed to prevent children in Maridi County from developing OAE by strengthening the onchocerciasis elimination program.

OBJECTIVES We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to strengthen local capacity to perform regular rapid health facility assessments. METHODS Using a two-stage lot quality assurance sampling (LQAS) design, we conducted a national cross-sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations. RESULTS Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick-child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick-child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in-service training and supervision, for seven and ten states, respectively. CONCLUSIONS Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state-by-state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states.

Background In order to decrease the prevalence of trachoma within the country, the Republic of South Sudan has implemented components of the SAFE strategy in various counties since 2001. Five counties in Eastern Equatoria state were surveyed in order to monitor progress of programmatic interventions and determine if additional rounds of Mass Drug Administration with azithromycin were needed. Methodology/ Principal findings Five counties (Budi, Lafon, Kapoeta East, Kapoeta South and Kapoeta North) were surveyed from April to October 2015. A cross-sectional, multi-stage, cluster-random sampling was used. All present, consenting residents of selected households were examined for all clinical signs of trachoma using the World Health Organization (WHO) simplified grading system. 14,462 individuals from 3,446 households were surveyed. The prevalence of trachomatous inflammation-follicular (TF) in children ages one to nine years ranged from 17.4% (95% Confidence Interval (CI): 11.4%, 25.6%) in Budi county to 47.6%, (95% CI: 42.3%, 53.0%) in Kapoeta East county. Trachomatous trichiasis (TT) was also highly prevalent in those 15 years and older, ranging between 2.6% (95% CI: 1.6%, 4.0%) in Kapoeta South to 3.9% (95% CI: 2.4%, 6.1%) in Lafon. The presence of water and sanitation were low in all five counties, including two counties which had a complete absence of latrines in all surveyed clusters. Conclusions/ Significance To our knowledge, these were the first trachoma surveys conducted in the Republic of South Sudan since their independence in 2011. The results show that despite years of interventions, four of the five surveyed counties require a minimum of five additional years of SAFE strategy implementation, with the fifth requiring at minimum three more years., Author summary Trachoma is the leading cause of preventable blindness in the world; however, with proper interventions the disease can be controlled. Despite a paucity of experienced trachoma graders, insecurity, and difficulty accessing some villages, population-based impact surveys were conducted in five counties of South Sudan in 2015, with over 10,600 persons examined by trained and certified graders. Results showed that all five counties surveyed in Eastern Equatoria state of South Sudan face considerable trachoma burdens. The presence of water and sanitation were low in all five counties, including two counties which had a complete absence of latrines in all surveyed villages. The global community cannot expect to eliminate trachoma by 2020 if South Sudan is not provided with the human and financial resources it needs to not only understand the full extent of the disease in the country but also to implement programmatic interventions.

Objectives We adapted a rapid monitoring method to South Sudan, a new nation with one of the world's highest maternal and child mortality rates, aiming to assess coverage of maternal, neonatal and child health (MNCH) services at the time of independence, and introducing a monitoring and evaluation system (M&E) for equity-sensitive tracking of progress related to Millennium Development Goals (MDG) 4 and 5 at national, state and county levels to detect local variability. Methods We conducted a national cross-sectional household survey among women from six client populations in all, but six of South Sudan's 79 counties. We used lot quality assurance sampling (LQAS) to measure coverage with diverse MNCH indicators to obtain information for national-, state- and county-level health system management decision-making. Results National coverage of MNCH services was low for all maternal and neonatal care, child immunisation, and child care indicators. However, results varied across states and counties. Central Equatoria State (CES), where the capital is located, showed the highest coverage for most indicators (e.g. ≥4 antenatal care visits range: 4.5% in Jonglei to 40.1% in CES). Urban counties often outperformed rural ones. Conclusions This adaptation of LQAS to South Sudan demonstrates how it can be used in the future as an M&E system to track progress of MDGs at national, state and county levels to detect local disparities. Overall, our data reveal a desperate need for improving MNCH service coverage in all states.

We conducted a case–control study to identify risk factors for the 2014 cholera outbreak in Juba County, South Sudan. Illness was associated with traveling or eating away from home; treating drinking water and receiving oral cholera vaccination were protective. Oral cholera vaccination should be used to complement cholera prevention efforts.

Background South Sudan has borne the brunt of years of chronic warfare and probably has the highest malaria burden in sub-Saharan Africa. Malaria is the leading cause of morbidity and mortality in the country. This nationally representative survey aimed to provide data on malaria indicators at household level across the country. Methods In 2009, data were collected using a two-stage random cluster sample of 2,797 households in 150 census enumeration areas during a Malaria Indicator Survey (MIS) in South Sudan. The survey determined parasite and anaemia prevalence in vulnerable population groups and evaluated coverage, use and access to malaria control services. Standardized Roll Back Malaria Monitoring and Evaluation Reference Group (RBM-MERG) MIS household and women’s questionnaires were adapted to the local situation and used for collection of data that were analysed and summarized using descriptive statistics. Results The results of this survey showed that 59.3% (95% CI: 57.5-61.1) of households owned at least one mosquito net. The proportion of the population with access to an ITN in their household was 49.7% (95% CI: 48.2-51.2). The utilization of insecticide-treated nets was low; 25.3% (95% CI: 23.9-26.7) for children under five (U5) and 35.9% (95% CI: 31.9-40.2) of pregnant women (OR: 1.66 (1.36-2.01); P =0.175). Prevalence of infection was 24.5% (95% CI: 23.0-26.1) in children U5 and 9.9% (95% CI: 7.4-13.1) in pregnant women. About two thirds (64%) of children U5 and 46% of pregnant women were anaemic. Only 2% of households were covered by indoor residual spraying (IRS) the previous year. Data shows that 58% reported that malaria is transmitted by mosquitoes, 34% mentioned that the use of mosquito nets could prevent malaria, 41% knew the correct treatment for malaria, and 52% of the children received treatment at a health facility. Conclusion The observed high malaria prevalence could be due to low levels of coverage and utilization of interventions coupled with low knowledge levels. Therefore, access and utilization of malaria control tools should be increased through scaling up coverage and improving behaviour change communication.

Long-lasting insecticidal nets (LLINs) are important tools in malaria control. South Sudan, like many other endemic countries, has struggled to improve LLIN coverage and utilization.In 2006, Southern Sudan - known as South Sudan after independence in 2011 - initiated a strategic plan to increase LLIN coverage so that at least 60% of households had at least one LLIN each. By 2008, the target coverage was 80% of households and the Global Fund had financed a phased scale-up of LLIN distribution in the region.South Sudan's entire population is considered to be at risk of malaria. Poor control of the vectors and the large-scale movements of returnees, internally displaced people and refugees have exacerbated the problem.By 2012, approximately 8.0 million LLINs had been distributed in South Sudan. Between 2006 and 2009, the percentage of households possessing at least one LLIN increased from about 12% to 53% and LLIN utilization rates increased from 5 to 25% among children younger than 5 years and from 5 to 36% among pregnant women. The number of recorded malaria cases increased from 71 948 in 2008 to 1 198 357 in 2012.In post-conflict settings, a phased programme for the national scale-up of LLIN coverage may not have a substantial impact. A nationwide campaign that is centrally coordinated and based on sound guidelines may offer greater benefits. A strong partnership base and effective channels for the timely and supplementary deployment of LLINs may be essential for universal coverage.Les moustiquaires imprégnées d'insecticide longue durée (MILD) sont des outils importants dans la lutte contre le paludisme. Le Soudan du Sud, comme beaucoup d'autres pays endémiques, s'efforce d'améliorer la couverture et l'utilisation des MILD.En 2006, le sud du Soudan - appelé Soudan du Sud après son indépendance en 2011 - a lancé un plan stratégique visant à augmenter la couverture des MILD, de sorte qu'au moins 60% des ménages disposent d'une moustiquaire au moins. En 2008, l'objectif de couverture était de 80% des ménages et le Fonds mondial a financé un élargissement progressif de la distribution des MILD dans la région.L’ensemble de la population du Soudan du Sud est considérée comme exposée au paludisme. Un contrôle médiocre des vecteurs et la forte ampleur des mouvements de rapatriés, de déplacés internes et de réfugiés ont exacerbé le problème.En 2012, environ 8 millions de MILD ont été distribuées au Soudan du Sud. Entre 2006 et 2009, le pourcentage de ménages possédant au moins une MILD est passé d'environ 12% à 53%, et le taux d'utilisation des MILD est passé de 5% à 25% chez les enfants de moins de 5 ans et de 5% à 36% chez les femmes enceintes. Le nombre de cas de paludisme enregistrés est passé de 71 948 en 2008 à 1 198 357 en 2012.Dans des contextes post-conflictuels, un programme échelonné pour l'élargissement au niveau national de la couverture des MILD peut ne pas avoir d'impact important. Une campagne nationale coordonnée de manière centrale et basée sur des directives judicieuses peut offrir de plus grands avantages. Une base de partenariat solide et des moyens efficaces pour le déploiement rapide et complémentaire de MILD peuvent être essentiels à une couverture universelle.Los mosquiteros insecticidas de larga duración (LLIN, por sus singlas en inglés) son herramientas importantes para el control de la malaria. Sudán del Sur, como muchos otros países endémicos, ha luchado por mejorar el uso y la cobertura de los LLIN.En 2006, Sudán meridional, conocido como Sudán del Sur desde su independencia en 2011, inició un plan estratégico para aumentar la cobertura de los LLIN a fin de que como mínimo el 60 % de los hogares dispusieran de al menos un LLIN. En 2008, la cobertura objetivo era un 80 % de los hogares y el Fondo Mundial había financiado un plan de ampliación por fases de distribución de LLIN en la región.Se considera que toda la población de Sudán del Sur está en riesgo de contraer la malaria. Además, el control deficiente de los vectores y los movimientos a gran escala de los repatriados, los desplazados internos y los refugiados han exacerbado el problema.En 2012 se habían distribuido unos 8 millones de LLIN en Sudán del Sur. Entre 2006 y 2009, el porcentaje de hogares que poseían al menos un LLIN aumentó de alrededor del 12 % al 53 % y las tasas de uso de LLIN aumentaron del 5 al 25 % entre los niños menores de 5 años y del 5 al 36 % entre las mujeres embarazadas. El número de casos registrados de malaria aumentó de 71 948 en 2008 a 1 198 357 en 2012.En los contextos posteriores a un conflicto, es posible que un programa gradual para la ampliación de la cobertura nacional de LLIN no tenga un efecto sustancial. Una campaña nacional que esté coordinada de forma central y se base en directrices sólidas puede ofrecer mayores beneficios. Por otro lado, una base de colaboración fuerte y canales eficaces para el despliegue oportuno y complementario de LLIN pueden ser esenciales para la cobertura universal.تمثل الناموسيات المعالجة بالمبيدات الحشرية طويلة الأجل أدوات مهمة في مكافحة الملاريا. وكافحت جنوب السودان، مثل غيرها من البلدان التي يتوطنها هذا المرض، لتحسين التغطية بالناموسيات المعالجة بالمبيدات الحشرية طويلة الأجل واستخدامها.بدأت جنوب السودان - التي عرفت بهذا الاسم بعد استقلالها في عام 2011 - خطة استراتيجية في عام 2006 لزيادة التغطية بالناموسيات المعالجة بالمبيدات الحشرية الطويلة الأجل حيث حصلت 60 % من الأسر المعيشية على الأقل على ناموسية معالجة بالمبيدات الحشرية طويلة الأجل لكل واحدة منها. وبحلول عام 2008، بلغت التغطية المستهدفة 80 % من الأسر المعيشية وقام الصندوق العالمي بتمويل الزيادة التدريجية في توزيع الناموسيات المعالجة بالمبيدات الحشرية طويلة الأجل في المنطقة.يعتبر جميع السكان في جنوب السودان عرضة لخطر الإصابة بالملاريا. وأدى ضعف مكافحة نواقل المرض وتحركات العائدين والمشردين داخلياً واللاجئين على نطاق واسع إلى تفاقم المشكلة.بحلول عام 2012، تم توزيع حوالي 8 مليون ناموسية معالجة بالمبيدات الحشرية طويلة الأجل في جنوب السودان. وزادت النسبة المئوية للأسر المعيشية التي يوجد لديها على الأقل ناموسية واحدة معالجة بالمبيدات الحشرية الطويلة الأجل في الفترة من 2006 إلى 2009 من 12 % إلى 53 % تقريباً وزادت معدلات استخدام الناموسيات المعالجة بالمبيدات الحشرية طويلة الأجل من 5 إلى 25 % بين الأطفال الأقل من 5 سنوات ومن 5 إلى 36 % بين النساء الحوامل. وزاد عدد حالات الملاريا المسجلة من 71948 في عام 2008 إلى 1198357 في عام 2012.قد لا يكون للبرنامج التدريجي لزيادة التغطية الوطنية بالناموسيات المعالجة بالمبيدات الحشرية طويلة الأجل أثر كبير في المناطق التي انتهى فيها الصراع. وقد توفر حملة وطنية ذات تنسيق مركزي وتستند على الدلائل الإرشادية السليمة مزيداً من الفوائد. وقد يكون إنشاء قاعدة شراكة قوية وقنوات فعالة لنشر الناموسيات المعالجة بالمبيدات الحشرية طويلة الأجل في الوقت المناسب وعلى نحو تكميلي شرطاً أساسياً للتغطية الشاملة.长效防虫蚊帐（LLIN）是控制疟疾的重要工具。南苏丹和许多其他地方病国家一样，一直在努力改善LLIN覆盖和利用情况。在2006年，南部苏丹（即在2011年独立的南苏丹）启动了一项提高LLIN覆盖率的战略计划，从而使至少60%的家庭至少拥有一顶LLIN。截至2008年，目标覆盖率是80%的家庭，全球基金已经为该地区阶段性扩大分发LLIN提供了资金。南苏丹整个人口被认为面临疟疾风险。对传播媒介控制不力以及回国人员、国内流离失所者和难民的大规模流动加剧了问题的严重性。截至2012年，南苏丹已经分发了大约800万顶LLIN。在2006和2009年之间，拥有至少一顶LLIN家庭的百分率从大约12%提升到53%。在不到5岁的儿童中，LLIN利用率从5%增加到25%，孕妇当中的利用率从5%增加到36%。登记的疟疾病例数量从2008年的71948例增加到2012年的1198357例。在冲突后的环境中，全国扩大LLIN覆盖的阶段性计划可能不具有实质的影响。集中协调并基于合理指导的全国性运动可能会有更好的效果。通过强大的合作伙伴群体和有效的渠道，进行及时和补充性的LLIN部署，可能对实现全民覆盖至关重要。Долговечные обработанные инсектицидами сетки (ДОИС) являются важным инструментом в борьбе с малярией. Южный Судан, как и многие другие эндемичные страны, приложил множество усилий для повсеместного распространения и использования таких сеток.В 2006 году Южный Судан, который обрел полную независимость только в 2011 году, инициировал стратегическую инициативу по увеличению охвата населения, пользующегося противомоскитными сетками, с тем, чтобы не менее 60% домохозяйств имело хотя бы одну такую сетку. К 2008 году целевой охват составил 80% домохозяйств и Всемирный фонд профинансировал поэтапное распространение ДОИС в регионе.Все население Южного Судана считается подверженным риску заболевания малярией. Плохой контроль над векторами развития и крупномасштабные перемещения репатриантов, вынужденных переселенцев и беженцев усугубили данную проблему.К 2012 году в Южном Судане было распространено примерно 8.0 млн. ДОИС. Между 2006 и 2009 гг. процент домохозяйств, имеющих, по крайней мере, одну ДОИС, увеличился с 12% до 53%, а коэффициент использования ДОИС увеличился с 5 до 25% среди детей в возрасте до 5 лет и с 5 до 36% среди беременных женщин. Число зарегистрированных случаев заболевания малярией возросло с 71 948 в 2008 году до 1 198 357 в 2012 году.В постконфликтных ситуациях поэтапная программа, предусматривающая в будущем всесторонний охват населения ДОИС в национальном масштабе, может не оказывать существенного влияния. Общенациональная кампания, координируемая из центра и основанная на разумно достижимых принципах, может принести больше пользы. Важную роль для обеспечения всеобщего охвата может сыграть сильная партнерская база и эффективные каналы для своевременного и дополнительного распространения ДОИС.

Background: Integrated vector management (IVM) based vector control is encouraged by the World Health Organization (WHO). However, operational experience with the IVM strategy has mostly come from countries with relatively well-established health systems and with malaria control focused programmes. Little is known about deployment of IVM for combating multiple vector-borne diseases in post-emergency settings, where delivery structures are less developed or absent. This manuscript reports on the feasibility of operational IVM for combating vector-borne diseases in South Sudan. Case description: A methodical review of published and unpublished documents on vector-borne diseases for South Sudan was conducted via systematic literature search of online electronic databases, Google Scholar, PubMed and WHO, using a combination of search terms. Additional, non-peer reviewed literature was examined for information related to the subject. Discussion: South Sudan is among the heartlands of vector-borne diseases in the world, characterized by enormous infrastructure, human and financial resource constraints and a weak health system against an increasing number of refugees, returnees and internally displaced people. The presence of a multiplicity of vector-borne diseases in this post-conflict situation presents a unique opportunity to explore the potential of a rational IVM strategy for multiple disease control and optimize limited resource utilization, while maximizing the benefits and providing a model for countries in a similar situation. Conclusion: The potential of integrating vector-borne disease control is enormous in South Sudan. However, strengthened coordination, intersectoral collaboration and institutional and technical capacity for entomological monitoring and evaluation, including enforcement of appropriate legislation are crucial.