Molecular and serological prevalence of Leptospira spp. among slaughtered cattle and associated risk factors in the Bahr El Ghazal region of South Sudan.

INTRODUCTION: Leptospirosis is a neglected emerging and zoonotic disease reported worldwide. This study sought to determine the molecular and serological prevalence of Leptospira spp. and the associated risk factors in slaughtered cattle from the Bahr El Ghazal region of South Sudan. MATERIALS AND METHODS: Between January 16th and February 25th, 2023, blood and urine samples were collected from 402 cattle at the Lokoloko Municipal Slaughterhouse in Western Bahr El-Ghazal State. Serum samples were tested using the microscopic agglutination test (MAT), with a panel of 12 serovars (sv) from 12 serogroups (sg) and 4 species (spp) of Leptospira spp. These serovars had been previously identified in Sudan and the East African region. Simultaneously, 400 corresponding urine samples were screened using qualitative real-time polymerase chain reaction (PCR) to detect the shedding of Leptospira spp. in urine. To identify the associated risk factors, the age, sex, breed and body condition score of each sampled cattle was noted at the time of sampling and subsequently analysed using logistic regression models. RESULTS: Among the 402 serum samples screened, a substantial 81.8% (329/402, 95% CI 77.9-85.3) displayed seropositivity for Leptospira spp. with a MAT titre ≥ 100. The prevalence of urine shedding determined by PCR was 6% (23/400, 95% CI 3.8-8.4), while probable recent leptospirosis with a MAT ≥ 1:800 was observed in 33.1% (133/402, 95% CI 28.6-37.8) of the cattle. Multiple reactions were detected in 34.8% (140/402, 95% CI 30.6-39.5) serum samples. The seropositivity was against L. borgpetersenii sg. Tarassovi (78.6%; 316/402, 95% CI 74.4-82.3), followed by L. borgpetersenii sg. Ballum at 20.4% (82/402, 95% CI, 16.7-24.4%), L. kirschneri sg. Autumnalis At 8.7% (35/402, 95% CI 5.7-11.7), L. interrogans sg. of Pomona at 7.0% (28/402, 95% CI 4.5-9.5), and L. interrogans sg. Hebdomadis was 5.0% (20/402, 95% CI 2.8-7.2). Several risk factors are associated with seropositivity. Older animals (≥ 2 years) had 2.0 times greater odds (95% CI 1.14-3.5) of being seropositive than younger animals (< 2 years), P-value = 0.016. Female animals demonstrated 2.1 times greater odds (95% CI 1.2-3.6) of seropositivity than males did (P-value = 0.008). Additionally, Felata/Mbororo cattle exhibited 2.4 times greater odds (95% CI 1.3-4.5) of being seropositive than did local Nilotic cattle (P-value = 0.005). The agreement between the MAT and PCR results was poor, as indicated by a kappa statistic value of 0.001 and a P-value of 0.913. But there was a moderate agreement between MAT high titres ≥ 800 and PCR positivity with a kappa statistic value = 0.501 and a P-value < 0.001. CONCLUSION: In addition to the high seroprevalence, Leptospira spp. were found in the urine of slaughtered cattle, suggesting that leptospirosis is endemic to the study area. This finding underscores the significance of cattle as potential sources of infection for slaughterhouse workers, the general public, and other animal species. To address this issue effectively in the Bahr El Ghazal Region and South Sudan, a comprehensive strategy involving a multidisciplinary approach is essential to minimize disease among animals, hence reducing potential zoonotic risks to humans.

Lot quality assurance sampling survey for water, sanitation and hygiene monitoring and evidence-based advocacy in Bentiu IDP camp, South Sudan.

BACKGROUND: Every year, 60% of deaths from diarrhoeal disease occur in low and middle-income countries due to inadequate water, sanitation, and hygiene. In these countries, diarrhoeal diseases are the second leading cause of death in children under five, excluding neonatal deaths. The approximately 100,000 people residing in the Bentiu Internally Displaced Population (IDP) camp in South Sudan have previously experienced water, sanitation, and hygiene outbreaks, including an ongoing Hepatitis E outbreak in 2021. This study aimed to assess the gaps in Water, Sanitation, and Hygiene (WASH), prioritise areas for intervention, and advocate for the improvement of WASH services based on the findings. METHODS: A cross-sectional lot quality assurance sampling (LQAS) survey was conducted in ninety-five households to collect data on water, sanitation, and hygiene (WASH) coverage performance across five sectors. Nineteen households were allocated to each sector, referred to as supervision areas in LQAS surveys. Probability proportional to size sampling was used to determine the number of households to sample in each sector block selected using a geographic positioning system. One adult respondent, familiar with the household, was chosen to answer WASH-related questions, and one child under the age of five was selected through a lottery method to assess the prevalence of WASH-related disease morbidities in the previous two weeks. The data were collected using the KoBoCollect mobile application. Data analysis was conducted using R statistical software and a generic LQAS Excel analyser. Crude values, weighted averages, and 95% confidence intervals were calculated for each indicator. Target coverage benchmarks set by program managers and WASH guidelines were used to classify the performance of each indicator. RESULTS: The LQAS survey revealed that five out of 13 clean water supply indicators, eight out of 10 hygiene and sanitation indicators, and two out of four health indicators did not meet the target coverage. Regarding the clean water supply indicators, 68.9% (95% CI 60.8%-77.1%) of households reported having water available six days a week, while 37% (95% CI 27%-46%) had water containers in adequate condition. For the hygiene and sanitation indicators, 17.9% (95% CI 10.9%-24.8%) of households had handwashing points in their living area, 66.8% (95% CI 49%-84.6%) had their own jug for cleansing after defaecation, and 26.4% (95% CI 17.4%-35.3%) of households had one piece of soap. More than 40% of households wash dead bodies at funerals and wash their hands in a shared bowl. Households with sanitary facilities at an acceptable level were 22.8% (95% CI 15.6%-30.1%), while 13.2% (95% CI 6.6%-19.9%) of households had functioning handwashing points at the latrines. Over the previous two weeks, 57.9% (95% CI 49.6-69.7%) of households reported no diarrhoea, and 71.3% (95% CI 62.1%-80.6%) reported no eye infections among children under five. CONCLUSION: The camp's hygiene and sanitation situation necessitated immediate intervention to halt the hepatitis E outbreak and prevent further WASH-related outbreaks and health issues. The LQAS findings were employed to advocate for interventions addressing the WASH gaps, resulting in WASH and health actors stepping in.

Using Vignettes to Gain Insights Into Social Norms Related to Voluntary Family Planning and Gender-Based Violence in South Sudan.

Social norms are the shared expectations about behaviors that are held within collective groups. These differ from attitudes and beliefs, which are individually held. In South Sudan, social norms can affect the use of voluntary family planning and reproductive health (FP/RH); some of these norms even present risks for women seeking FP/RH care and their FP/RH providers. This cross-sectional, descriptive study conducted in 5 counties in South Sudan used vignettes as a qualitative method to explore social norms related to FP/RH and decisions related to contraceptive use and gender-based violence. Participants were asked to respond to vignettes about a fictional couple during various life stages of care-seeking. Vignettes allow respondents to share their opinions and feelings without directly speaking about their own experiences. Respondents included community members, FP/RH providers, and key influencers (e.g., religious leaders, traditional leaders, elders). The study identified restrictive social norms related to FP/RH, including entrenched, dominant gender roles (i.e., requiring male consent to use contraceptives) and risk for the woman and her provider if she accesses FP/RH services. Of note, supportive social norms are gaining acceptance regarding women's voice and agency; it was found that some women can negotiate their reproductive choice with their partners and participate in planning their families, which has not always been a widely accepted norm. The use of vignettes can lead to a better understanding of the challenges and provide insights on effective implementation approaches. It is essential for programs working to promote the use of FP/RH services in South Sudan to consider the challenges presented by social norms. Findings from this study were shared with stakeholders and communities to codesign interventions aimed at increasing the use of FP/RH services. Additionally, the dialogue stimulated by this study should lead to an organic transformation toward supportive social norms through collective agency.

Assessing attitudes towards violence against women and girls, their determinants and health-seeking behaviour among women and men in South Sudan: a cross-sectional national survey.

OBJECTIVE: Investigating attitudes accepting two categories of violence against women and girls (VAWG) (intimate partner violence-IPV-and other expressions of VAWG) and their association with seven demographic/social determinants and health-seeking behaviours in South Sudan. DESIGN: Cross-sectional study using data from the South Sudan National Household Survey 2020. SETTING: South Sudan. PARTICIPANTS AND METHODS: 1741 South Sudanese women and 1739 men aged 15-49 years; data captured between November 2020 and February 2021 and analysed using binary logistic regression. RESULTS: People with secondary or higher education displayed attitudes rejecting acceptance of IPV (OR 0.631, 95% CI 0.508 to 0.783). Women and men living in states with more numerous internally displaced people (IDP) or political/military violence had attitudes accepting IPV more than residents of less violence-affected regions (OR 1.853, 95% CI 1.587 to 2.164). Women had a higher odd of having attitudes accepting IPV than men (OR 1.195, 95% CI 1.014 to 1.409). People knowing where to receive gender-based violence healthcare and psychological support (OR 0.703, 95% CI 0.596 to 0.830) and with primary (OR 0.613, 95% CI 0.515 to 0.729), secondary or higher education (OR 0.596, 95% CI 0.481 to 0.740) displayed attitudes rejecting acceptance of other expressions of VAWG. People residing in states with proportionately more IDP and who accepted IPV were more likely to have attitudes accepting other expressions of VAWG (OR 1.699, 95% CI 1.459 to 1.978; OR 3.195, 95% CI 2.703 to 3.775, respectively). CONCLUSION: Attitudes towards accepting VAWG in South Sudan are associated with women's and men's education, gender, residence and knowledge about health-seeking behaviour. Prioritising women's empowerment and gender transformative programming in the most conflict-affected areas where rates of VAWG are higher should be prioritised along with increasing girls' access to education. A less feasible strategy to decrease gender inequalities is reducing insecurity, military conflict, and displacement, and increasing economic stability.

Predictors of under-weight among children younger than 24 months in Nimule Border Town, Eastern Equatoria State, South Sudan: a community-based cross sectional study.

BACKGROUND: Underweight is a public health problem globally, and more severe in South Sudan with wide sub-regional differences. In Nimule border town, which represents other border towns in South Sudan, data on underweight among children below two years is unavailable. Thus, this study set out to assess predictors of underweight among children younger than 24 months in Nimule border town, Magwi County, Eastern Equatoria State, South Sudan. METHODS: An analytical cross-sectional study was conducted in Nimule boarder town targeting 390 children younger than two years. Systematic sampling and simple random sampling methods were used. Data were collected through a researcher-administered questionnaire with both open and closed ended questions. Data was entered in EpiData and then exported into Statistical Package for Social Sciences research (SPSS) version 20 for analysis. Descriptive data analysis was conducted and data were summarized into frequencies and percentages, means with standard deviations, and medians with interquartile ranges. Bivariate analysis was conducted with the Chi-squared and Fisher's exact tests for categorical independent variables, and the student's t-test for numerical variables. Finally, multivariate analysis was done via logistic regression analysis and results were stated as odds ratios (OR) with corresponding 95% confidence interval (CI). The level of statistical significance was set at 5%. RESULTS: Out of the total 390 participants, 112 (28.7%) were under weight. The study showed primary (aOR, 0.38; 95% CI, 0.12-1.18; P = 0.095) and secondary (aOR, 0.37; 95% CI, 0.12-1.17; P = 0.091 levels of education were associated with underweight but not tertiary level of education (aOR, 0.76; 95% CI, 0.21-2.74; p = 0.671). Household income of 5000 to 10,000 (aOR, 0.26; 95% CI, 0.10-0.68; P = 0.006) and above 10,000 (aOR, 0.11; 95% CI, 0.04-0.28; P < 0.001) South Sudanese pounds, supplementary feeding before 6 months (aOR; 0.01; 95% CI, 0.02-0.05; P < 0.001) were associated with underweight and irregular hand washing (aOR; 2.17; 95% CI, 1.14-4.11; P = 0.018) was associated with increased odds of underweight. CONCLUSIONS: This study established a high prevalence of underweight. Maternal level of education particularly primary, secondary, higher household incomes in excess of 5,000 South Sudanese pounds reduced the risk of underweight. While irregular hand washing was a risk factor for underweight.

"Implementation of intensified COVID-19 vaccination optimization (ICVOPT) campaigns strategy in complex humanitarian emergency settings and hard-to-reach areas; a case of South Sudan".

INTRODUCTION: The COVID-19 pandemic is still a public health concern in South Sudan having caused suffering since the first case of COVID-19 was introduced on 28th February 2020. COVAX vaccines have since been introduced using a number of strategies including fixed site, temporary mobile, hit and run in flooded and conflict affected areas. We aim to describe the 2 ICVOPT campaigns that were conducted to improve the uptake and document lessons learnt during the initial rollout of the COVID-19 vaccination programin South Sudan between February 2022 and June 2022 each lasting for 7-days. METHODOLOGY: We conducted an operational cross-sectional descriptive epidemiological study of a series of the intensified COVID-19 vaccination Optimization (ICVOPT) campaigns from February 2022 to June 2022. Before the campaign, a bottom up micro-planning was conducted, validated by the County Health Departments (CHDs) and national MOH team. Each of the 2 campaigns lasted for 7 days targeting 30% of the eligible unvaccinated target population who were18 years and above. Each team consisted of 2 vaccinators, 2 recorders and 1 mobilizer. The teams employed both fixed site, temporary mobile, hit and run in flooded and conflict affected areas. The number of teams were calculated based on the daily workload per day (80 persons per team/day) for the duration of the campaigns. RESULTS: A total of 444,030 individuals were vaccinated with primary series COVID-19 vaccine (J&J) out of the targeted 635,030 persons. This represented 69.9% of target population in the selected 28 counties and 10 states of South Sudan in 7 days' ICVOPT campaigns. More eligible persons were reached in 7 days campaigns than the 9 months of rollout of the COVID-19 vaccine prior to ICVOPT campaigns using the fixed site strategy at the health facility posts. CONCLUSION: Intensified COVID-19 vaccination Optimization (ICVOPT) campaigns were vital and fast in scaling up vaccination coverages as compared to the fixed site vaccination strategies (2022 progress report on the Global Action Plan for Healthy Lives and Well-being for All Stronger collaboration for an equitable and resilient recovery towards the health-related Sustainable Development Goals, incentivizing collaboration, 2022) in complex humanitarian emergency settings and hard-to-reach areas of South Sudan.

Measuring refugees' capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda.

BACKGROUND: Forcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda. We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done. RESULTS: The Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences. CONCLUSIONS: In this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

Health and well-being of young mothers displaced by conflict: Experiences from South Sudan and the Kurdistan Region of Iraq.

Giving birth during adolescence is linked to a variety of negative outcomes, including poor health and well-being. Girls who have been displaced by conflict are at increased risk for becoming young mothers. While prevalence rates and health outcomes have been documented, rarely have the complex personal narratives of early motherhood been examined from the perspectives of mothers themselves, particularly in the Global South. This study relies on in-depth, inductive, narrative analysis of qualitative interviews with 67 young mothers and 10 relatives in South Sudan and the Kurdistan Region of Iraq (KRI) who had been displaced by conflict. This study provides deep insights into the contributing circumstances and consequences of young motherhood from sexual and reproductive health and well-being perspectives, with additional insights on mothering in humanitarian crisis.

Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study.

BACKGROUND: As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes. METHODS: A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols. RESULTS: Very few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI - 30.2, - 26.5) and 5.1 days (CI - 6.2, - 4.0); the full adapted protocol had a decrease of 3.0 (CI - 5.1, - 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18-3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45-2.19); and fully adapted protocol AOR = 2.41 (CI 1.69-3.45). CONCLUSIONS: This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing.

From humanitarian crisis to employment crisis: The lives and livelihoods of South Sudanese refugee health workers in Uganda.

Despite the many benefits of refugee health workers for health systems, they commonly face challenges integrating into host country workforces. The Global Code of Practice on International Recruitment of Health Personnel, which should monitor and protect migrant health workers, offers little guidance for refugees and research is needed to inform strategy. Based on interviews with 34 refugee health workers and 10 leaders across two settlements supporting populations fleeing the humanitarian crisis in South Sudan since 2013, we describe the governance and social dynamics affecting South Sudanese refugee health worker employment in Uganda. Refugees in Uganda legally have the right to work but face an employment crisis. Refugee health workers report that systemic discrimination, competition from underemployed domestic workers, unclear work permit rules and expensive credentialling processes exclude them from meaningful work in public health facilities and good jobs in the humanitarian response. This pushes them into unchallenging roles in private clinics, poorly remunerated positions on village health teams or out of the health sector altogether. Health system strengthening initiatives in Uganda to integrate humanitarian and government services and to deter the domestic workforce from emigration have overlooked the potential contributions of refugee health workers and the employment crisis they face. More effort is needed to increase fairness in public sector recruitment practices for refugee health workers, support credentialling, training opportunities for professional and non-professional cadres, job placements, and to draw attention to the public benefits of refugee health worker employment alongside higher spending on human resources for health.