Tackling a deadly outbreak of tropical disease in war torn South Sudan

The conflict that erupted in South Sudan little more than a year ago has left people more vulnerable to a deadly tropical disease known as kala azar (visceral leishmaniasis). The risk of infection increases as people are displaced by fighting into areas where the disease is prevalent and malnutrition lowers their ability to fight the infection. With many health facilities not functioning in conflict areas, getting treatment is more difficult.
Last year, Médecins Sans Frontières (MSF) treated over 6,700 cases of kala azar in South Sudan, more than double the number of cases it treated the year before (2714 cases treated in 2013). The majority of people treated were in Lankien, a dusty settlement in the conflict affected state of Jonglei. Casey O'Connor oversees MSF's activities in Lankien and reflects on a tough year.
"For nearly 20 years, MSF has been running a clinic and hospital in Lankien, providing primary healthcare services and treatment for tropical diseases such as kala azar. Early in 2014 it was evident that both the outpatient clinic and the hospital were overwhelmed by war-wounded patients plus we were providing healthcare services to the growing number of people who had been displaced by the conflict," said Casey.
In Jonglei state, people have been uprooted from their homes by fighting and insecurity. Many have moved into acacia forests where sandflies, which are the vectors for kala azar, breed. Sleeping out in the open, often without a mosquito net, increases the risk of infection. 
Most health facilities which were providing testing and treatment for kala azar before the conflict started are no longer functioning or are struggling to get medical supplies in which makes it more difficult for sick people to get treated rapidly. This has lethal consequences as without treatment the disease has a near 100% fatality rate in eastern Africa. 
"Already busy, the outpatient clinic started overflowing with patients in June, with rising numbers testing positive for kala azar, much earlier in the season than anyone could remember and in numbers not seen before in Lankien," said Casey. "What at first appeared as an anomaly was soon recognized as an unprecedented outbreak, with staff trying desperately to manage – hiring more paramedics, working long hours, ordering more drugs for a rise in a disease that normally peaks in September."
The disease attacks organs such as the liver, spleen, and bone marrow, and depletes the immune system, leaving those infected vulnerable to serious infections. The disease is complicated to treat. For most people, the treatment takes 17 days and requires two daily injections. In severe cases, or for pregnant women or people with HIV, it requires admission to hospital and the administration of intravenous medications for 5 days. 
"At some points 5 injection teams were treating 800 patients per day, compared to 250 now. And no one likes the treatment – painful intra-muscular injections into the buttocks. Not just once, but for 17 painful days. All day you can hear the children crying from the pain of the injection," said Casey.
In Lankien last year, MSF treated 4611 Kala Azar patients, more than triple the amount treated in 2013 (1346 patients). It meant that from July to September 2014, nearly 2000 patients were on treatment, which rivals the worst outbreak in Lankien since data started being recorded in 1999. Since then, the outbreak has slowed. Numbers went down in late October and started to level off, but concern remains.
"There is a critical shortage of drugs for treatment on a global level – some of them take 6 months to manufacture and the world-wide supply is under strain as there is only one manufacturer. Any rupture in the supply of medications means treatment is interrupted and the patient must start all over again with painful injections. But getting early and sufficient treatment means the difference between certain death and recovery with the likelihood of life-long immunity to this disease."
In Jonglei, MSF provides treatment for Kala Azar in Lankien, Chuil and Yuai. In neighboring Upper Nile, teams are responding in Malakal and Melut. In 2014, MSF treated a total of 6754 Kala Azar cases in South Sudan compared to 2714 cases in 2013.
Musa's story: 
"I fled with my wife and seven children because there was an attack in Canal. We left everything behind and walked for an entire week. Even then I was not feeling well. My eighth child had already died of kala azar in February. During the day, I could still walk and carry my children but at night I had a high fever and needed to rest. We came to a place where there were many other displaced people. I knew I was sick with kala azar, as my child died of it before, and that MSF was in Lankien. We had to leave five children behind with some people we knew so as to be able to reach the hospital in Lankien. We walked for four more days to reach Lankien. I have been on treatment for twelve days now. As soon as I finish, and get stronger, we will go and collect the children and move to Akobo where my parents live. There I hope we will have peace, a tukul and food for the children." Musa, from Khorfulus (December 2014) 
Patient quotes:
"I have 7 children and four of them got kala azar. One of them died. I have been here in the clinic since June. We fled Malakal when the conflict broke out last December and went to Uror County where we had relatives. I am worried about my children being sick, one of them still suffers from kala azar and is in a very severe condition." - Woman (30) displaced from Malakal (November 2014)
"What is happening is not fair, people are fighting and there are many diseases. My son has kala azar. I fled Chuil in May and settled in a village near Lankien where I had a few relatives. I have nothing to sleep on, nothing to cook with; we have to beg our relatives for food all the time." Woman (36), Lankien, (November 2014)
"I escaped the fighting in Bor with my son and my husband in January. We came with a big group of people. My son has kala azar, so we have been here in the hospital for three months. As soon as he gets better I hope we can join my parents near Yuai." Woman (19), displaced from Bor into Nyriol County (November 2014) 
South Sudan