As the world’s youngest country readied measures to prevent widespread COVID-19 infections, its years of conflict and natural disasters suddenly presented an unparalleled challenge: protecting thousands of displaced persons from COVID-19 within the sites set up over the past decade as refuge.  

Of the 1.7 million displaced persons in the country, nearly 168 000 currently live in one of the 116 camps or settlements, where conditions meant physical distancing is virtually impossible. Basic services in camps can sometimes be limited, with water, sanitation and hygiene services as well as food and shelter supply outstripped by the needs of camp residents.

Just like much of the country, many of the displaced persons sites have inadequate health care provision and limited ability to care for severely sick patients.

“The COVID-19 outbreak poses an enormous threat to vulnerable populations in camps and settlements, where overcrowded living conditions and inadequate access to social services challenge effective coronavirus prevention and control,” says Dr Olushayo Olu, World Health Organization (WHO) Representative for South Sudan.

Having moved into the camps away from civil conflict, war, famine and /or flooding, the residents thought staying put was their safest option. “I believed if things are going to get worse, then I would rather be here under [the United Nations Mission in South Sudan protection], where I know they will have to do something rather than me going away and most likely face difficulties I’m not equipped to handle,” explains a leader of the 1921 residents of Bor Protection of Civilian Site in Jonglei State.

Preventing the coronavirus from reaching any community in the country or the camps became a priority of the government, the United Nations and local and international non-government organizations – all coming together in response.

As the global health agency, WHO coordinated their activities, which revolved around building trust, introducing transmission-prevention measures, maintaining continuity of health services and supplies and establishing separate dedicated COVID-19 treatment and isolation centres.

“The South Sudan national COVID -19 response plan addressed the needs of displaced persons camps and settlements, and WHO provided guidelines, tools and kits to partners to facilitate enhanced case and mortality surveillance. This allowed rapid identification, testing and isolation of cases as well as contact listing and quarantine to prevent the risk of widespread outbreaks,” explains Dr Joseph Wamala, Country Preparedness and International Health Regulations Officer for WHO South Sudan in Juba.

Protecting people in overcrowded conditions

By the end of March, a nationwide awareness-raising campaign through radio and SMS messaging was urgently explaining the virus and how people could best protect themselves and their family. The campaign extended into the displaced persons camps and settlements, where leaders, teachers, outreach volunteers, local committees and partners were also engaged to help protect their camp communities.

WHO, in collaboration with the Ministry of Health and other partners, supported the training of nearly 400 health care workers in the camps and settlements on caring for COVID-19 patients and how to prevent and control the spread of the virus.

Any resident of a camp or a settlement for the displaced confirmed to be infected with COVID-19 and in need of isolation or treatment in a dedicated facility is referred to government-run facilities. Given their limited capacity, additional isolation facilities were established for every camp and settlement hosting more than 5000 individuals. The United Nations is supporting 14 isolation centres for displacement camps and settlements.

In mid-April, South Sudan closed its schools, suspended internal flights between states and established a curfew. The camps and settlements were included in the lockdown in a bid to reduce movement and the potential spread of the virus.

Community leaders in some camps took ownership of certain containment measures, such as gate control and deciding who, when and how people enter the camp. WHO and other partners provided supplies for temperature screening of residents at the camp entry locations.

Contact tracing and fears

The Government initiated contact tracing soon after the first cases was detected on 5 April. The first four confirmed cases were United Nations workers.

Dr John Odong, a Sudanese medical doctor trained by WHO in the epidemiology, prevention and control of COVID-19, works with 40 other professionals in the country’s contact tracing team. “From April, we followed up contacts daily for 14 days or more, reporting any signs and symptoms. We collected samples, listed contacts and undertook community awareness on COVID-19.”

It hasn’t been easy, he adds. “Frequently we face negative reactions and even violence. People were, and still are, afraid – worried by the stigma of being infected.”

Dr Odong, who previously worked extensively in cholera outbreak response and especially with affected communities, found contact tracing particularly difficult among the displaced persons in camps and settlements due to the congestion and sheer number of potential contacts involved.

But working in teams of ten professionals, he and colleagues not only traced contacts inside and outside the camps and settlements but addressed the concerns of the residents.

“Despite some threats and the difficult working conditions, we have managed to get through to people. We have provided health education and psychological support to relieve them from stigma and fear of COVID,” he says.

No large outbreak to date

So far South Sudan’s vulnerable displaced populations have not experienced a huge number of COVID-19 cases. The prevention and control measures taken appear to have helped. As of 30 September, only 59 cases among displaced persons had been confirmed from the camps and settlements. And as of 12 October, the country had recorded 2798 cases of COVID-19 and 55 deaths.