South Sudan faces high risk of Ebola importation, assessment finds

Credit: World Vision

South Sudan faces a sustained risk of Ebola being imported from neighboring Democratic Republic of Congo and Uganda, while gaps remain in public awareness and perceptions of the disease, according to a new assessment.

The assessment by REACH found high awareness of Ebola Virus Disease, or EVD, in most of the high-risk areas surveyed. But some respondents did not believe there was an active outbreak in neighboring countries or that they or their communities were at risk.

South Sudan’s porous borders and strong social and economic ties with Congo and Uganda increase the likelihood of cross-border transmission of Bundibugyo virus disease, according to the assessment.

The rapid assessment was conducted in Juba, Yambio, Gangura, Nimule and Kajo-keji. It included 1,065 individual surveys carried out between June 29 and July 11, along with six focus group discussions. GOAL separately collected data in Kajo-keji using similar tools.

Nearly one-fifth of respondents in Juba said they had not heard of Ebola, despite the capital being among the areas considered at high risk of importation.

The assessment said the absence of Ebola cases in South Sudan may be contributing to lower perceptions of risk. Some focus group participants also questioned messaging about bushmeat as a risk factor because it remains part of local diets.

Participants in Yambio and Nimule, however, showed strong awareness of the risks associated with cross-border movement and called for protective equipment and improved water, sanitation and hygiene facilities.

Respondents were able to recall some common Ebola symptoms, but participants said they would have difficulty distinguishing Ebola from other diseases with similar symptoms, including malaria.

The assessment also found widespread demand for more information about Ebola.

Health workers, health facilities and radio were among the most common sources of health information.

But access to radio remains limited in some remote communities, with participants reporting that some households lack radio sets or cannot receive radio signals.

Health workers, health facilities and government sources were generally considered more trustworthy than radio. Community leaders were also identified as trusted sources, particularly in Yambio.

The assessment said trained community leaders could help deliver Ebola information in areas where access to health workers and radio is limited. Participants also suggested face-to-face awareness campaigns and the use of megaphones.

The assessment found extensive movement between South Sudan, Congo and Uganda for trade, family visits and access to markets.

Participants described the borders as highly porous, with informal routes used to avoid taxes and administrative restrictions.

REACH said border closures are unlikely to prevent the spread of Bundibugyo virus disease and, citing a recent World Health Organization warning, noted that such restrictions could increase the risk of Ebola transmission.

Movement routes identified by participants included destinations in Uganda such as Elegu, Pagirinya, Adjumani, Moyo, Obongi and Yumbe. Some respondents also reported travel to Juba and Kampala.

The assessment highlighted the Ituri-Arua corridor as a potential transmission route because of established cross-border movement.

Screening was reported at official border crossings with Congo and Uganda, but participants raised concerns about gaps in testing.

In Nimule and Kajo-keji, screening reportedly was not conducted at night and did not routinely target local residents crossing the border. Some participants in Yambio said they were unaware of screening despite regularly crossing into Congo.

Participants also said screening procedures were not always clearly explained at checkpoints.

Despite those concerns, they viewed screening as an important protective measure and called for checks to be expanded to public places beyond official border crossings.

The assessment found that people were generally willing to report suspected Ebola cases, but awareness of the disease hotline varied sharply.

Awareness was highest in Gangura, where 73% of respondents knew about the hotline, and lowest in Kajo-keji, at 24%.

Some participants questioned whether the hotline could respond quickly enough in their communities. Others valued it because it is toll-free and allows people to report suspected cases anonymously.

Traditional burial practices could also complicate an Ebola response.

Physical contact with the deceased is an important part of burial rituals in many South Sudanese communities. In Yambio, 22% of respondents said they would wash the body of an Ebola victim.

Participants said restrictions on traditional burial practices could create tensions, but indicated that restrictions clearly explained and supported by health workers would likely be accepted because of the trust placed in health workers.

The assessment found that willingness to wait for health workers before burial varied by location. In Kajo-keji, many respondents said they would not wait even one day, underscoring the importance of rapid deployment of health personnel during an outbreak.

REACH cautioned that the findings should be considered indicative of the assessed areas and are not representative of the three towns, payams or counties as a whole.

The assessment said sampling did not follow a strict probability-based approach and that fieldwork was affected by practical constraints. In Yambio, for example, data collection focused more heavily on areas near the road to Congo.

The assessment is part of a wider series of REACH studies examining the Bundibugyo virus disease outbreak and population movement between Congo, Uganda and South Sudan.