Impact of Policy and Funding Decisions on COVID-19 Surveillance Operations and Case Reports - South Sudan, April 2020-February 2021

Abstract

Early models predicted substantial COVID-19-associated morbidity and mortality across Africa (1-3). However, as of March 2021, countries in Africa are among those with the lowest reported incidence of COVID-19 worldwide (4). Whether this reflects effective mitigation, outbreak response, or demographic characteristics, (5) or indicates limitations in disease surveillance capacity is unclear (6). As countries implemented changes in funding, national policies, and testing strategies in response to the COVID-19 pandemic, surveillance capacity might have been adversely affected. This study assessed whether changes in surveillance operations affected reporting in South Sudan; testing and case numbers reported during April 6, 2020-February 21, 2021, were analyzed relative to the timing of funding, policy, and strategy changes.* South Sudan, with a population of approximately 11 million, began COVID-19 surveillance in February 2020 and reported 6,931 cases through February 21, 2021. Surveillance data analyzed were from point of entry screening, testing of symptomatic persons who contacted an alert hotline, contact tracing, sentinel surveillance, and outbound travel screening. After travel restrictions were relaxed in early May 2020, international land and air travel resumed and mandatory requirements for negative pretravel test results were initiated. The percentage of all testing accounted for by travel screening increased >300%, from 21.1% to 91.0% during the analysis period, despite yielding the lowest percentage of positive tests among all sources. Although testing of symptomatic persons and contact tracing yielded the highest percentage of COVID-19 cases, the percentage of all testing from these sources decreased 88%, from 52.6% to 6.3% after support for these activities was reduced. Collectively, testing increased over the project period, but shifted toward sources least likely to yield positive results, possibly resulting in underreporting of cases. Policy, funding, and strategy decisions related to the COVID-19 pandemic response, such as those implemented in South Sudan, are important issues to consider when interpreting the epidemiology of COVID-19 outbreaks.

FIGURE 1

COVID-19 test results, by test reporting date (N = 99,553) — South Sudan, April 6, 2020–February 21, 2021 * Surveillance data analyzed were from point of entry screening, testing of symptomatic persons who contacted an alert hotline, contact tracing, sentinel surveillance, and outbound travel screening.

FIGURE 2

Number and results of COVID-19 tests, by surveillance source, and major policy and funding changes correlated with changes in testing/positive case counts — South Sudan, April 6, 2020–February 21, 2021 Abbreviations: MOH = Ministry of Health; POE = point of entry. * Y-axes scaled differently in each panel. † Travel screening tested outbound travelers. Contact tracing tested those with a known exposure to a confirmed positive case. Alert testing consisted of rapid response teams testing persons with COVID-19–compatible symptoms who called the COVID-19 alert hotline. Point of entry screening tested persons as part of screening during inbound travel. Sentinel site surveillance was conducted at health facilities and tested persons who sought care for any reason and were experiencing COVID-19–compatible symptoms.