situation report #42 on cholera in south sudan as at 23:59 ......1 republic of south sudan situation...
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Republic of South Sudan
Situation Report #42 on Cholera in South Sudan
As at 23:59 Hours, 2 August 2015
Situation Update As of 2 August 2015, a total of 1,427 cholera cases including 42 deaths (CFR 2.94%) have been reported in Juba and Bor Counties in Central Equatoria and Jonglei States respectively. In Juba County, 1,307 cases including 41 deaths (CFR 3.14%) have been reported from seven Payams (Table 1). In Bor, 120 cases including one death (CFR 0.83%) have been reported from Malou in Makuach Payam and other areas within the County. The initial cases in Juba were traced back to 18 May 2015 in UN House PoC where the first cholera case was confirmed on 1 June 2015. The most affected Payams in Juba County are Kator, Rejaf, Northern Bari, and Munuki that have registered attack rates (cases per 10,000) of 225, 200, 141, and 25 respectively (Annex 1). In Bor, the initial cases were reported from Malou in Makuach Payam. Makuach Payam is the most affected in Bor and has registered an attack rate (cases per 10,000) of 31 (Annex 1 and 2).
Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 2 August 2015 Reporting Sites New
admisions New
discharges New
deaths Total cases
currently admitted
LAMA* Total facility deaths
Total community
deaths
Total deaths
Total cases discharged
Total cases
CES – Juba County 13 14 0 26 208 25 16 41 1032 1307 IMC UN House PoC clinic 0 0 0 0 0 0 1 1 73 74
Juba Teaching Hospital 5 3 0 24 204 21 7 28 718 974
MedAir Gumbo CTU 0 3 0 2 0 1 0 1 80 83
MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8
HLSS Nyakuron ORP 4 4 0 0 0 0 0 0 27 27
HLSS Kator ORP 0 0 0 0 0 0 0 0 7 7
HLSS Gurei ORP 2 2 0 0 0 0 0 0 37 37
HLSS Munuki ORP 0 0 0 0 0 0 0 0 3 3
HLSS Al Sabah ORP 1 1 0 0 0 1 0 1 11 12
HLSS Lologo ORP 0 0 0 0 0 0 0 0 8 8
MSF Munuki CTC 1 1 0 0 4 0 0 0 42 46
Other sites in Juba 0 0 0 0 0 2 8 10 18 28
Jonglei State – Bor 2 0 0 4 3 1 0 1 112 120
Bor State Hospital 2 0 0 4 3 1 0 1 112 120
Total 15 14 0 30 211 26 16 42 1144 §1427
*LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- Central Equatoria State; § Following data cleaning, 56 duplicate records were deleted from the database.
A total of 15 new cholera cases were reported in Juba and Bor on 2 August 2015 (Table 1 and Figure 1). o 13 new cases were reported from Juba County, with the majority originating from Nyakuron. o The two new admissions in Bor state hospital originated from Hai Salam and Malou (Figure 1),
Figure 1: New cholera cases in Juba and Bor by residence on 2 August 2015
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Atlabara Lologo KorWilliam
Mauna Nyakuron Gudele LemonGaba
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During week 31 of 2015 (week of 2 August 2015), most of the cholera cases in Juba originated from Kor William and Lologo in Kator; Jebel Dinka, Lokuilili, and Hai Baraka in Northern Bari; Nyakuron, and Mauna in Munuki; and Gumbo and Shirkat in Rejaf (Figure 1.1). During week 31 of 2015, the most affected Payams in Juba County were Kator, Rejaf, Northern Bari, and Munuki that registered attack rates (cases per 10,000) of 18.4, 14.8, 10.1, and 1.9 respectively (Annex 1). Figure 1.1: New cholera cases by residence during week 31 of 2015
Cumulatively, 1,427 cholera cases including 42 deaths (26 facility and 16 community) have been reported in Juba and Bor Counties since the initial case was reported on 26 May 2015 in Juba (Tables 1 and 2). Of the 42 deaths, nine (21%) occurred in children under five years while 27 (64%) occurred in males. In Juba County, Juba Payam has registered the highest CFR followed by Northern Bari, Munuki, Rejaf, and Kator (Annex1). Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 2 August 2015
Reporting Facility
New cases by epidemiological week of 2015
Grand Total 21 22 23 24 25 26 27 28 29 30 31
CES – Juba County 4 2 7 56 130 229 235 161 237 150 95 1307
JTH 0 2 2 32 119 208 207 116 146 93 49 974
Juba 3 IMC clinic 4 0 4 9 6 13 10 10 11 5 2 74
HLSS Nyakuron ORP 0 0 0 0 0 0 2 3 11 2 9 27
HLSS Kator ORP 0 0 0 0 0 0 0 3 1 2 1 7
MedAir Gudele ORP 0 0 0 0 0 0 0 4 3 1 8
MedAir Gumbo CTU 0 0 0 0 0 5 15 20 25 10 8 83
HLSS Gurei ORP 0 0 0 0 0 0 0 1 11 10 15 37
HLSS Munuki ORP 0 0 0 0 0 0 0 1 0 2 3
HLSS Al Shabah ORP 0 0 0 0 0 0 0 0 4 3 5 12
HLSS Lologo ORP 0 0 0 0 0 0 0 0 2 4 2 8
MSF Munuki CTC 0 0 0 0 0 0 0 0 23 18 5 46
Other sites in Juba 0 0 1 15 5 3 1 3 0 0 28
Jonglei State – Bor County 0 0 0 0 0 5 46 33 21 8 7 120
Bor State Hospital 0 0 0 0 0 5 46 33 21 8 7 120
Grand Total 4 2 7 56 130 234 281 194 258 158 103 1427
As seen from Figure 2, the initial and isolated cases were reported from UN House PoC in Juba starting on 26 May 2015. However, following epidemiological investigations on 27 May 2015, cases could be traced back to 18 May 2015. Cholera was eventually confirmed on 1 June 2015 in Juba after Vibrio cholerae inaba was isolated from the one of five samples tested in the National Public Health Laboratory. From 6 June 2015, sustained and consistently increasing community transmission was established in Juba as seen from the multiple transmission peaks. The highest transmission peak occurred on 19 July 2015 and was attributed to a funeral in Atlabara B. This trend is attributed to sustained community transmission in Kator, Rejaf, Northern Bari, Munuki, and Juba.
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ewdown
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Juba Bor
Numberofcases
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In Bor, the initial case occurred on 26 June 2015 with increasing cases from week 26 to week 27 when the highest transmission peak was registered. In the subsequent weeks, successively shorter transmission peaks were registered, a trend that is consistent with declining community transmission. Figure 2: Epidemic curve for cholera cases in Juba and Bor, 18 May – 2 August 2015
JS: Jonglei State; CES: Central Equatoria State; CFR: Case Fatality Rate
The probable risk factors fueling transmission include: residing in a crowded IDP camp with poor sanitation and hygiene; using untreated water from the Water tankers; lack of household chlorination of drinking water; eating food from unregulated roadside food vendors or makeshift markets; open defecation/poor latrine use; and attending/eating food at a funeral. Figure 3: Spot map for cholera cases by residence in Juba, 18 May – 2 August 2015
As of 2 August 2015, the sites reporting the majority of cases in Juba include Gumbo, New site, Juba 3 PoC, Gudele 2, Atlabara B, and Munuki with satellite cases distributed in seven Payams in Juba County (Figure 3). In Bor County, the majority of the cases originated from Malou 41 (36%) and Langbar 12 (10.4%) in Makuach Payam.
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The most affected age groups in Juba and Bor counties are children under five and 5-9 years old. Additionally, a significant number of cases have occurred among 25-29 year olds in Juba County (Tables 3.1 and 3.2).
Table 3.1: Cholera case distribution by age in Juba County, 18 May – 2 August 2015
Table 3.2: Cholera case distribution by age in Bor County, 18 May – 2 August 2015
Out of the 1,301 cholera cases with known gender in Juba, 570 (44%) were female, while 731 (56%) were male while in Bor, 71 (59%) of the cases were females, while 49 (41%) were males (Table 4). Table 4: Case distribution by gender and age in Juba and Bor Counties, 18 May – 2 August 2015
Case distribution by gender N (%)
CES - Juba 1301
Female 570 (44)
Male 731 (56)
Jonglei state – Bor County 120
Female 71 (59)
Male 49 (41)
Grand Total 1421
Laboratory updates Table 5: Cholera laboratory test results for Juba and Bor, 18 May – 2 August 2015
Health Facility Number of RDT tests
Number of cholera RDT positives
Number of stool cultures
Number of cholera Culture positives
CES – Juba 221 199 89 35
78 67 40 49
75 85 46 39 25 19 16 11 7 5 7
103 89
43 45
79
114
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46
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Cholera case distribution by age in Juba County, week 21-31, 2015
Male
Female
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Cholera case distribution by age in Bor County, week 26-31, 2015
Male
Female
5
1 Juba Teaching Hospital 126 113 54 17
2 Juba 3 PoC clinic 69 63 22 11
3 MSF Munuki CTC 14 14 1 0
4 Other sites in Juba 12 9 10 5
5 MedAir Gumbo CTU 0 0 2 2
Jonglei state – Bor 57 49 17 8
1 Bor State Hospital 57 49 17 8
Total 278 248 106 43
As seen from Table 5, 248 (89%) of the samples have been RDT positive while 43 (41%) have been confirmed by culture after the National Public Health Laboratory isolated Vibrio cholerae inaba. Most of the culture confirmed cases have been reported from Juba 3 PoC, New site, Munuki, and Nyakuron West in Juba while in Bor, Malou has registered the highest number of confirmed cases (Figure 4). Seven stool samples were shipped to the Central Public Health Laboratory in Uganda for testing. Vibrio cholerae Inaba serogroup, 01 serotype was isolated from one of the samples while six samples tested negative for cholera but were positive for nonpathogenic Escherichia coli. Three isolates were confirmed as positive and three negative samples tested negative on repeat testing in Uganda thus confirming earlier test results by the National Public Health Laboratory. The four isolates were sensitive to tetracycline and ciprofloxacin; intermediate for Ampicillin and chloramphenicol and resistant to Sulphamethoxazole. Figure 4: Number of culture positives by residence in Juba and Bor, 18 May – 2 August 2015
Table 6: Cholera Alerts – 23 to 2 August 2015 Date of notification
Details of the alert Area Action
28-Jul-15 A community death involving a 5-year-old boy occurred in Gumbo. He was buried on 27 July 2015 and his mother was admitted in the MSF Munuki CTC with cholera symptoms on the same day.
Gumbo, Rejaf Payam
- State and county surveillance officers notified to verify the death.
- Mother to the deceased case admitted to MSF Munuki CTC for treatment.
26-Jun-15 Nineteen suspect cholera cases were initially reported in Kajo Keji Civil hospital. The cases have now risen to a cumulative total of 65.
Kajo Keji, CES
- A total of 65 acute watery diarrhoea cases have been line listed with two cases on admission at the hospital
- 21 samples submitted for microbiological culturing
- 19 samples tested negative for cholera following microbiological culturing at the National Public Health Laboratory while two are pending
- An assessment by MedAir revealed there were no active suspect cases. Refresher training on cholera undertaken and cholera case management stockpiles were replenished
-
Since 25 June 2015, at least 10 alerts of suspect cholera cases have been reported outside Juba. The national and respective state cholera taskforce committees have initiated the recommended follow up actions as described in Table 6.
Case management surveillance and laboratory update
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During week 31, the Central Equatoria state rapid response team verified one community death in Gumbo. This involved a 5-year-old boy with onset of illness on 26 July 2015 and died 27 July 2015. The mother was subsequently admitted with cholera symptoms on 27 July 2015 and was later discharged after improving on treatment. There are three operational cholera treatment centers (Juba Teaching Hospital [JTH], Munuki, and Bor State Hospital), two cholera treatment units (Gumbo and Juba 3 PoC), and six ORPs in Nyakuron, Kator, Gurei, Munuki, Al Sabah, and Lologo.
Four standby ambulances have been strategically located in Gumbo, Nyakuron, Gurei, and Munuki and can be accessed through the cholera hotline to support case referrals to the cholera treatment centres.
Overall, the number of cases seen in all the cholera treatment facilities has reduced greatly during the week.
MedAir and IOM support to JTH CTC wad initially planned till 31 July 2015. This week a review is underway to determine if this should be extended.
In the same way, the contract between HLSS and UNICEF to operate the six ORPs was initially planned to last up to 31 July 2015. This contract will be reviewed to determine the duration of extension based on the current trends.
The other interventions including case surveillance, suspect case verification, regular epidemiological updates, and oral cholera vaccination are ongoing with the following highlights
Laboratory testing of samples from suspect cases is ongoing in the National Public Health Laboratory with at least 43 confirmed cases.
Plans are underway to conduct a coverage survey after two rounds of oral cholera vaccination in UN House PoC.
At least 66,755 doses of oral cholera vaccines are expected to arrive in the country by 6 August 2015 to support a two-dose vaccination campaign in Malakal PoC.
With support from MSF Swiss and WHO, the Ministry of Health is conducting a single-dose vaccination with oral cholera vaccine targeting cholera transmission hotspots and vulnerable groups in Juba County. The campaign started on 31 July 2015 and is expected to last up to 5th August 2015. There at least 19 vaccination sites in New site, Mangatain, Gumbo, Kator – Lologo and Atlabara with the coverage for the first two days of the campaign estimated at 63,000. The turn up is still low due to the deliberate low-level of social mobilization however this is being addressed with support from the local leaders. The campaign is also expected to target other high-risk groups like prisons, healthcare workers, and cholera case management teams.
Planned and On-going Activities 1. The next national cholera taskforce meeting is scheduled for Monday 10 August 2015 at 10:00 am in the
Ministry of Health Ministerial Boardroom. 2. The next cholera coordination meeting in UN House PoC is scheduled for 6 August 2015 at 11:30 am in
the RRP Boardroom.
Many thanks to the staff at CTCs, MoH at national level and state levels, especially the Department of IDSR, who have helped to gather the information presented here. Situation Reports are posted on the WHO website: http://www.who.int/hac/crises/ssd/en/ as well as on the Humanitarian Info webpage: http://southsudan.humanitarianresponse.info/clusters/health.
The MoH/WHO surveillance team welcomes feedback and data provided by individual agencies. Given the fast evolving nature of this epidemic, errors and omissions are inevitable: we will be grateful for any information that helps to rectify these. Send any comments and feedback to: E-mail: [email protected], The Toll free numbers for alerts are: Zain: 0912000098.
Contacts For more information please contact:
Dr. John Rumunu Director General - Preventive Health Services MoH, Republic of South Sudan Tel: +211955668178
Dr. Thomas Akim Ujjiga Director - IDSR MoH, Republic of South Sudan Tel: +211955150406
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Annex: Cholera Data tables and Charts – 18 May 2015 to 2 August 2015
Annex 1: Cholera attack rates and case fatality rates by Payam, 18 May to 2 August 2015
Location
New cases in
week 31, 2015 Total
Cases Total
Deaths Populati
on
Case Fatality Rate [%]
Attack rate [cases per 10,000] for week 31 of
2015
Cumulative Attack rate [cases per
10,000]
CES 96 1307 41 279871 3.1 3.4 46.7
Gondokoro 1 8
7115 - 1.4 11.2
Juba 7 139 11 91254 7.9 0.8 15.2
Kator 21 256 5 11395 2 18.4 224.7
Lokiliri 0 3
5995 - 5.0
Munuki 24 318 8 129133 2.5 1.9 24.6
Northern Bari 21 293 8 20753 2.7 10.1 141.2
Rejaf 21 284 7 14226 2.5 14.8 199.6
(Blank) 1 5 2
40.0 JS 7 120 1 181708 0.8 0.4 6.6
Baidit 1 5
51042 - 0.2 1
Bor 1 5
61224 - 0.2 0.8
Kolnyang 0 1
40021 - 0.2
Makuach 4 92 1 29421 1.1 1.4 31.3
Grand Total 103 1427 42 461579 3.0 2.2 30.9
Annex 2: Cholera epidemic curves by Payam – 18 May to 2 August 2015
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CholeraEpidemiccurveNorthernBariPayam2015
NorthernBari
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CholeraEpidemicCurveRejafPayam2015
Rejaf
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CholeraEpidemicCurveMunukiPayam2015
Munuki
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CholeraEpidemicCurveKatorPayam2015
Kator
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CholeraEpidemicCurveGondokoroPayam2015
Gondokoro
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CholeraEpidemicCurveLokiliriPayam2015
Lokiliri
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0
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4
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8
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7/30/15
8/1/15
Numberofcases
CholeraEpidemicCurveMakuachPayam,Bor2015
Makuach