1

Republic of South Sudan

Situation Report #55 on Cholera in South Sudan

As at 23:59 Hours, 15 August 2015

Situation Update As of 15 August 2015, a total of 1,581 cholera cases including 45 deaths (CFR 2.85%) have been reported in Juba and Bor Counties in Central Equatoria and Jonglei States respectively. In Juba County, 1,451 cases including 44 deaths (CFR 3%) have been reported from eight Payams (Table 1). In Bor, 130 cases including one death (CFR 0.77%) have been reported from Malou in Makuach Payam and other areas within the County. Kator, Rejaf, Northern Bari, and Munuki are the most affected Payams in Juba County with attack rates (cases per 10,000) of 252, 219, 166, and 27 respectively (Annex 1). Makuach is the most affected Payam in Bor and has registered an attack rate (cases per 10,000) of 33 (Annex 1 and 2).

Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 15 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 19 8 1 21 213 26 18 44 1173 1451 IMC UN House PoC clinic 0 0 0 0 0 0 1 1 73 74

Juba Teaching Hospital 10 2 0 19 209 22 7 29 792 1049

MedAir Gumbo CTU 0 0 0 0 0 1 0 1 93 94

MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8

HLSS Nyakuron ORP 2 2 0 0 0 0 0 0 37 37

HLSS Kator ORP 0 0 0 0 0 0 0 0 6 6

HLSS Gurei ORP 0 0 0 0 0 0 0 0 58 58

HLSS Munuki ORP 0 0 0 0 0 0 0 0 3 3

HLSS Al Sabah ORP 4 4 0 0 0 1 0 1 19 20

HLSS Lologo ORP 1 0 1 0 0 0 1 1 10 11

MSF Munuki CTC 2 0 0 2 4 0 0 0 56 62

Other sites in Juba 0 0 0 0 0 2 9 11 18 29

Jonglei State – Bor 2 0 0 4 3 1 0 1 122 130

Bor State Hospital 2 0 0 4 3 1 0 1 122 130

Total 21 8 1 25 216 27 18 45 1295 1581 *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- Central Equatoria State

A total of 21 new cholera cases were reported in Juba and Bor on 15 August 2015 (Table 1 and Figure 1).

Figure 1: New cholera cases in Juba and Bor by residence on 15 August 2015

During week 33 of 2015 (week of 15 August 2015), most of the cholera cases in Juba originated from Mobil, Gurei, Lemon Gaba, and Mangatain, Jebel Dinka, Gorom, and Gudele 2 in Northern Bari; Gumbo in Rejaf; Nyakuron and Jebel Kujur in Munuki; Kor William in Kator; and Buluk and Tongping in Juba (Figure 1.1).

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During week 33 of 2015, the most affected Payams in Juba County were Northern Bari, Kator, Rejaf, Munuki, and Juba that registered attack rates (cases per 10,000) of 14, 8.8, 4.9, 1.0, and 0.5 respectively (Annex 1). Figure 1.1: New cholera cases by residence during week 33 of 2015

Cumulatively, 1,581 cholera cases including 45 deaths (27 facility and 18 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 45 deaths, 11 (24%) occurred in children under five years while 30 (67%) occurred in males. In Juba County, Juba Payam has registered the highest CFR followed by Northern Bari, Munuki, Rejaf, and Kator (Annex1). Weekly case fatality rates have been declining from 14.3% in week 23 and 17.9% in week 24 to 1.9% in week 30 and 2.9% in week 33 respectively (Figure 2). Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 15 August 2015

Reporting Facility

New cases by epidemiological week of 2015 Grand Total 21 22 23 24 25 26 27 28 29 30 31 32 33

CES – Juba County 4 2 7 56 130 229 235 160 237 149 100 77 65 1451

JTH 0 2 2 32 119 208 207 115 146 92 52 44 30 1049

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 3 7 37

HLSS Kator ORP 0 0 0 0 0 0 0 3 1 2 1 6

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 9 2 94

HLSS Gurei ORP 0 0 0 0 0 0 0 1 11 10 15 10 11 58

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 3 5 20

HLSS Lologo ORP 0 0 0 0 0 0 0 0 2 4 2 1 2 11

MSF Munuki CTC 0 0 0 0 0 0 0 0 23 18 7 7 7 62

Other sites in Juba 0 0 1 15 5 3 1 3 0 0 1 29

Jonglei State – Bor County 0 0 0 0 0 5 46 33 21 8

9 4 4 130

Bor State Hospital 0 0 0 0 0 5 46 33 21 8 9 4 4 130

Grand Total 4 2 7 56 130 234 281 193 258 157 109 81 69 1581

As seen from Figure 2 and 2.1, sustained and consistently increasing community transmission was established in Juba from the 6 June 2015 [23

rd epidemiological week] with two transmission peaks in week 27

and 29.However, cholera cases have been declining since 20 July 2015 [30th epidemiological week]. Ongoing

transmission in Juba during week 33 is largely driven by cases reported from Northern Bari, Munuki, and Rejaf Payams (Annex 1 and 2). In Bor, the initial case occurred on 26 June 2015 [26

th epidemiological week] with increasing number of 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 (Figures 2 and 2.1).

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Figure 2: Epidemic curve for cholera cases in Juba and Bor, 18 May – 15 August 2015

JS: Jonglei State; CES: Central Equatoria State; CFR: Case Fatality Rate

Figure 2.1: Cholera cases in Juba and Bor by week of onset, week 21-33 of 2015

Figure 3: Spot map for cholera cases by residence in Juba during week 32 of 2015

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During week 32 of 2015 (week of 3 August 2015), most of the cholera cases in Juba originated from Kor William, Giada, and Kator in Kator Payam; New site, Lokuilili, and Gurei in Northern Bari; and Gumbo (Central, Shirkat, and Hai Camp) in Rejaf Payam (Figure 3). As of 15 August 2015, the sites reporting the highest cumulative number of cholera cases included Gumbo, New site, Juba 3 PoC, Gudele 2, Atlabara B, and Munuki with satellite cases distributed in seven Payams in Juba County (Figure 3.1). In Bor County, the majority of the cases originated from Malou, Langbar, Achingdii, Arek, and Hai Salam in Makuach Payam. Figure 3.1: Spot map for cholera cases by residence in Juba from 18 May 2015 to 15 August 2015

Within Juba County and its most affected Payams of Juba, Northern Bari, Munuki, Rejaf, and Kator, children under 10 years and young adults aged 20-34 years are the most affected while in Makuach Payam, Bor County, children under 10 years are the most affected. (Tables 3.1 and 3.2; Annex 3).

Table 3.1: Cholera case distribution by age in Juba County, 18 May – 15 August 2015

92 73

44 52 84 92

53 44 27 22 17 11 9 7 7

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Male

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Table 3.2: Cholera case distribution by age in Bor County, 18 May – 15 August 2015

Out of the 1,445 cholera cases with known gender in Juba, 635 (44%) were female, while 810 (56%) were male while in Bor, 75 (58%) of the cases were females, while 55 (42%) were males (Table 4). Table 4: Case distribution by gender and age in Juba and Bor Counties, 18 May – 15 August 2015

Case distribution by gender n (%)

CES - Juba 1445

Female 635 (44)

Male 810 (56)

Jonglei state – Bor County 130

Female 75 (58)

Male 55 (42)

Grand Total 1575

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.

Laboratory updates Table 5: Cholera laboratory test results for Juba and Bor, 18 May – 15 August 2015

Health Facility Number of RDT tests

Number of cholera RDT positives

Number of stool cultures

Number of cholera Culture positives

CES – Juba 286 261 96 37

1 Juba Teaching Hospital 183 170 55 17

2 Juba 3 PoC clinic 69 63 22 11

3 MSF Munuki CTC 18 16 4 0

4 Other sites in Juba 12 9 10 5

5 MedAir Gumbo CTU 4 3 5 4

Jonglei state – Bor 71 61 17 9

1 Bor State Hospital 71 61 17 9

Total 357 322 113 46

As seen from Table 5, 322 (90%) of the samples have been RDT positive while 46 (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 and Achingdii have 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

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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 – 15 August 2015

Table 6: Cholera Alerts – 15 August 2015 Date of notification

Details of the alert Area Action

15-Aug-15 One RDT positive suspect cholera case reported in Pibor

Pibor - Sample collected and sent to Juba for microbiological culturing

- Investigations underway by SAR surveillance team

16-Aug-15 Community death involving a 4 year old boy occurred in Lologo on 15-Aug-15

Lologo - Verification conducted by the state RRT - Follow up conducted by hygiene promotion and

OCV vaccination teams

16-Aug-15 At least eight cholera cases reported from Mobil; an area where 500 other people are gathered

Mobil - SPLA medical corps duly informed

- Supplies including ORS, Ringers lactate, Aqua tabs, cannulas, giving sets, cotton wool and plaster supplied

- Plans underway to train SPLA medical corps to conduct reactive OCV vaccination

Since 25 June 2015, at least 15 alerts of suspect cholera cases have been reported. The national and respective state cholera taskforce committees have initiated the recommended follow up actions.

Highlight of the Response As of 15

th August additional activities initiated to the already on-going response by cluster or sub working

groups are as followed:

COMMUNICATION Intensive cholera awareness campaigns continue through 22 radio stations in Central Equatoria, Eastern Equatoria, Upper Nile State and Mingkaman IDP camp

This week, 50 UNICEF-trained volunteers from South Sudan Red Cross conducted house-to-house cholera awareness reaching 3,280 households (19,680 Individuals) and distributed 3,280 Sachets of ORS and 22,960 sachets of PUR. This brings to a cumulative total of 13,946 households (over 83,600 individuals) reached with cholera prevention and control key messages.

The Central Equatoria State Ministry of Health conducted 7 days of intensive cholera awareness through Street Announcements covering main streets, residential areas and market places (Konyokonyo, Juba Town, Gumbo, Shirkat, Munuki, Gudele, Jebel Market, New Site, Gurei, CheckPoint, Rock City, Thonping, Mauna and Khor Romula). The street announcements educate public on cholera prevention and controls reaching over 50,000 people with key messages and over 1000 posters and other IEC materials have been distributed to shopkeepers to display in shops in the above areas.

The social mobilization group, this week held refresher trainings for 121 social mobilizers who will be deployed Juba Block, Kator Block, Nyakuron East and West, Rajaf Payam and Gondokoro Islands. The social mobilizers will educate communities on critical practices to prevent and control cholera targeting estimate of over 15,000 households

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In Bentiu Unity State, UNICEF trained 30 participants including 21 school-children (9 girls 12 boys) and 9 teachers (7 males 2 females). The trained school club members will conduct cholera prevention and hygiene promotion activities in schools targeting 3,000 school children with hygiene messages.

This week during commemoration of International Youth Day, Community leaders together with Community Health Committee educated a gathering of about 6,000 youth and children on cholera prevention and control and other communicable diseases.

In Bor Jonglei, 45 social mobilizers reached 2,630 households (15,780 Individuals) this week with cholera messages in Bor town and PoC. The trained social mobilizers also conducted 17 community meetings in Bor town and PoC which were attended by community leaders and women and youth representatives.

WASH

The WASH cluster distributed WASH supplies including soap, collapsible jerry cans and Aquatabs® to 4,000 households in Manga Tain IDP camp.

UNICEF is contracting dislodging at Juba Teaching Hospital (JTH) CTC as well as providing fuel (200L) to support the backup generator for pumping water to the elevated tank and for incineration purposes

Health Cluster Case management surveillance and laboratory update With the support of WHO during week 33, the state rapid response teams verified four cholera alerts in Hai Referendum, Lologo, and Mobil in Juba; and Pibor. Two of these were confirmed as probable cholera deaths (Lologo and Hai Referendum) while investigations and appropriate public health responses are underway in response to the alerts from Mobil in Juba and Pibor. With the support of WHO onsite rapid diagnostic testing for cholera is ongoing in all CTCs with 322 RDT positive samples. In addition, National Public Health Laboratory has confirmed 46 cholera cases by microbiological culturing. The Health cluster continues its efforts to improve access to timely rehydration with three operational cholera treatment centers (Juba Teaching Hospital [JTH], Munuki, and Bor State Hospital), one cholera treatment unit (Juba 3 PoC), and six ORPs in Nyakuron, Kator, Gurei, Munuki, Al Sabah, and Lologo. A four- day, two-dose OCV campaign in Malakal PoC with targeted population of 33,378 ended on 16 August 2015 with an administrative coverage 37,718 individuals aged one year and above reached. During a separate OCV campaign a total of 7,058 individuals were reached with single-dose OCV, soap, water purification tablets, and hygiene promotion leaflets in Lokuilili, Kor Williams, Munuki Block B, and Bodyri in response to the confirmed cholera cases reported In response to the declining cholera cases treated at the designated cholera treatment facilities, with the support of WHO the following have been instituted.

Onsite cholera rapid diagnostic testing for all new cholera cases seen at oral rehydration points, cholera treatment units, and cholera treatment centers is ongoing

Mobile laboratory teams from state Ministry of Health and MSF-Holland have been trained and facilitated to support testing at the designated cholera treatment facilities.

The Central Equatoria state rapid response team has been reactivated to conduct community surveillance and response in all the current transmission hotspots. Their interventions will entail active case search, initiation of oral rehydration therapy for all new suspect cases, referral of suspect cases, hygiene promotion including the distribution of nonfood items like water purification tablets and soap to affected households.

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Planned and On-going Activities 1. The next national cholera taskforce meeting is scheduled for Monday 17 August 2015 at 2:30 pm in the

MoH Ministerial Boardroom. 2. The next cholera coordination meeting in UN House PoC is scheduled for 20 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: outbreak_ss_2007@yahoo.com, 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 15 August 2015 Annex 1: Cholera attack rates and case fatality rates by Payam, 18 May to 15 August 2015

Location

New cases in week 33,

2015 Total Cases

Total Deaths Population

Case Fatality Rate [%]

Attack rate [cases per 10,000] for week 33 of

2015

Cumulative Attack rate [cases per

10,000]

CES 65 1451 44 297551 3.0 2.2 48.8

Gondokoro 0 8

7115 - 0 11.2

Juba 5 147 11 91254 7.5 0.5 16.1

Kator 10 287 6 11395 2.1 8.8 251.9

Lokiliri 0 3

5995 - 5.0

Munuki 13 342 8 129133 2.3 1.0 26.5

Northern Bari 29 345 10 20753 2.9 14.0 166.2

Rejaf 7 312 7 14226 2.2 4.9 219.3

Mangala 1 1 17680 0.6 0.6

(Blank) 0 5 2

40.0 JS 4 130 1 181708 0.8 0.2 7.2

Baidit 0 5

51042 - 0 1.0

Bor 2 10

61224 - 0.3 1.6

Kolnyang 0 1

40021 - 0 0.2

Makuach 2 96 1 29421 1.0 0.7 32.6

Grand Total 69 1581 45 461579 2.8 1.5 34.3

Annex 2: Cholera epidemic curves by Payam – 18 May to 15 August 2015

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7/3/15

7/5/15

7/7/15

7/9/15

7/11/15

7/13/15

7/15/15

7/17/15

7/19/15

7/21/15

7/23/15

7/25/15

7/27/15

7/29/15

7/31/15

8/2/15

8/4/15

8/6/15

8/8/15

8/10/15

8/12/15

8/14/15

8/16/15

Numberofcases

CholeraEpidemicCurveMunukiPayam2015

Munuki

0

10

20

30

40

50

60

0

5

10

15

20

25

5/16/15

5/18/15

5/20/15

5/22/15

5/24/15

5/26/15

5/28/15

5/30/15

6/1/15

6/3/15

6/5/15

6/7/15

6/9/15

6/11/15

6/13/15

6/15/15

6/17/15

6/19/15

6/21/15

6/23/15

6/25/15

6/27/15

6/29/15

7/1/15

7/3/15

7/5/15

7/7/15

7/9/15

7/11/15

7/13/15

7/15/15

7/17/15

7/19/15

7/21/15

7/23/15

7/25/15

7/27/15

7/29/15

7/31/15

8/2/15

8/4/15

8/6/15

8/8/15

8/10/15

8/12/15

8/14/15

8/16/15

NumberofcasesinAtlabaraB

Numberofcasesinothervillagesin

Kator

CholeraEpidemicCurveKatorPayam2015

Kator Atlabara

0

5

10

15

20

25

5/16/15

5/18/15

5/20/15

5/22/15

5/24/15

5/26/15

5/28/15

5/30/15

6/1/15

6/3/15

6/5/15

6/7/15

6/9/15

6/11/15

6/13/15

6/15/15

6/17/15

6/19/15

6/21/15

6/23/15

6/25/15

6/27/15

6/29/15

7/1/15

7/3/15

7/5/15

7/7/15

7/9/15

7/11/15

7/13/15

7/15/15

7/17/15

7/19/15

7/21/15

7/23/15

7/25/15

7/27/15

7/29/15

7/31/15

8/2/15

8/4/15

8/6/15

8/8/15

8/10/15

8/12/15

8/14/15

8/16/15

Numberofcases

CholeraEpidemicCurveGondokoroPayam2015

Gondokoro

11

0

5

10

15

20

25

5/16/15

5/18/15

5/20/15

5/22/15

5/24/15

5/26/15

5/28/15

5/30/15

6/1/15

6/3/15

6/5/15

6/7/15

6/9/15

6/11/15

6/13/15

6/15/15

6/17/15

6/19/15

6/21/15

6/23/15

6/25/15

6/27/15

6/29/15

7/1/15

7/3/15

7/5/15

7/7/15

7/9/15

7/11/15

7/13/15

7/15/15

7/17/15

7/19/15

7/21/15

7/23/15

7/25/15

7/27/15

7/29/15

7/31/15

8/2/15

8/4/15

8/6/15

8/8/15

8/10/15

8/12/15

8/14/15

8/16/15

Numberofcases

CholeraEpidemicCurveLokiliriPayam2015

Lokiliri

0

5

10

15

20

25

6/22/15

6/24/15

6/26/15

6/28/15

6/30/15

7/2/15

7/4/15

7/6/15

7/8/15

7/10/15

7/12/15

7/14/15

7/16/15

7/18/15

7/20/15

7/22/15

7/24/15

7/26/15

7/28/15

7/30/15

8/1/15

8/3/15

8/5/15

8/7/15

8/9/15

8/11/15

8/13/15

8/15/15

Numberofcases

CholeraEpidemicCurveMakuachPayam,Bor2015

Makuach

12

Annex 3: Cholera case distribution by age, gender, and Payam – 18 May to 15 August 2015

6 5 3 6 8 8

5 3 1 2 2 2 1 1

9

3 4

7

11

21

10

7 8

3 2 1 1 0

5

10

15

20

25

30

35

Nu

mb

er

of

case

s

Cholera case distribution by age in Juba Payam, week 26-33, 2015

Male

Female

20

9 5

11

21

13 8 11

3 5 5 2 2 2

20

16

8

11

19 34

17 16

12 4

5 1

2 4 1 05

101520253035404550

Nu

mb

er

of

case

s

Cholera case distribution by age in Kator Payam, week 26-33, 2015

Male

Female

16 15 19 17

28 26

14 7 6 5

10 1 1 1

17 10

11 16

26 29

27

13 8

4 1

4 2 4 4 0

10

20

30

40

50

60

Nu

mb

er

of

case

s

Cholera case distribution by age in Munuki Payam, week 26-33, 2015

Male

Female

13

23 18

7 9 12 20

9 14 12

5 2 1 3 2 2

41

25

13 10

20

23

22 17 13

4 5 4 1 0

10

20

30

40

50

60

70

Nu

mb

er

of

case

s Cholera case distribution by age in Northern Bari Payam, week 26-33,

2015

Male

Female

26 24

10 7 15

25 15

9 4 5 3 2 3 1 1

33 41

9 4

10

16

13

12

6 5 3 1

5 4

0

10

20

30

40

50

60

70

Nu

mb

er

of

case

s

Cholera case distribution by age in Rejaf Payam, week 26-33, 2015

Male

Female

30

8 3 1 1 1 5 2 3 1 2 1

27

5

2 1 1 1 0

10

20

30

40

50

60

70

underfives

5-9years

10-14years

15-19years

20-24years

25-29years

30-34years

35-39years

40-44years

45-49years

50-54years

55-59years

Nu

mb

er

of

case

s

Cholera case distribution by age in Makuach Payam, Bor week 26-33, 2015

Male

Female