Weekly Epidemiological Bulletin Republic of Integrated Disease Surveillance and Response (IDSR) W16| 24th to 30th April 2017

Highlights Special focus on cholera

• Completeness for weekly reporting was 50% IDSR sites and 66% • Cumulatively, 7,386 cholera cases including 243 deaths (74 facilities for the IDP sites. and 169 community) (CFR 3.29%) have been reported in South Sudan (Figs 19.2&19.3; Table 4.2) • Malaria remains the leading cause of morbidity in nonconflict areas while ARI is the leading cause of morbidity in the IDPs. • Active transmission currently reported in Yirol East, Yirol West, Awerial; Duk; , Fangak, Pigi, Kodok, and Mayom (Figs • A total of 17 suspect measles cases were reported from Juba, 19.2&19.3; Table 4.2). Tonj North , Wau and Aweil South. • During the reporting period, cholera was confirmed in three samples from Yirol East (1) and Yirol West (2) • Active transmission currently reported in Yirol East, Yirol West, Awerial; • A total of 18 counties in 10 (31%) of 32 states countrywide have Duk; Ayod, Fangak, Pigi, Kodok, and Mayom. confirmed cholera outbreaks (Figs 19.2&19.3; Table 4.2).

• A total of 27 HEV cases reported from Bentiu POC in Week 16. Early Warning, Alert and Response

• Chickenpox cases continue to be reported from Wau PoC with Active responses over 3,000 cases recorded since December 2016. Cholera • During the week, medical complications of severe acute Measles malnutrition and TB/HIV/AIDS were the leading cause of mortality Kala azar in Bentiu PoC. Hepatitis E virus Public Health Priorities Active alerts: Figure 1a | IDSR Proportional morbidity WK 16, 2017 ! AFP AWD Event based surveillance W16 of 2017 11% ABD 2% In Week 16, event based surveillance data was received from Western Bar el Ghazal and Eastern Equatoria Hubs. Eight events were reported Malaria ! 54% with 4 measles(Wau and Torit), one AFP (Torit) and three Cholera 33% Measles (Kapoeta South). Investigations were initiated within 24 hours. 0% Others Figure 1c | Health Facility Functionality by county in W16 2017

Figure 1b | Proportional morbidity in IDPs W16 2017

Measles 10%

0% Malaria

ARI 50% 29% AWD

ABD System performance10% 1% Other

Out of the 1392 health faciltiies, 1165 (84%) are currently functional and expected to report Figure 1c. Figure 1d | IDSR Completeness by county in W16 2017 Completeness for weekly reporting was 50% for the routine surveillance (IDSR sites) and 66% for the EWARS (IDP sites) (Table 1).

During the week, Seven counties attained 100% reporting completeness. A total of 15 (19%) counties attained the target completeness of at least 80% (Figures 1c).

Timeliness for weekly reporting stands at 43% for the routine reporting sites and 66% for the IDP sites (Table 1).

Table 1 | Surveillance performance in South Sudan as of W16 2017

Timelines Completeness Timeliness Completeness Total System Facilities in Week 16 of 2017 Cumulative for 2017

IDSR 1167 497(43%) 585(50%) 421(30%) 571(41%)

EWARN 47 31(66%) 31(66%) 36(77%) 37(78%) Table 2 | Reporting Performance [Timeliness and Completeness] by Partner and County as of W16 2017

Number of health W16 2017 Partner IDSR IDSR facilities Completeness Timeliness No. Silent Counties W16 2017 Silent Counties W16 2017 Morobo Wulu % # % # # Budi Yirol East ARC 3 0 0% 0 0% Ikotos Mayendit COSV 0 0 0% 0 0% Kapoeta North Mayom Akobo Payinjiar GOAL 2 2 100% 2 100% Ayod Pariang Duk* Akoka HLSS 2 0 0% 0 0% Fangak Baliet IMA 5 2 40% 2 40% Nyirol* Luakpiny/Nasir* Pibor Maban IMC 8 6 75% 6 75% Pochalla Maiwut Uror Malakal* IOM 11 11 100% 11 100% Awerial* Melut Cueibet Panyikang IRC 1 1 100% 1 100% Rumbek Centre Renk* Rumbek North Abyei Medair 2 2 100% 2 100%

MSF-E 2 2 100% 2 100% *Counties with EWARS reporting sites , MSF-H 4 3 75% 3 75%

SMC 6 0 0% 0 0% UNIDO 0 0 0% 0 0% UNKEA 2 2 100% 2 100% This week, the nine health facilities in the IDP sites that did World Relief 1 0 0% 0 0% not submit their reports are supported by WR, HLSS, SMC, Total 47 31 66% 31 66% MSF-H, IMC, and IMA (Table 2).

This week, 20 hospitals (39%), 145 PHCCs (44%), and 420 PHCUs (41%) in 43 counties submitted their IDSR reports (Table 2). A significant improvement The best performing partner-supported facilities during the from the previous weeks week were GOAL, IRC, Medair, MSF-E, UNKEA and IOM. Number of counties that did not submit any IDSR report increased from 28 in Week 15 to 32 in Week 16 (Table 2). However, seven of these counties submit their data through EWARS (Table 2). Consultations Sixteen (16) partner-supported health facilities in the IDP sites did not submit their reports (Table 2). Table 3 | Consultations in South Sudan as of W16 2017 Trends for top causes of Morbidity Surveillance Consultations in Week 16 of 2017 Cumulative consultations for 2017 Table 4 | Top causes of morbidity in 2016 and 2017 System <5 years ≥5 years Total <5 years ≥5 years Total Cumulative cases week 1 to New cases W16 IDSR 25,219 39,590 64,809 466,720 728,575 1,195,295 System Disease Week 16 of 2016 2017 2016 2017 EWARN 26,719 443,245 Malaria 22,856 21,676 350,128 358,165 ! AWD 9,745 7,050 114,566 121,508 Total 91,528 1,638,540 Meningitis 0 0 9 3 IDSR ABD 1,760 1,253 25,568 19,509 Table 4 summarizes the consultations in the IDP and IDSR reporting Measles 35 15 277 298 sites. AJS 0 0 7 15 Malaria 5,843 2,615 119,231 57,298 Malaria remains the top cause of morbidity in the IDSR reporting sites followed AWD 3,791 2,620 53,200 41,106 by Acute watery diarrhea while for the IDP sites ARI is the leading cause of ARI 5,953 7,839 91,682 120,318 morbidity followed by malaria (Figures 1a, 1b, 6a, 6b, Table 4). EWARN ABD 391 291 6,415 3,538 Measles 29 2 254 218 AJS 23 27 1005 246 Meningitis 0 2 11 20 Malaria 28,699 24,291 469,359 415,463 AWD 13,536 9,670 167,766 162,614 ARI 5,953 7,839 91,682 120,318 Total ABD 2,151 1,544 31,983 23,047 Measles 64 17 531 516 AJS 23 27 1012 261 Meningitis 0 2 20 23 Overall morbidity trends for 2017 Figure 6b | EWARN Priority Disease Proportionate Morbidity W52 2013 to W16 2017 Figure 6a | IDSR priority disease morbidity trends W1 to W16 2017

IDSR Priority Disease Morbidity trends from week 01 - 16, 2017. South Sudan 80% 70.0 500.0 450.0 70% 60.0 400.0 60% 50.0 350.0 50% 40.0 300.0 250.0 40% 30.0 200.0 30% 20.0 150.0

Completeness (%) 100.0 20% 10.0 50.0 10% 0.0 0.0 Percentage of all consultations

0% Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week cases per 100,000 population 15 13 08 06 03 30

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 ------12 07 02 09 04 10 ------Epidemiological Weeks 2013 2014 2015 2015 2016 2016 Completeness ABD Malaria Measles AWD %_Malaria %_ARI %_Measles Status: Urgent Malaria

This week malaria accounted for 33% and 10% of consultations in IDSR IDSR Malaria Incidence rate by year, 2015, 2016 and 2017* and IDP sites respectively (Fig. 1a, 1b). The incidence (cases per 600.0 100,000) of malaria decreased from 182 in Week 15 to 177.2 in Week 16. 500.0 400.0 As the malaria season approaches, the incidence in Week 16 of 2017 is 300.0 comparable to the corresponding periods in 2014, 2015 and 2016. 200.0 As seen from Figs. 8a-f, analysis of malaria trends at state level showed 100.0 that malaria cases were within expected levels at state hub level.(Fig 8a- cases per 100,000 population d). 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 The malaria incidence in the IDP sites has remained within expected Epidemiological Weeks levels. (Figs. 10a-d) 2015 2016 2017 During the week, one malaria death was reported from Abiemnhom.

Malaria trends by state hub

IDSR Malaria Incidence rate for Western Equatoria Hub by year, 2015, IDSR Malaria Incidence rate for Western Bhar el Ghazal State 2016 and 2017* by year, 2015, 2016 and 2017* 500.0 1200.0 450.0 400.0 1000.0 350.0 800.0 300.0 250.0 600.0 200.0 150.0 400.0 100.0 200.0 cases per 100,000 population 50.0

0.0 cases per 100,000 population 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological Weeks Epidemiological Weeks 2015 2016 2017 2015 2016 2017

IDSR Malaria Incidence rate for Unity State by year, 2015, IDSR Malaria Incidence rate for Northen Bhar el Ghazal State by year, 2015, ! 2016 and 2017* 2016 and 2017* 600.0 2000.0 1800.0 500.0 1600.0 1400.0 400.0 1200.0 300.0 1000.0 800.0 200.0 600.0 cases per 100,000 population 400.0 100.0 cases per 100,000 population 200.0 0.0 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological Weeks Epidemiological Weeks 2015 2016 2017 2015 2016 2017

Malaria

IDSR Malaria Incidence rate for Lakes State by year, 2015, IDSR Malaria Incidence rate for by year, 2016 and 2017* 2015, 2016 and 2017* 1400.0 200.0

1200.0 150.0 1000.0

800.0 100.0 600.0

400.0 50.0 200.0 cases per 100,000 population 0.0 0.0 cases per 100,000 population 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological Weeks Epidemiological Weeks 2015 2016 2017 2015 2016 2017

*Actual disease trends may be masked by low reporting rates Malaria in IDPs

400 Figure 10c | EWARN trends for Malaria in UN House(Juba) PoC 2015 to Figure 10| EWARN trends for Malaria in Renk, 2015 to 2017 2017 600 300

400 200

200 100 cases per 10,000 Pop

- - 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epi week incidence 2015 incidence 2016 incidence 2015 incidence 2016 incidence 2017 Third quartile incidence 2017 Third quartile

Figure 10a | Malaria trend for IDPs in Bentiu PoC 2015 to 20 900 Figure 10b | Malaria trend for IDPs in Malakal PoC 2015 to 2017

800 700 700 600 600 500 500 400 400 300 300

Cases per 10,000 pop 200 200 cases per 10,000 100 100 - 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 - 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 Epi Week incidence 2015 incidence 2016 Week of reporting

incidence 2017 Third quartile incidence 2015 incidence 2017 Third quartile incidence 2016 Acute Respiratory Infection (ARI)

Figure 11 | ARI trends in IDPs W51 2013 to W16 2017 35% Figure 11b | ARI Incidence by IDP Site in W16 2017 90% 30% 80% 70% 25% 60% 50% 20% 40% 30% 15% 20% 10% … … … … 10% 0% … !

5% Percent of total consultations E Hospital -

0% IMC ER PoC 1 Percent of all consultations MSF H Lankien PHCC -

010305070911131517192123252729313335373941434547495153 IRC Sector 4 Clinic UNKEA Jikmir PHCC IMC Akobo Hospital IOM Wau PoC Clinic H Bentiu Town Clinic MSF Medair Abayok Clinic - E Malakal Town PHCC H Bentiu PoC Hospital IMC UN House Clinic 1 - - IMC UNMISS PoC Clinic IOM Malakal PoC Clinic Medair Wonthow Clinic

Epidemiological week of reporting GOAL Dethoma Camp 2 GOAL Koradar IDP clinic IOM Nazareth IDP Camp IMC Malakal PoC Clinic 1 IMC Malakal PoC Clinic 2 IOM Bentiu Sector 3 PoC IOM Bentiu Sector 1 PoC IOM Bentiu Sector 5 PoC IOM Halaka Mobile Clinic IOM Gerger Mobile Clinic MSF IOM Ramela Mobile Clinic Gap Medical Mobile Clinic IOM Cathedral Church IDP MSF 2014 2015 MSF IOM Wonthou Mobile Clinic

Figure 11b shows ARI morbidity by IDP site in Week 16 of 2017 ARI proportionate morbidity decreased from 28.19% in Week 15 to 29.34% in Week 16. Comparatively, the ARI proportionate morbidity in 2017 is higher than the corresponding period in 2014, 2015, and 2016.

Chickenpox

• Chicken pox cases are declining in Wau PoC. management of chickenpox cases • The current response is limited to symptomatic case • Recommended supportive management entails - using management of mildly ill cases and admission of calamine lotion, antihistamines, and analgesics for mildly ill complicated cases. cases while complicated cases are admitted for specialized • Implementing partners from IDP collective sites as well as treatment by clinicians. from Wau municipality are supporting the response • Arrangements are underway to procure medicines for • Over 3,000 cases have been line listed since December 2016. supportive care and Unicef is developing a communications • WHO has shared a guidance document on supportive strategy for chickenpox. Meningitis (suspected) Suspect meningitis Epi-curve showing rapid pastorex results, Bentiu PoC, week 47 of 2016 to week 12, 2017 For the second consecutive week, there was no 7 suspected meningitis case reported from across 6 the country. 5 4 Even as the meningitis season is coming to 3 an end, partners are still urged to maintain No. cases heightened surveillance, and to ensure that 2 all patients meeting the suspect case definition 1 for meningitis are investigated and where 0 possible samples collected and notifications sent to the next level for prompt action.

Week of onset Cumulatively from week 47 of 2016, a total of 18 rapid pastorex Streptococcus pneumoniae H.Influenzae b N. meningitidis Y/W 135 Negative S.Pneumonlae cases have been reported (Fig. 11c). Only one rapid pastorex Neisseria meningitidis Y/W135 case has been reported since week 47 of 2016 (Fig. 11c). Suspect meningitis attack rates & CFR by week, Bentiu PoC 12 30 Figure 11d shows the attack rates (cases per 10 25 100,000) and case fatality rates by week for suspect meningitis cases in Bentiu PoC. While 8 20 the alert threshold has been surpassed for at 6 15

least four weeks since week 47, the epidemic 4 10 CFR [%] threshold has not been reached. The current cases per 100,000 2 5 trends are still below the epidemic threshold.

Surveillance for suspect cases of meningitis is 0 0 45 46 47 48 49 50 51 52 01 02 03 04 05 06 07 08 09 10 11 12 high in Bentiu PoC and countrywide. ------2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 Nearly 40% of the cases are below one year Epi week of onset and 68% are below five years of age. Children AR Alert threshold Action threshold CFR and young adults constitute 53% of the cases. Males constitute 61% of the total cases reported (Table 4c).

Heighten Surveillance for meningitis has been Table 4c: Suspect meningitis case age & sex distribution, Bentiu PoC, wk 47, 2016 to wk 10, maintained across the country, especially in the 2017 high risk locations Like Malakal and Bentiu Count of SN Column Labels ! PoC. Age Female Male Total Percentage The second phase of the MenAfriVac <1yr 8 8 16 41% preventive campaigns are slated for the fourth 1-4yrs 2 9 11 28% quarter of 2017 targeting the states in the greater Upper Nile region. 5-14yrs 2 3 5 13% 15-29yrs 1 3 4 10% 30+yrs 2 1 3 8% Total 15 24 39 100% Acute watery diarrhoea (AWD)

AWD remains among the top three causes of morbidity in the IDSR Acute Watery Diarrhoea Incidence rate by year, 2015, 2016 Country, this week it accounted for 11% and 10% of all and 2017* 140.0 consultations in the routine reporting(IDSR) and IDP sites respectively (Fig. 1a, 1b). 120.0 100.0

The AWD Incidence [cases per 100,000] decreased further to 80.0 57.6 in Week 16 from the IDSR reporting sites.(Fig. 12). 60.0 In the IDP sites, AWD morbidity has increase over the last four 40.0 consecutive weeks. This week, the proportionate morbidity is 20.0 lower than the corresponding period in 2014, 2015, and 2016 cases per 100,000 population 0.0 (Fig. 13). Figure 14 shows AWD morbidity by IDP site in Week 16 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 of 2017 Epidemiological Weeks 2015 2016 2017

Acute watery diarrhoea (AWD)

Figure 11b | AWD Incidence by IDP Site in W16 2017 40% 25% Figure 13 | AWD trends in IDPs W51 2013 to W16 2017 35% 30% 20% 25% 20% 15% 15% 10% 5% … … … … 10% 0% …

5% E Hospital - IMC ER PoC 1 Percent of all consultations MSF H Lankien PHCC Percent of all consultations - IRC Sector 4 Clinic IMC Akobo Hospital 0% IOM Wau PoC Clinic H Bentiu Town Clinic MSF Medair Abayok Clinic - E Malakal Town PHCC H Bentiu PoC Hospital IMC UN House Clinic 1 - 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 - IMC UNMISS PoC Clinic IOM Malakal PoC Clinic Medair Wonthow Clinic GOAL Dethoma Camp 2 GOAL Koradar IDP clinic IOM Nazareth IDP Camp IMC Malakal PoC Clinic 1 IMC Malakal PoC Clinic 2 IOM Bentiu Sector 5 PoC IOM Bentiu Sector 3 PoC IOM Bentiu Sector 1 PoC IOM Halaka Mobile Clinic IOM Gerger Mobile Clinic MSF IOM Ramela Mobile Clinic Gap Medical Mobile Clinic IOM Cathedral Church IDP Goa Medical Mobile Clinic MSF MSF

2014 2015 IOM Wonthou Mobile Clinic 2016 2017

Acute bloody diarrhoea (ABD) IDSR Acute Bloody Diarrhoea Incidence rate by year, 2015, 2016 and ! 2017* For the sixth consecutive week, the ABD burden remained at 25.0 2% and 1% of all consultations in the IDSR and IDP sites respectively (Fig. 1a, 1b). 20.0 For the routine reporting sites ABD incidence [cases per 15.0 100,000] decreased from 11.5 in Week 15 to 10.2 in Week 16 (Fig. 15). 10.0 Among the IDPs, the current ABD proportionate morbidity increased in Week 16 but is still remains low compared to 5.0 the corresponding period in 2014, 2015, and 2016 (Fig. 16 cases per 100,000 population and 17). 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Figure 17 shows the number of ABD cases by IDP clinic in Epidemiological Weeks Week 16 of 2017. 2015 2016 2017

Acute6% bloody diarrhoea (ABD) Figure 17 | ABD Incidence by IDP Site in W16 2017 Figure 16 | ABD trends in IDPs W51 2013 to W16 2017 18% 16% 5% 14% 12% 4% 10% 8% 3% 6% 4% 2% 2% Percent of all consultations

0% … 1% Percent of all consultations E Hospital -

0% IMC ER PoC 1 MSF H Lankien PHCC 010305070911131517192123252729313335373941434547495153 - IRC Sector 4 Clinic UNKEA Jikmir PHCC IMC Akobo Hospital IOM Wau PoC Clinic H Bentiu Town Clinic MSF Medair Abayok Clinic - E Malakal Town PHCC H Bentiu PoC Hospital IMC UN House Clinic 1 - - IMC UNMISS PoC Clinic IOM Malakal PoC Clinic UNKEA Mandeng PHCC Medair Wonthow Clinic GOAL Dethoma Camp 2 GOAL Koradar IDP clinic 2014 2015 2016 2017 IMC Malakal PoC Clinic 2 IMC Malakal PoC Clinic 1 IOM Halaka Mobile Clinic IOM Gerger Mobile Clinic MSF IOM Ramela Mobile Clinic Gap Medical Mobile Clinic IOM Cathedral Church IDP Goa Medical Mobile Clinic MSF MSF IOM Wonthou Mobile Clinic IOM Nazareth IDP Camp Clinic IOM Bentiu Sector 5 PoC Clinic IOM Bentiu Sector 1 PoC Clinic IOM Bentiu Sector 3 PoC Clinic Table 4.1| Measles cases by location and status as at W16 of 2017

New suspect Samples Measles Suspect cases Confirmed Confirmed Outbreak status in County cases W16, tested in in 2017 Measles 2017 Rubella 2017 2017 2017 2017 In Week 16, a total of 17 new suspect measles cases were reported Juba (12), Tonj North (1), Wau(2) and Aweil South Wau IDPs 2 289 15 26 96 Confirmed

(1) (Table 4.1). Malakal PoC 0 2 0 2 Alert

Cumulatively, in 2017 a total of least 590 suspect measles Gogrial East 0 43 5 8 Alert cases including 4 deaths (CFR 0.70%) have been reported Gogrial West 0 53 15 29 Confirmed from 19 counties.. Abyei 0 12 0 7 17 Alert

Most of the cases have been reported from Wau, Gogrial East, Tonj North 1 12 0 0 0 Alert Gogrial West and Yambio counties (Figure 18.1). Aweil South 1 6 7 7 Confirmed

The majority of the cases are under five years of age (Figure Yambio 0 82 2 13 27 Alert 18.3). Cueibet 0 1 0 0 0 Alert

Since the beginning of 2017, measles outbreaks have been Mayom 0 15 0 0 0 Alert confirmed in five counties - Wau, Yambio, Aweil South, Gogrial Nzara 0 3 0 Alert West, Gogrial East, and Juba (Table 4.1 and Figure 18.2). Ezo 0 1 0 0 0 Alert At least 52 measles IgM positive and 46 rubella IgM cases Table of CountiesAweil West with Suspected0 9 Outbreaks in 20171 and SpotAlert Map of Confirmed have been confirmed in 2017 (Table 4.1 and Figure 18.2). 0 Aweil Center Cases(Lab confirmed,0 Epi1 Link0 and Clinically0 0 CompatibleAlert cases)* Most counties have not attained the non-measles febrile/rash Suspected Confirmed_La Confirmed_ Suspected_with_ Number Of Number Rubella Number Of Number Of Admitted Non_Admitt Month DistrictofResidence ProvinceKajo Of-keji Residence 0 5 0 0 Alert illness rate of at least 1/100,000 (Figure 18.4). This highlights Cases b_EpiLink Lab Lab_Result Samples Cases Clinicals Discarded _Alive ed_Alive the need to enhance measles case-based investigation1 AWEIL SOUTH and NORTHERNJuba BAHR EL GHAZAL 612 0 34 4 13 6 6 29 0 Alert 0 2 1 3 sample collection. 1 GOGRIAL EAST WARRAP 5 0 5 5 5 0 0 0 0 5 Torit 1 2 0 0 39 Alert 1 GOGRIAL WEST WARRAP 11 0 7 10 11 0 1 3 3 5 The follow-up measles campaign is scheduled for1 theWAU first and WESTERNDuk BAHR EL GHAZAL 630 0 15 5 0 55 63 0 26 Alert 8 50 2 11 second week of May 2017. 2 GOGRIAL WEST WARRAP 3 0 3 3 3 0 Alert 0 0 2 1 2 JUBA CENTRALJur River EQUATORIA 80 0 2 4 0 8 0 8 0 0 0 4 1 3 2 YAMBIO WESTERNMundri West EQUATORIA 120 0 1 0 0 8 0 12 1 4 Alert 4 8 0 4 3 ABYEI WARRAP 6 0 0 5 6 2 0 5 0 0 3 JUBA CENTRALTotal EQUATORIA 175 0590 4 52 4 46 5 256 0 1 0 1 4 3 WAU WESTERN BAHR EL GHAZAL 9 0 5 8 9 2 0 3 5 0 3 YAMBIO WESTERN EQUATORIAFig 18.2| Counties with confirmed measles outbreaks as at W16 of 201721 0 0 21 21 11 0 21 0 0

Measles cases by Epidemiological week and county , week 1-18, 2017

90 80 ! 70 60 50 40 Number of cases 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Epidemiological week in 2017

Juba Gogrial West Aweil South Aweil Center Malakal Wau Jur River Yambio Torit * As of WeekGogrial East 14, 2017

Fig 18.4| Non-measles cases Febrile/Rash illness per 100,000 by county Fig 18.3| Measles case distribution by age group and country, week 1-18, as at W16 of 2017 2017

Measles case distribution by age group and county, week 1-18, 2017

100%

90%

80%

70%

60%

50% Age distrib. % 40%

30%

20%

10%

0% Juba Gogrial West Aweil South Aweil Center Malakal Wau Jur River Yambio Torit Gogrial East

<1yr 1-4yrs 5-9yrs 10-14yrs 15+yrs Visceral Leishmaniasis | Kala-azar In week 16, two (2) health facilities reported 8 cases, 6 new cases, 0 relapses and 2 PKDL. No death and defaulters reported. Since the beginning of 2017, a total of 994 cases including 19 deaths (CFR 3.0%) and 7(1.1%) defaulters have been reported from 16 treatment centers however, currently 12 treatment centers are reporting. Of the 991 cases reported, 810 (81.5%) were new cases, 58(5.8%) PKDL and 126(12.7%) relapses.

In the corresponding period in 2016, a total of 568 cases including 29 deaths (CFR 5.1%) and 25(4.4%) defaulters were reported from 21 treatment centers.

Majority of cases were reported from Old fangak (355), Lankien (346), Kurwai (110) , Walgak (45), Malakal IDP (35), KCH (31), Bunj (18) and Ulang (16) etc The most affected groups included, males [345 cases (54.7%)], those aged 5 - 14years [274(29.3%) and ≥15years and above [265 cases (28.5)]. A total of 93 cases (10.0%)] occurred in children <5years.

Hepatitis E Virus (HEV)

A total of 27 HEV cases reported from Bentiu PoC (Fig. 19) were reported in Figure 19 | HEV trends in Mingkaman, Bentiu & Lankien W10 2014 to Week 16. W16 2017 16 350 14 Cumulatively, a total of 236 HEV cases have been reported from Bentiu PoC 300 12 in 2017. The transmission is linked to sub-optimal access to safe water and 250 10 sanitation. Multi-sectoral response has made some progress in reducing the 200 8 incident but control is yet to be attained due to a multiplicity of factors. (Fig. 150 6 19) 100

4 No. cases in Bentiu

No, cases in other sites 50 Cumulatively, from the beginning of the crisis, 3,484 HEV cases including 2 25 deaths (CFR 0.72%) reported in Bentiu; 174 cases including seven deaths 0 0 3 9 15212733394551 5 1117232935414753 6 12182430364248 2 8 (CFR 4.4%) in Mingkaman; 38 cases including one death (CFR 2.6%) in 2014 2015 2016 2017 Lankien; 3 confirmed HEV cases in Melut; 3 HEV confirmed cases in Guit;1 Epidemiological week HEV confirmed case in Leer; and Mayom/Abyei [75 cases including 13 Awerial Lankien Bentiu deaths with 7 HEV PCR positive cases.

Other diseases of public health importance Table.|Non Polio AFP rate by county as of Week 16 of 2017 !

Acute Flaccid Paralysis | Suspected Polio

In Week 16, Three new AFP cases were reported with date of onset in 2017 from Eastern Equatoria hub (1), Lakes hub (1), and Northern Bar Ghazal Hub (1).

During 2017, a cumulative of 91 AFP cases have been reported countrywide. the annualized non-Polio AFP (NPAFP) rate (cases per 100,000 population children 0-14 years) is 3.6 per 100,000 population of children 0-14 years (target ≥2 per 100,000 children 0- 14 years).

Stool adequacy was 91% in 2017, a rate that is higher than the target of ≥80%.

Guinea Worm | Dracunculiasis Viral Haemorrhagic Fever No new suspect hemorrhagic fever cases reported from across the During the week no suspect Guinea worm case was Country in the week. reported. More than 3,000 alerts have been investigated in 2017 with three samples collected out of which two were negative while the third is still pending.

Cumulatively in 2016; six (6) confirmed Guinea worm Animal bites | Suspected rabies cases were reported compared to Four (4) cases in 2015. There were no suspect rabies cases in the week.

The Ministry of Health through the South Sudan Guinea Worm Eradication Program(SSGWEP) continues to offer cash reward of 5,000 SSP. for reporting a Guinea worm. Cholera Figure 19.2 | Cholera Epidemic curve in South Sudan as of 28 Apr 2017

• Cumulatively, 7,386 cholera cases including 243 deaths (74 Figure 2.2 Epidemic curve for cholera cases in South Sudan from week 24, 2016 to week 18, 2017 facilities and 169 community) (CFR 3.29%) have been 500 25 reported in South Sudan (Figs 19.2&19.3; Table 4.2) 450

400 20

• Active transmission currently reported in Yirol East, Yirol 350

West, Awerial; Duk; Ayod, Fangak, Pigi, Kodok, and Mayom 300 15 (Figs 19.2&19.3; Table 4.2). 250 CFR %

200 10 • During the reporting period, cholera was confirmed in three Number of cases samples from Yirol East (1) and Yirol West (2) 150 100 5 • A total of 18 counties in 10 (31%) of 32 states countrywide 50 (Figs 19.2&19.3; Table 0 0 have confirmed cholera outbreaks 24 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 4.2). 2016 2017

Alive Died CFR %

Readers are referred to the cholera situation report for details on the ongoing cholera response in South Sudan

Table 4.2| Cholera cases and deaths by county as of 28 April 2017

Reporting sites Total cases Total Facility deaths Total community deaths Total deaths Juba county 2,045 8 19 27 435 5 32 435 87 1 4 5 Terekeka county 22 0 8 8 Awerial county 1,082 2 11 13 Yirol East 753 14 39 53 Yirol West 83 0 0 0 Pageri county 29 0 1 1 356 4 0 4 239 0 38 ! 38 Rubkona county 1176 7 2 9 Mayom county 7 0 4 4 Leer county 94 3 0 3 Panyijiar county 501 20 4 24 FigureMayendit county1.0: Cholera226incidence (cases0 per 105 ,000) and case5 Pigi county 202 5 5 fatalityKodok rate (%) as of30 13 October3 2016 1 4 Malakal 19 0 0 Total 7,386 74 169 243

Figure 19.3 | Cholera incidence (cases per 10,000) and case fatality rate (%) as of 28 Apr 2017 Mortality Table 6 | Proportional mortality by cause of death in IDPs W16 2017 Table 5 | Mortality from IDSR reports countrywide W16 2017

Total Cholera Malaria Total deaths deaths COUNTY ≥5yrs ABD <5yrs ≥5yrs <5yrs ≥5yrs Yirol West 2 0 0 0 2 Abiemnhom 0 0 1 0 1 Yambio 0 1 0 1 0 Total 2 1 1 1 3

In Week 16, Four deaths were reported through IDSR, with two deaths attributed Cholera in Yirol West, the remaining being due to malaria and bloody diarrhoea h(Table 5).

Among the IDPs, mortality data was received from Bentiu , Juba , Wau and Malakal in Week 16. (Table 6). Fourteen deaths were reported from the IDP sites. Bentiu PoC reported 11 deaths, the highest among the IDPs in the week. Overall, two out of the 14 deaths were children <5 years (Table 6). The Crude Mortality Rates [CMR] in all the IDP sites that submitted The causes of death in the IDP sites during the current week are mortality data in Week 16 of 2017 were below the emergency threshold of shown in Table 6. 1 death per 10,000 per day (Fig. 21).

The U5MR in all the IDP sites that submitted mortality data in Week 16 of 2017 is below the emergency threshold of 2 deaths The other causes of mortality in the week are shown in Tables 5 and 6. per 10,000 per day (Fig. 20).

Note: Mortality rates are calculated for PoC sites only and are based on the latest available population data from OCHA. They are reported from line lists and should include community and facility-based deaths. However, due to rapid in/out migration from the PoC sites, and possible under-reporting of community-level deaths, they should be interpreted carefully. ! Crude and under five mortality rates in IDPs Figure 20 | EWARN U5MR by Site - W1 2016 to W 16 of 2017 Figure 21 | EWARN Crude Mortality Rate for W1 2016 to W 16 of 1.2 2.5 2017 1.0 2.0 0.8 1.5 0.6 1.0 0.4 0.5 0.2 0.0 0.0 1 3 5 7 9 111315171921232527293133353739414345474951 1 3 5 7 9 111315 deaths per 10,000 per day 1 3 5 7 9 111315171921232527293133353739414345474951 1 3 5 7 9 111315

deaths per 10,000 per day 2016 2017 2016 2017 Epidemiological week Epidemiological week

Bentiu Juba 3 Malakal Mingkaman Bentiu Juba 3 Malakal Mingkaman Melut Melut Akobo Wau Shiluk Threshold Akobo Wau Shiluk Threshold Wau PoC

Overall mortality in 2017

Table 7 | Mortality by IDP site and cause of death W16 2017 Azar - SAM GSW Burns Sepsis Others Cancer A total of 280 deaths Injuries cholera malaria distress Asthma Wasting diarrhea Drowned Kala Unknown syndrome accidental Meningitis pneumonia pneumonia Respiratory Grand Total Chicken pox Septic shock TB/HIV/AIDS Heart Failure acute watery Cardiac arrest chronic illness Chronic illness perinatal death IDP site maternal death have been reported Bentiu 42 25 21 5 5 4 3 5 3 4 2 4 2 1 2 2 2 2 2 1 1 2 1 30 171 from the IDP sites in Juba 3 14 7 2 3 3 1 4 1 3 1 1 5 45 2017 Table 7. Malakal 4 2 2 2 2 1 1 9 23 The top causes of Wau PoC 2 6 2 1 11 mortality in the IDPs Akobo 1 8 2 5 2 1 1 1 1 5 27 in 2017 are shown in Kodok 1 2 3 Table 7.

Grand Total 46 44 21 20 15 14 9 5 5 4 4 4 4 3 3 3 3 3 2 2 2 2 2 2 2 2 2 52 280 Proportionate mortality [%] 16.4 16 8 7 5 5 3 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19 100 Data sources

This bulletin presents disease trends from the Integrated Disease Surveillance and Response (IDSR) System and the Early Warning Alert and Disease Network (EWARN).

The respective data is submitted by public health facilities serving host communities (non-conflict affected states or non IDP sites) and partner-supported facilities serving internally displaced persons (IDP) in the Republic of South Sudan.

Editorial

Editorial: Dr. Alice L. Igale, Dr. Abraham Adut, Korsuk L. Scopus, Robert M. Lasu, Rose A. Dagama, Jane Pita, Dr. Patrick, R. Otim , Gabriel , Dr. Allan M. Mpairwe, Dr. Joseph F. Wamala, Dr. John P. Rumunu

Acknowledgements Contact

MoH and WHO gratefully acknowledge the support For more information, please contact: of all MoH staff in the states, WHO Field Officers, Department of Epidemics, Preparedness and Response and implementing-health cluster partners in MoH Republic of South Sudan collecting and reporting the data used in this bulletin. Email: [email protected]

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