Situation Report #87 on Cholera in South Sudan As at 23:59 Hours, 28 September to 4 October 2015

Situation Update During week 40 of 2015 (28 Sept- 4 Oct 2015), two new suspect cholera cases reported from [Gorom (1) and Tongping (1)] Juba county tested negative for cholera using the direct and modified rapid diagnostic cholera test. Therefore they were discarded and not captured in the line list.

Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 4 October 2015 New New New Total cases Total Total Total Total cases Total cases admisions discharges deaths currently facility community deaths discharged Reporting Sites LAMA* Week 40 Week 40 Week 40 admitted deaths deaths Week 40 CES – Juba County 0 0 0 0 218 26 19 45 1354 1618 IMC UN House PoC clinic 0 0 0 0 0 0 1 1 75 76 Juba Teaching Hospital 0 0 0 0 214 22 8 30 887 1132 MedAir Gumbo CTU 0 0 0 0 0 1 0 1 97 98 MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8 HLSS Nyakuron ORP 0 0 0 0 0 0 0 0 40 40 HLSS Kator ORP 0 0 0 0 0 0 0 0 7 7 HLSS Gurei ORP 0 0 0 0 0 0 0 0 101 101 HLSS Munuki ORP 0 0 0 0 0 0 0 0 4 4 HLSS Al Sabah ORP 0 0 0 0 0 1 0 1 34 35 HLSS Lologo ORP 0 0 0 0 0 0 1 1 13 14 MSF Munuki CTC 0 0 0 0 4 0 0 0 70 74 Other sites in Juba 0 0 0 0 0 2 9 11 18 29 CES – Kajo keji County 0 0 0 0 0 1 0 1 56 57

Kajo Keji 0 0 0 0 0 1 0 1 56 57 Jonglei State – Bor 0 0 0 0 3 1 0 1 135 139 Bor State Hospital 0 0 0 0 3 1 0 1 135 139 Total 0 0 0 0 221 27 19 47 1545 1814 *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- Central Equatoria State

Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 4 October 2015 New cases by epidemiological week in 2015 28 29 30 31 32 33 34 35 36 37 38 39 40 Grand Reporting facility Total Central Equatoria state 168 239 150 101 77 86 45 39 32 18 8 4 0 1675 Juba county 160 237 149 100 77 86 45 39 32 18 8 4 0 1618 JTH 115 146 92 52 44 44 20 25 13 10 1 0 0 1132 Juba 3 IMC clinic 10 11 5 2 1 1 0 0 0 0 0 76 Medair Gudele ORP 4 3 1 0 0 0 0 0 0 0 0 0 0 8 Medair Gumbo CTU 20 25 10 8 9 4 2 0 0 0 0 0 98 MSF Munuki CTC 0 23 18 7 7 9 6 4 0 0 0 0 0 74 Other sites in Juba 3 0 0 0 0 1 0 0 0 0 0 0 0 29 HLSS Nyakuron ORP 3 11 2 9 3 7 1 2 0 0 0 0 0 40 HLSS Kator ORP 3 1 2 0 0 0 1 0 0 0 0 0 7 HLSS Gurei ORP 1 11 10 15 10 13 13 5 5 8 6 4 0 101 HLSS Munuki ORP 1 0 2 0 0 0 0 1 0 0 0 0 0 4 HLSS Al Sabah ORP 0 4 3 5 3 5 0 0 14 0 1 0 0 35 HLSS Lologo ORP 0 2 4 2 1 2 2 1 0 0 0 0 0 14 Kajo Keji county 8 2 1 1 0 0 0 0 0 0 0 0 0 57 Kajo keji hospital 8 2 1 1 0 0 0 0 0 0 0 0 0 57 Jonglei state 33 21 8 9 4 4 2 4 1 1 1 0 139 Bor county 33 21 8 9 4 4 2 4 1 1 1 0 139 Bor State Hospital 33 21 8 9 4 4 2 4 1 1 1 0 139 Grand Total 201 260 158 110 81 90 47 43 33 19 8 5 0 1814

A total of 57 cases including one death from Kajo Keji were retrospectively added to the line list. Cases were epidemiologically linked to a laboratory confirmed cases on 20 August 2015.

As of 4 October 2015, a total of 1,814 cholera cases including 47 deaths (CFR= 2.59%) have been reported from three counties of South Sudan. In Juba county, 1,618 cases including 45 deaths (CFR= 2.78%) have been reported from seven Payams. In Kajo Keji county, 57 cases including one death (CFR 1.75%) have been reported from four Payams. In Bor, 139 cases including one death (0.72%) have been reported from Makuach Payam and other areas in the county (Table 1 and 2).

There were no new cases reported in week 40 of 2015. As seen from Figures 2 and 2.1, the current transmission pattern in Juba, Kajo Keji, and Bor counties is consistent with an outbreak that is nearly controlled.

Figure 2: Epidemic curve for cholera cases in Juba and Bor, 18 May - 4 October 2015

80 20

JS 18 70 17.9 CES 16 CFR 60 14.3 14 50 12

40 10

30 Number of cases 6.2 6

20 Case Fatality Rate [%] 3.8 4 10 1.9 2.3 2 1.4 1.5 1.6 1.2

0 0 0 0 0 0 0 0 0 0 0

6/2/15 6/5/15 6/8/15 7/2/15 7/5/15 7/8/15 8/1/15 8/4/15 8/7/15 9/3/15 9/6/15 9/9/15

5/15/15 5/18/15 5/21/15 5/24/15 5/27/15 5/30/15 6/11/15 6/14/15 6/17/15 6/20/15 6/23/15 6/26/15 6/29/15 7/11/15 7/14/15 7/17/15 7/20/15 7/23/15 7/26/15 7/29/15 8/10/15 8/13/15 8/16/15 8/19/15 8/22/15 8/25/15 8/28/15 8/31/15 9/12/15 9/15/15 9/18/15 9/21/15 9/24/15 9/27/15 9/30/15 10/3/15 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

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 21-40 of 2015 350 20.0

17.9 JS 18.0 300 CES CFR[%] 16.0 246 250 14.3 259 239 14.0

12.0 200 168 10.0 150 150 8.0 134

100 6.0 6.0 Case Fatality Rate [%] Number of cases 101 4.0 3.4 77 50 86 2.2 56 1.7 1.9 2.1 2.0 2 7 1.5 1.5 45 39 4 1.2 32 4 0 - - - - - 18 - - 0 0 - 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 388 39 40

Week of onset

Though all age groups have been affected, the most affected were children under 10 years and those aged 20-34 years in Juba County and children under 10 years in Bor. There was no clear pattern of cholera risk by age group in Kajo keji (Figures 3, 3.1 and 3.2).

2 Figure 3: Cholera case distribution by age and sex in Juba County, 18 May - 4 October 2015 Cholera case distribution by age in Juba County, week 21-39, 2015

300

250

200 145 140 150 107 98 Male

100 99 Female 83 Number of cases of Number 51 49 49 50 100 91 98 83 27 49 58 58 47 17 31 22 10 14 13 11 0 17 12 11 8 7 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ fives years years years years years years years years years years years years years years

Figure 3.1: Cholera case distribution by age and sex in Bor County, 26 May - 4 October 2015 Cholera case distribution by age in Bor County, week 27-39, 2015

90 80 70 60 37 50 Male 40

30 Female Number of cases of Number 20 42 10 8 1 3 8 1 10 3 1 0 5 1 1 3 2 3 1 3 12 1 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 65-69 fives years years years years years years years years years years years years

Figure 3.2: Cholera case distribution by age and sex in Kajo keji County, 15 June - 4 October 2015

Cholera case distribution by age in Kajo Keji County, week 30-40, 2015

8 Male 7 Female 6 5 1 1 1 4 6 3 1 3 2 2 2 2

Number of cases of Number 2 4 4 4 3 1 1 1 1 2 2 2 2 2 2 1 1 1 1 0 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 70+ fives years years years years years years years years years years years years years

As of 4 October 2015, the sites reporting the highest number of cholera cases included Northern Bari, Muniki, Kator, Rejaf and Juba Town in Juba County. In Kajo keji county, the most affected Payams included Kangapo 2, Kangapo 1, Lire, and Liwolo. In Bor County, the majority of the cases originated from Malou, Langbar, Achingdii, Arek, and Hai Salam in Makuach Payam (Figure 4).

3 Figure 4: Map for cholera cases by place of residence, Juba and Bor Counties, 18 May 2015 - 4 October 2015

The probable risk factors fueling transmission include: residing in a crowded IDP camp with poor sanitation and hygiene; using untreated water from 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 Since the beginning of the outbreak, 202 specimens have been collected from cholera treatment facilities in Juba, Kajo keji, and Bor counties and sent to the National Public Health Reference Laboratory (NPHRL) in Juba for microbiological culturing. Of these 48 were positive for cholera after

4 Vibrio cholerae was isolated. Of the 48 positive cases, 38 were from Juba County, one from Kajo Keji and nine from Bor County. Table 3

Table 3: Distribution of cholera positive cases, 26 May - 4 October 2015 Number Number culture Health Facilities Culture positive negative Grand Total CES 39 64 103 JTH 18 12 30 Juba 3 IMC clinic 11 7 18 Medair Gumbo CTU 4 0 4 MSF Munuki CTC 0 1 1 Other sites in Juba 5 2 7 Kajo keji 1 42 43 JS 9 6 15 Bor State Hospital 9 6 15 Grand Total 48 70 118

Planned and On-going Activities 1. The next national cholera taskforce meeting is scheduled for Monday 12 October 2015 at 10:00 am in the MoH Ministerial Boardroom. 2. The national cholera evaluation meeting is scheduled for 6-7 October 2015 in Aron International Hotel.

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 Dr. Thomas Akim Ujjiga Director General - Preventive Health Services Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211955150406