Situation Report #35 on Cholera in South Sudan As at 23:59 Hours, 26 July 2015

Republic of South Sudan

Situation Update As of 26 July 2015, a total of 1,375 cholera cases including 42 deaths (CFR 3%) have been reported in Juba and Bor Counties in Central Equatoria and Jonglei States respectively. In Juba County, 1,264 cases including 41 deaths (CFR 3.24%) have been reported from seven Payams (Table 1). In Bor, 111 cases including one death (CFR 0.9%) 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 205, 189, 134, and 26 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 29 (Annex 1 and 2).

Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 26 July 2015 Reporting Sites New New New Total cases LAMA* Total Total Total Total cases Total cases admisions discharges deaths currently facility community deaths discharged admitted deaths deaths

CES – Juba County 17 14 0 35 197 25 16 41 989 1264 IMC UN House PoC clinic 0 1 0 1 0 0 1 1 67 71 Juba Teaching Hospital 9 6 0 29 193 21 7 28 686 936 MedAir Gumbo CTU 2 1 0 1 0 1 0 1 75 77 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 6 6 HLSS Gurei ORP 0 1 0 0 0 0 0 0 30 30 HLSS Munuki ORP 1 1 0 0 0 0 0 0 5 5 HLSS Al Sabah ORP 0 1 0 0 0 1 0 1 10 11 HLSS Lologo ORP 0 0 0 0 0 0 0 0 9 9 MSF Munuki CTC 5 3 0 4 4 0 0 0 33 41 Other sites in Juba 0 0 0 0 0 2 8 10 20 30 Jonglei State – Bor 0 1 0 0 3 1 0 1 107 111 Bor State Hospital 0 1 0 0 3 1 0 1 107 111 Total 17 15 0 35 200 26 16 42 1096 1375 *LAMA: LEAVE AGAINST MEDICAL ADVICE. CES: Central Equatoria State

A total of 17 new cholera cases were reported in Juba on 26 July 2015 (Table 1 and Figure 1). o 17 new cases were reported from Juba County, with the majority of the cases reported from Lokilili and Gumbo.

Figure 1: New cholera cases by residence on 26 July 2015

4 3 3 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1

Number Number casesof 0 Gumbo Malakia Lokuilili Atlabara Lologo 1 Lologo Gudele 2 Gudele Gudele II Gudele Munuki B Munuki Munuki A Munuki Tongping Hai Matara Hai Jebel Dinka Jebel Kor William Kor Gudele west Gudele

Juba Kator Munuki Northern BariRejaf Juba

1 During week 30 of 2015 (week of 20 July 2015), most cholera cases originated from Lologo, Malakia and Atlabara B in Kator; Suk Jebel, Munuki, and Nyakuron West in Munuki; and Gumbo in Rejaf (Figure 1.1). During week 30 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 37, 16, 15 and 4 respectively (Annex 1)

Figure 1.1: New cholera cases by residence during week 30 of 2015

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Juba Kator Munuki Northern Bari Rejaf Gondokoro

Cumulatively, 1,375 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%) have occurred in children under five years. In Juba County, Juba Payam has registered the highest CFR followed by Northern Bari, Rejaf and Munuki (Annex1).

Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 26 July 2015 New cases by epidemiological week of 2015 Reporting Facility 21 22 23 24 25 26 27 28 29 30 Grand Total CES – Juba County 4 2 7 56 131 234 236 161 268 165 1264 JTH 0 2 2 32 119 212 208 116 150 95 936 Juba 3 IMC clinic 4 0 4 9 6 13 10 10 11 4 71 HLSS Nyakuron ORP 0 0 0 0 0 0 2 3 30 5 40 HLSS Kator ORP 0 0 0 0 0 0 0 3 1 2 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 26 11 77 HLSS Gurei ORP 0 0 0 0 0 0 0 1 16 13 30 HLSS Munuki ORP 0 0 0 0 0 0 0 1 0 4 5 HLSS Al Shabah ORP 0 0 0 0 0 0 0 0 5 6 11 HLSS Lologo ORP 0 0 0 0 0 0 0 0 3 6 9 MSF Munuki CTC 0 0 0 0 0 0 0 0 23 18 41 Other sites in Juba 0 0 1 15 6 4 1 3 0 0 30 Jonglei State – Bor County 0 0 0 0 0 5 46 33 21 6 111 Bor State Hospital 0 0 0 0 0 5 46 33 21 6 111 Grand Total 4 2 7 56 131 239 282 194 289 171 1375

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.

Since 6 June 2015, sustained and consistently increasing community transmission was established in Juba with increasingly more suspect cases reported outside UN House PoC. There are four discernible transmission peaks with the initial peak of 15 cases occurring on 13 June 2015 while the subsequent and higher peaks occurred on 20 June, and 26 June before reaching the second highest peak on 28 June. Since then, successively shorter transmission peaks were registered. This trend was largely driven by sustained community transmission in Juba, Northern Bari, Rejaf, and Munuki Payams (Annex 2). On 19 July 2015, a

2 total of 61 new cases in Juba County were linked to a funeral in Atlabara B, thus resulting into the highest peak during the outbreak.

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 have been registered, a trend that is consistent with declining community transmission.

Figure 2: Epidemic curve for cholera cases in Juba, 18 May – 26 July 2015

90 20 80 17.9 18 70 16 60 14.3 14 50 12 10 40 Number Number of cases 8 30

6.1 6 CaseFatality Rate [%] 20 3.8 4 10 1.4 1.5 1.4 1.7 2 0 00 6/2/15 6/5/15 6/8/15 7/2/15 7/5/15 7/8/15 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

20 21 22 23 24 25 26 27 28 29 30 31

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

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 – 26 July 2015

3 As of 26 July 2015, the sites reporting the majority of cases in Juba include Gumbo, New site, Juba 3 PoC, Gudele 2 and Munuki with satellite cases distributed in seven Payams in Juba County (Figure 3). In Bor County, the majority 39 (41%) of the cases originated from Malou in Makuach Payam and later from areas like Arek, Block 8, Hai Salam, Achengdii and Langbar.

The most affected age groups in Juba and Bor counties are the under fives and 5-9 years olds. Additionally, the 25-29 year olds are significantly affected in Juba County (Tables 3.1 and 3.2).

Table 3.1: Cholera case distribution by age in Juba County, 18 May – 26 July 2015

18.0 16.0 14.0 12.0 16.0 10.0 14.4

Percentage 12.2 11.5 8.0 9.9 6.7 7.3 6.8 6.0 5.3 4.0 2.7 2.2 1.1 1.4 1.3 1.2 2.0 0.0 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 65-69 70+ 5 years years years years years years years years years years years years years years years

Table 3.2: Cholera case distribution by age in Bor County, 18 May – 26 July 2015

70.0

60.0

50.0

40.0 58.4 Percentage 30.0

20.0 12.4 7.1 0.9 0.9 8.0 3.5 3.5 0.9 2.7 1.8 10.0

0.0 under 5 5-9 10-14 15-19 20-24 30-34 35-39 40-44 45-49 50-54 55-59 years years years years years years years years years years years Out of the 1,258 cholera cases with known gender in Juba, 544 (43%) were female, while 714 (57%) were male while in Bor, 64 (58%) of the cases were females, while 47 (42%) were males (Table 4).

Table 4: Case distribution by gender and age in Juba and Bor Counties, 18 May – 26 July 2015 Case distribution by gender N (%) CES - Juba 1258 Female 544 (43) Male 714 (57) Jonglei state – Bor County 111 Female 64 (58) Male 47 (42) Grand Total 1369

4 Laboratory updates

Table 5: Cholera laboratory test results for Juba and Bor, 18 May – 26 July 2015 Number of Number of cholera Number of stool Number of cholera Health Facility RDT tests RDT positives cultures Culture positives CES – Juba 210 191 80 35 1 Juba Teaching Hospital 118 105 44 17 2 Juba 3 PoC clinic 64 61 22 11 3 MSF Munuki CTC 14 14 0 0 4 Other sites in Juba 14 11 12 5 5 MedAir Gumbo CTU 0 0 2 2 Jonglei state – Bor 52 44 13 8 1 Bor State Hospital 52 44 13 8 Total 262 235 93 43

As seen from Table 5, 235 (90%) of the samples have been RDT positive while 43 (46%) 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, 18 May – 26 July 2015

12 10 11 8 5 6 1 1 2 2 1 1 1 1 1 1 3 2 1 1 3 2 1 1 1 4 2

0 Arek Number Number of cases Kator Giada Malou Digala Bilpam Gumbo Kodoro Munuki Gakyom Atlabara Gudele1 Block-10 Newsite Achingdii Juba3 PoC JebelKujur JubaNabari Kor William MangatainIDP Nyakuron West

Juba Bor Table 6: Cholera Alerts – 23 to 26 July 2015 Date of Details of the alert Area Action notification 19-July-15 A total of 55 acute watery diarrhoea Atlabara Funeral visited by the state rapid response team cases reported on 19 July 2015 involving B, Juba for health education and case finding individuals who attended an overnight - At least 55 cases referred to Juba Teaching funeral in Atlabara B, Juba Hospital CTC for treatment - Premises disinfected by state rapid response team - Interviewed participants reported eating bread and roasted meat at the funeral before they - developed vomiting and diarrhoea. One of five samples collected from this cluster tested positive for cholera after Vibrio cholera - was isolated from the sample.

5 Date of Details of the alert Area Action notification 26-Jun-15 Nineteen suspect cholera cases were Kajo Keji, A total of 65 acute watery diarrhoea cases have initially reported in Kajo Keji Civil hospital. CES been line listed with two cases on admission at The cases have now risen to a - the hospital cumulative total of 65. 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 replenished Arrangements underway to ship one RDT positive sample to Juba for culturing. -

- Since 25 June 2015, at least ten 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 A verification mission visited Kajo-keji to investigate the suspect cholera case cluster from 22 to 24 July 2015. There were no suspect cases admitted in the hospital. Refresher training on cholera conducted for 25 County Health Department and Hospital staff by the health and WASH MedAir team. A new suspect case presented after the team departed. WHO will support sample transport to Juba for microbiological culturing.

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 seven ORPs in Nyakuron, Gudele, Kator, Gurei, Munuki, Al Sabah and Lologo.  The MedAir Gudele ORP will however be closed on 27 July 2015, as no cases have been treated in the area for over one week.  The MedAir and IOM support to JTH CTC will continue till 31 July 2015 when this will be reviewed.  IOM deployed a team of four clinical officers, three nurses, three mid wives to support triage, clinical care, and health education in JTH CTC  Replenishing of case management and WASH supplies for JTH CTC is ongoing with support from WHO, UNICEF and IOM.

The other interventions including case surveillance, suspect case verification, regular epidemiological updates, and oral cholera vaccination are ongoing with the following highlights  One of five samples from the cluster of 69 cases linked to a funeral in Atlabara B on 19 July 2015 tested positive for cholera after Vibrio cholera was isolated.  Two rounds of oral cholera vaccination completed in Bentiu PoC and Juba 3 PoC with administrative coverage for two doses of the vaccine being 71,200 (97%) in Bentiu while on Juba 3 PoC, coverage was 27,340 (82%) and 24,024 (72%) during the first and second rounds respectively. Low coverage in Juba 3 PoC attributed to an overestimated target population.  The ICG has approved 66,755 doses of oral cholera vaccine for Malakal PoC.  With support from MSF Swiss and WHO, the Ministry of Health plans to conduct a single-dose vaccination with oral cholera vaccine targeting cholera transmission hotspots and vulnerable groups in Juba County in week 31 of 2015. The target population is estimated at 270,000 and includes populations in New site, Mangatain IDP, Lologo, Atlabara, Giada, Kor William, Kator, Malakia and Gumbo.

Water, Sanitation and Hygiene (WASH) Juba PoC/IDP sites: A WASH monitoring assessment to Juba POC reported poor solid waste disposal, irregular disinfectant spraying at entry/exit gates and increasing open defecation (OD). Solidarites International (SI), ACTED and UNICEF now ensuring chlorination, spraying and hand washing is on-going. Sixty six adolescents from the TdH Child Friendly Spaces in Juba PoC were trained by UNICEF to roll out hygiene promotion in peace clubs. Bor: UNICEF has provided safe drinking water to Bor Hospital CTC, for cleaning, disinfection, ORS solution and cleaning the CTC. UNICEF delivered 30 boxes (750 PCs) of soap to islands and hard to reach areas of Twic East

6 Bor POC: IAS and UNICEF have established hand washing and disinfection spraying stations at the entry and exit gates of the PoC. Hand washing and foot spraying with disinfection is now compulsory. Solid waste is being collected and disinfected before disposal outside the PoC. Three drainage blocks within the Bor POC have been cleared and disinfected. IAS and UNICEF have covered 905 households (2,272 people) with cholera WASH-based interventions at households level and received water treatment supplies. A Jerry Can cleaning campaign has been conducted with a total of 344 Jerry cans being cleaned using soap.

Social Mobilisation Cholera awareness campaigns continue on 20 radio stations in Central Equatoria, Eastern Equatoria and Upper Nile State. In CES alone, a total of 4,625 cholera jingles and over 20 talk-shows have be broadcast, reaching an estimated 70 per cent of the state’s population with key messages on how to prevent and control cholera. MoH, UNICEF, WHO and Zain South Sudan are disseminating key messages on cholera prevention and control through the Short Message Service (SMS) to Zain users countrywide. Fifty trained volunteers from South Sudan Red Cross (SSRC) have reached a total of 5,720 households comprised of over 33,000 individuals with cholera prevention and control key messages through house-to- house social mobilization in Mauna, Hai Tarawa and New Site residential areas. MoH, supported by UNICEF, WHO and partners trained 365 master trainers that include; health workers, teachers, city councilors, religious leaders and Public health officers. A total of 340 hygiene promoters/social mobilizers were also trained. The trained will cascade cholera sensitizations activities to communities. Bor: With UNICEF support, Radio Jonglei and Mingkaman FM broadcast a total of 832 cholera jingles to reached 60 per cent of population with cholera preventive and control messages. Through house-to-house mobilization, 45 UNICEF-trained Social Mobilizers (11 mobilizers in Bor POC and 34 from outside POC) provided cholera household awareness reaching to a total of 3,290 households which over 19,000 people with cholera key messages. Information, Education and Communication (IEC) materials distribution: Total 575 posters and banners have been distributed at markets, churches, road junctions and school in Bor town.

Planned and On-going Activities 1. The next national cholera taskforce meeting is scheduled for Monday 3 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 29 July 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 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

7 Annex: Cholera Data tables and Charts – 18 May 2015 to 26 July 2015

Annex 1: Cholera attack rates and case fatality rates by Payam, 18 May to 26 July 2015 New Attack rate cases in [cases per Cumulative week 30, Case 10,000] for Attack rate 2015 Total Total Populati Fatality week 30 of [cases per Location Cases Deaths on Rate [%] 2015 10,000] CES 165 1264 41 279871 3.2 5.9 45.2 Gondokoro 1 7 7115 - 1.4 9.8 Juba 17 134 11 91254 8.2 1.9 14.7 Kator 42 233 5 11395 2.1 36.9 204.5 Lokiliri 0 3 5995 - 5.0 Munuki 51 334 8 129133 2.4 3.9 25.9 Northern Bari 32 279 8 20753 2.9 15.4 134.4 Rejaf 22 269 7 14226 2.6 15.5 189.1 (Blank) 0 4 2 50.0 JS 8 111 1 181708 0.9 0.4 6.1 Baidit 0 4 51042 - 0.8 Bor 3 5 61224 - 0.5 0.8 Kolnyang 0 1 40021 - 0.2 Makuach 5 86 1 29421 1.2 1.7 29.2 Grand Total 173 1355 42 461579 3.1 3.7 29.8

Annex 2: Cholera epidemic curves by Payam – 18 May to 26 July 2015 Cholera Epidemic Curve Juba Payam 2015 14

s 12 e s

a 10 c f

o 8 r

e 6 b

m 4 u

N 2

0 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 3 5 7 9 1 1 1 1 1 2 2 2 2 2 1 3 5 7 9 1 1 1 1 1 2 2 2 2 6 8 0 2 4 6 8 0 / / / / / 1 3 5 7 9 1 3 5 7 9 / / / / / 1 3 5 7 9 1 3 5 7 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Juba

8 Cholera Epidemic curve Northern Bari Payam 2015 20 s e s

a 15 c f o

r 10 e b m

u 5 N 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 0 6 6 6 6 6 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 2 2 2 2 1 3 5 7 9 1 3 5 7 9 6 8 0 2 4 6 8 0 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 5 7 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Northern Bari

Cholera Epidemic Curve Rejaf Payam 2015 16 s 14 e s

a 12 c f 10 o r 8 e b 6 m u 4 N 2

0 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 2 2 2 2 1 3 5 7 9 1 3 5 7 9 6 8 0 2 4 6 8 0 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 5 7 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Rejaf

Cholera Epidemic Curve Munuki Payam 2015 25 s

e 20 s a c

f 15 o r e

b 10 m u

N 5

Munuki

9 Cholera Epidemic Curve Kator Payam 2015 70

s 60 e s a 50 c f

o 40 r e 30 b m

u 20 N 10 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 0 6 6 6 6 6 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 3 5 7 9 1 1 1 1 1 2 2 2 2 2 1 3 5 7 9 1 1 1 1 1 2 2 2 2 6 8 0 2 4 6 8 0 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 5 7 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Kator

Cholera Epidemic Curve Gondokoro Payam 2015 2 s e s a c f o

r 1 e b m u N

Gondokoro

Cholera Epidemic Curve Lokiliri Payam 2015 3 s e s a

c 2 f o r e b

m 1 u N

Lokiliri

10 Cholera Epidemic Curve Makuach Payam, Bor 2015 10 s e

s 8 a c f 6 o r e b 4 m u

N 2 0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 2 4 6 8 0 /2 /4 /6 /8 0 2 4 6 8 0 2 4 6 /2 /2 /2 /2 /3 7 7 7 7 /1 /1 /1 /1 /1 /2 /2 /2 /2 6 6 6 6 6 7 7 7 7 7 7 7 7 7

Makuach