Cholera in Juba, South Sudan

Cholera outbreak in Juba, Central Equatoria State

Situation Report (Sitrep No. 6) as at 18:00 Hours, 21 May 2014

Background On 29 April 2014, a suspected case of cholera was reported from MSF clinic at UN House/Juba 3 IDP camp. The previous day he had visited relatives in Gudele where he developed severe diarrhea. One of the contacts in the household had developed acute watery diarrhea on the 24 April 2014. Following field investigations and laboratory confirmation; on 15 May 2014, the Ministry of Health declared an outbreak of cholera in Juba. Since then, several suspected cases have been recorded and laboratory confirmed from different suburbs in Juba.

Situation Update The table below summarizes the number of suspected and confirmed cases reported in Juba.

Table 1 Summary of Cholera Cases No. Summary of cases 19/05/2014 20/05/2014 21/05/2014 A New admissions today 50 78 49 B Number of cases discharged today 68 82 17 C New deaths reported today 0 4 1 D Total number of cases currently admitted 63 59 87 E Health facility deaths since the onset of the outbreak 3 6 7 F Community deaths since the onset of the outbreak 6 7 7 G Cumulative cases discharged 113 195 212 H Cumulative number of cases seen in community 9 9 9 I Leave Against Medical Advice/Refusal to be discharged 3* 0 J Cumulative cases (D+E+G+H) 188 266 315 K Specimens collected today 22 19 0 L Total Samples shipped to AMREF, Nairobi 79 101 120 M Cumulative specimens collected 103 122 122 N Number of cases with laboratory confirmationby culture 3 3 3

O Number of confirmed cases by cholera rapid diagnostic test. 2 2 2

Forty nine (49) new cases were admitted at cholera treatment centre (CTC) in Juba Teaching Hospital (JTH) on 20 May 2014. A total of 17 cases were discharged on 20 May 2014 leaving 87 patients on admission in the cholera treatment centre. Overall, a cumulative of 315 cholera cases including seven (7) health facility deaths and seven (7) community deaths (CFR 4.4%) have been reported since the onset of the outbreak on 24 April 2014. The majority of the reported cases 228 (72.4%) have been treated at the JTH CTC. Cholera cases have been reported from six Payams in Juba county with the most affected being Northern Bari 144 (46%), Muniki 69 (22%), Rejaf 29 (9%), Juba 44 (14%), and Kator 18 (6%).

Table 2 Cholera cases by area of origin in Juba 21 May 2014

Payam Number of cholera cases by week Cases by Payam n (%) Week 17 Week 18 Week 20 Week 21 Northern Bari 1 1 96 46 144 (46%) Muniki 0 0 42 27 69 (22%) Rejaf 1 15 13 29 (9%) Juba 0 0 16 28 44 (14%) Kator 0 0 11 7 18 (6%) Gondokoro 0 0 2 0 2 (1%) Missing 0 0 2 7 9 (3%) Total by epi- 1 2 184 128 315 (100%) (100%) week

The map below shows the geographical distribution of cholera cases in Juba since 24th April 2014.

Figure 2 shows the outbreak trends since the start of the outbreak on 24 April 2013. These trends show an outbreak with increasing transmission in the affected communities.

An assessment of risk factors is underway, however, preliminary results indicate that most people are drinking untreated water from the River Nile and eating un-hygienically prepared food from markets. However, most of the restaurants and roadside food vendors have been closed in the past couple of days by the enforcement of a Juba City Council by law.

Figure 1 Cholera Cases in Juba, Week 17-21 of 2014

50 cases 40 of

Number 20

0 21/04/2009 23/04/2011 24/04/2012 25/04/2013 27/04/2015 22/04/2010 26/04/2014 28/04/2014 29/04/2014 30/04/2014 01/05/2014 02/05/2014 03/05/2014 04/05/2014 05/05/2014 06/05/2014 07/05/2014 08/05/2014 09/05/2014 10/05/2014 11/05/2014 12/05/2014 13/05/2014 14/05/2014 15/05/2014 16/05/2014 17/05/2014 18/05/2014 19/05/2014 20/05/2014 21/05/2014 17 18 19 20 21 Date and epidemiologic week of onset

Alive Heath Facility Death Community Death

The majority of the reported cholera cases are males 176 (56%) in the 20-34 year age group 139 (44.4%).

Figure 2 Cholera cases by age, Juba- Week 18-21, 2014

50 37 cases 40 of

30 23 Male 10 22 20 Female Number 9 17 11 26 15 19 19 10 7 6 4 4 12 12 10 6 7 6 6 6 0 3 5 4 5

r rs rs rs rs rs rs rs rs rs rs rs rs rs 1y y y y y y y y y y y y y y < ‐4 ‐9 4 9 4 9 4 9 4 9 4 9 + 2 5 ‐1 ‐1 ‐2 ‐2 ‐3 ‐3 ‐4 ‐4 ‐5 ‐5 0 0 5 0 5 0 5 0 5 0 5 6 1 1 2 2 3 3 4 4 5 5 3

The main risk factors for cholera in Juba are suspected to include the following: • drinking of untreated river water which in Juba is primarily supplied by water tankers, • Use of untreated river water for drinking • poor latrine use, • eating foods sold on the roadside and at makeshift markets. • Poor personal hygiene practices (for example hand washing) and community hygiene. In addition, open defecation, consumption of water from unsafe sources such as surface water-river and ponds, poor community handling of dead bodies and unsupervised burials are other factors that increase the risk of the Juba community to contracting cholera.

Cholera Alerts:

No new information has been received since the last situation report # 5. Findings of the investigations conducted in Kaka and Panyagor shall be shared in due course. Find below a summary of the alerts shared in situation report # 5.

Table 3 Summary of Cholera Alerts Received by 21 May 2014

No Date Details of the alert Area Needs/Actions taken received 1. 19/05/2014 Kaka military Manyo county, • Investigation & initial barracks: 50 AWD Upper Nile State response by SMoH, IMA & cases including 9 UNICEF on 21/05/2014 deaths • Preliminary assessment & response by MSF Spain on 20/05/2014 • IV fluids, chlorine for disinfection, and antibiotics provided 2. 19/05/2014 Panyagor military Bor county, Jonglei • Investigation & initial barracks: 27 AWD state response by SMoH, IMA, cases including three UNICEF & WHO on (3) deaths 20/05/2014

3. 19/05/2014 Owiny Kibul: Magwi, Eastern • Meeting with military high increasing AWD Equatoria command on 21/05//2014 to 4. 19/05/2014 Esidu on Juba-Nimule plan response inc road sensitization, sample 5. 19/05/2014 Luri collection and orientation on case management/social mobilization • EPR team to visit Luri on 22/05/2014

Response Actions Today

Coordination The National Cholera Taskforce meeting was held today, chaired by the Ministry of Health. The following were the action points agreed on: Mobile disinfection and burial teams to be set up in all blocks in Juba. They are charged with disinfection of patient households and appropriate management of cholera burials. Ambulances to be placed at strategic areas within blocks to support referral of critical cases. A second CTC is under construction in Gurei PHCC. The CTC will be managed by MSF B. MSF F is assessing other CTC locations in Juba and will support construction and management of another CTC should the need for one arise.

Case management: (Medair, MOH and WHO) A total of 15 health workers drawn from 10 health facilities within Juba City and SPLA Medical Corps were trained today on cholera preparedness and response activities. Following reports of suspected cholera cases among soldiers in Luri, the Ministry of Health and partners visited the Commander of the Presidential Guard. The Commander agreed to facilitate the identification of health workers to be trained in cholera management. Limited number of health workers to support case management at the CTC.

Surveillance and Laboratory: (WHO & MOH) Sample collection and analysis of patient descriptive and exposure data to inform the response is ongoing. Continued to support partners with Carry Blair for sample collection from all areas that reported suspected cases.

Social mobilization: (ART, CES, SSRC, Medair, MOH, UNICEF and WHO) One hundred and twenty five (125) community volunteers were trained in cholera prevention and control. Information, Education and Communication (IEC) materials have been distributed to partners to increase community awareness of cholera. Three telephone companies have been requested to support the response with toll free lines to facilitate patient referral to CTCs and reporting of community deaths. Two lines will be availed on 22 May 2014 by Gemtel and Vivacell telecommunication companies. ZAIN has provided hotline number: 0912000098. Radio campaigns are running in seven stations covering Juba county. The campaigns are being conducted in English, Arabic, Dinka, Nuer and Bari languages.

WASH: (Medair, NPA, OXFAM, PIN and UNICEF) Water quality monitoring, chlorination of water and provision of drinking water continued in Juba Teaching Hospital.

An additional 2,000 litre water tanker was installed in Juba Teaching Hospital to increase water storage capacity at the CTC. Soap was distributed in Tongping POC as part of cholera prevention activities. A joint assessment of the hospital water supply system to ensure continuous water supply in the hospital and the CTC has been conducted. Chlorine, soap and hand washing buckets were distributed to 30 health centres in Juba to support hand washing and disinfection at health facilities. WASH partners joined a team of health partners to conduct an assessment at Kaka military barracks. In Tongping PoC: ¾ Seven new hand washing stations were constructed, ¾ 32 staff were recruited to spray feet and hands at the entrance/exit of Tong Ping PoC area. ¾ Soap was distributed to the female in the PoC area and ¾ three water tanks were cleaned. A hand-washing station was erected at Gudele 2 market. In Ghabat: 53 volunteers trained were trained, hygiene sessions on cholera prevention and control conducted, IEC materials set up in market, PuR distributed to HH, SWAT cleaned and started producing treated water, 10,000 L bladder was also added to increase the capacity of SWAT and two hand washing stations were established. Hygiene promotion session was conducted in MTC.

Current gaps: Provision of food for patients admitted in the JTH CTC remains a gap. Patients admitted in the CTC still lack insecticide treated mosquito nets and blankets. Community engagement is still limited. There is still no supervision of burials at the community level. In addition, the disinfection of dead bodies at the community level and patients’ households has not yet started.

Planned activities The WASH Cluster is in the process of shipping cholera response supplies to various locations where suspected cases have been reported. Training of both private and government health workers in cholera case management shall continue. Support the transportation of all collected samples to AMREF Nairobi for culture.

Conclusion and recommendation: All EPR working groups have started implementing their work plans. Additional partners continue to join the response. There is a risk of the outbreak spreading to other surrounding counties and villages if community interventions are not rigorously conducted. Plans and budgets for community level interventions have been developed, however their implementation is challenging due to financial constraints. From all indications, if community level interventions are implemented, the spread of cholera will be interrupted.

The inadequate number of human resources to support case management at the CTC is a challenge that needs to be urgently addressed.

For more information please contact:

Dr. Pinyi Nyimol Mawien Dr Othwonh Thabo Director General – Preventive Health Services Ag. Director - Integrated Disease Surveillance and Ministry of Health - Republic of South Sudan Response Tel: +211955604020 Ministry of Health - Republic of South Sudan Tel: +211 0954082015