Republic of South Sudan
Situation Report #109 on Cholera in South Sudan As at 23:59 Hours, 24 February 2017
Situation Update A total of 13 counties in 9 (28%) of 32 states countrywide have confirmed cholera outbreaks (Table 1; Figure 1.0). The most recent cases were confirmed in Yirol East, Eastern Lakes state on 22 February 2017. Suspect cholera cases have been reported in Malakal Town; Pajatriei Islands, Bor county; Panyagor, Twic East county; and Moldova Islands, Duk county (Table 4). During week 8 of 2017, a total of 4 samples from Yirol East and 2 samples from Mayendit tested positive for cholera (Table 3). Cumulatively, 185 (37.8 %) samples have tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 24 February 2017 (Table 3).
Table 1: Summary of cholera cases reported in South Sudan as of 24 February 2017
New New Total cases Total Reporting New deaths Total facility Total cases admissions discharges currently community Total deaths Total cases Sites WK 8 deaths discharged WK 8 WK 8 admitted deaths
Jubek – Juba - - - - 8 19 27 2,018 2,045
Jonglei-Duk - - - - 3 5 8 92 100
Jonglei-Bor - 15 - 7 1 3 4 51 62
Terekeka - - - - - 8 8 14 22
Eastern Lakes 12 5 - 5 2 8 10 478 493 - Awerial
Eastern Lakes 1 5 - 1 5 12 17 176 194 - Yirol East
Imatong ------1 1 28 29 Pageri
Western Bieh - - - - - 4 - 4 266 270 Fangak Northern Liech - - - - 3 7 2 9 1,144 1,156 Rubkona Southern - - - - 3 - 3 91 94 Liech - Leer Southern Liech - - - - - 17 4 21 435 456 Panyijiar Southern Liech - 2 2 - - - 5 5 214 219 Mayendit Central Upper 5 181 Nile - Pigi 3 2 3 5 173
Total 18 29 - 19 55 67 122 5,180 5,321
Highlights in week 8 of 2017: 1. Cholera confirmed in Yirol East after four of 10 samples tested positive for cholera Table 3. 2. New suspect cholera cases reported in Malakal Town, Central Upper Nile state Table 4. 3. A total of 18 cases reported in week 8 compared to 111 cases in week 7 of 2017 Figure 1.1. 4. Integrated response teams are supporting the response in Mingkaman, Yirol East, and Bor. 5. Transmission has declined in Yirol East, Mingkaman, Bor, Southern Liech, and Northern Liech Figure 2.1
1 A new cholera outbreak has been confirmed in Yirol East after four of 10 samples tested positive for cholera on 22 February 2017. The initial cases in Yirol East were reported on 3 February 2017 from Adior, Shambe, and Langmatot. The response in Yirol East was led by the state MoH, CHD, and health [CUAMM, WHO, UNICEF, IOM, and MSF-B] and WASH partners. Transmission has subsided and current efforts are aimed at addressing the underlying risk factors and improving skills for case management and infection prevention and control at existing cholera treatment facilities.
Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 24 February 2017
World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24, 2016 to 7 of 2017
Map Date: 20 February, 2017 Manyo
Renk The boundaries and names shown and the designations used on this map do not imply ofcial endorsement or acceptance by the United Nations.
Sudan 0 50 100 200 Melut Kilometers Fashoda Maban Abyei Pariang Malakal Abiemnhom Baliet Aweil East Panyikang Aweil North Rubkona Fangak Guit Longochuk Twic Mayom Pigi Aweil West 0.78 2.92 1.48 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Leer Tonj NorthMayendit Ayod 3.19 2.39 Ethiopia Tonj East Duk Panyijiar Uror Akobo Jur River Rumbek North 8.0 4.61 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Bor South Nagero Yirol West Awerial 7.14 Pibor Wulu Tambura 2.11 Mvolo Legend Terekeka xx Case fatality rate (CFR) 36.36 Counties with Cholera alert Mundri WestMundri East Lafon Kapoeta North Cases per 10,000 population Ezo Ibba Maridi Kapoeta East Juba > 60 Yambio Nzara 1.32 46 - 60 Kapoeta South 31 - 45 Torit Budi Yei Lainya 16 - 30 Magwi Ikotos 0.1 - 15 Kajo-Keji 2.84 Kenya No case reported Morobo Pageri River Democratic Republic of Congo Uganda
Figure 1.1: New cholera cases admitted by location in week 7 and 8 of 2017
120 111
week 7 week 8 100
80
60
39 40 29 29 Number of Cases 18 20 12 9 1 2 2 3 3 0 Awerial Yirol East Bor South Rubkona Mayendit Pigi- canal Eastern Lakes Jonglei Northern Liech Southern Liech Central Upper Nile Total by week
2
The transmission in the other active transmission areas in Mingkaman, Bor, Northern and Southern Liech has declined significantly Figure 2.1. However new suspect cases are being investigated in Pajatriei Island, Bor South county and Malakal Town in Central Upper Nile state Table 4. Following the identification of the two suspect cholera cases in Malakal Town, samples were obtained for confirmatory testing and follow up visits to the community to determine the source and identify additional suspect cholera cases. The taskforce has been activated and the response plan has been updated to guide preparedness and response actions by the taskforce.
Rapid response mission from 19-24 Feb 2017 visited Koyom and Moldova Islands in Duk. At least 8 suspect cases were reported in Koyom PHCU since 3 Feb 2017 Table 4. The team conducted sensitization on cholera prevention and left case management supplies with JDF. There is no access to safe water on the islands and there are only two communal latrines constructed by Africa Rise in 2016. The mission to Koyom and Moldova Islands was supported by WHO.
Figure 1.2: Cumulative cholera cases by state and county of residence as at 24 February 2017
6000 5321
5000
4000
3000
Number of Cases 2045 2000 1156 1000 456 493 270 219 194 181 22 94 62 100 29 0 FANGAK Terekeka Leer Mayendit Panyijiar Rubkona Juba Bor South Duk Pageri Awerial Yirol East Pigi- canal Western Terekeka Southern Liech Northern Jubek Jonglei Imatong Eastern Lakes Central Grand Bieh Liech Upper Total Nile
On 22 February 2017, a rapid response mission was organized by MSF-B to Kuei Islands in Bor South county. There is one ‘Tukul’ (Hut) used as health facility with 3 Nurses, 3 health promoters, 1 hygiene officer, 2 clinicians, and 2 laboratory technicians – all working as volunteers. There were case management supplies donated by SMC – a national NGO. The immediate needs included training of the team on cholera protocols, securing a tent for case isolation, latrine facility, and safe water. There is no borehole on the island and only one communal latrine. These needs will be addressed in follow up visits organized by state and national taskforce.
Table 1.1: Cholera cases and deaths by state and county as of 24 February 2017 State County Population Week 8 Weeks 24, 2016 to 8, 2017 at risk New Cases per No. Cases per 10,000 CFR [%] cases 10,000 cases population W8 population Western Bieh Fangak 168,947 0 - 270 16.0 1.48 Northern Liech Rubkona 126,976 0 - 1156 91.0 0.78 Southern Liech Leer 95,731 0 - 94 9.8 3.19 Southern Liech Panyijiar 78,020 0 - 456 58.4 4.61 Southern Liech Mayendit 97,127 2 0.21 219 22.5 2.28 Eastern Lakes Awerial 114,837 12 1.04 493 42.9 2.03 Eastern Lakes Yirol East 104,694 1 0.10 194 18.5 8.76 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Bor South 331,611 0 - 62 1.9 6.45 Jonglei Duk 96,259 0 - 100 10.4 8 Jubek Juba 579,778 0 - 2,045 35.3 1.32
3 State County Population Week 8 Weeks 24, 2016 to 8, 2017 at risk New Cases per No. Cases per 10,000 CFR [%] cases 10,000 cases population W8 population Terekeka Terekeka 209,902 0 - 22 1.0 36.36 Central Upper Nile Pigi 150,800 3 0.20 181 12.0 2.76 Total 2,369,812 18 0.08 5,321 22.5 2.29
Cumulatively, 5,321 cholera cases including 122 deaths (55 facilities and 67 community) (CFR 2.29%) have been reported in South Sudan involving 13 counties in 9 states since the initial case was reported on 18 June 2016 for Jubek state; 3rd July 2016 for Duk in Jonglei state; 14 July 2016 for Terekeka state, 15 August 2016 for Mingkaman in Eastern Lakes and Pageri in Imatong states; 10 August 2016 for Fangak in Western Bieh state; 29 September 2016 for Rubkona in Northern Liech state; 11 October 2016 for Leer; 22 October 2016 for Panyijiar in Southern Liech state; 10 October 2016 for Pigi in Central Upper Nile state; 7 October 2016 for Mayendit in Southern Liech state; 30 January 2017 for Bor South in Jonglei state; and 3 February 2017 for Yirol East in Eastern Lakes state (Figure 2.1 and Table 1.1).
Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 24 February 2017
350 25
300 21.05 20 250 16.92 15 200
150 CFR [%] Number of cases 10
100 6.67 6.91 5.11 4.48 5 50 3.33 3.33 3.49 2.75 2.42 2.05 1.85 2.26 2.00 2.24 2.30 1.42 1.55 1.35 1.76 1.27 0.62 0.86 0.42 0.76 0.75 0.82 0.63 0.57 0.79 0.60 0 - - - - - 0 22 23 24 25 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
Epidemiological week of onset 2016 2017
Jonglei Jubek Terekeka Imatong Eastern Lakes
Western Bieh Northern Liech Southern Liech Central Upper Nile CFR[%]
Figure 3:1 Cholera case distribution by gender and county 24 February 2017 Cholera case gender distributionby IDP site wk 27 of 2016 to week 8 of 2107 100%
90%
35 37 80% 44 42 41 50 48 50 54 56 57 57 55 54 70%
60%
50%
e itiuin % Sex distribution 40%
65 63 30% 56 58 59 50 52 50 46 44 43 43 45 46 20%
10%
0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Yirol East Overall
Female Male
Overall, males and females have been affected evenly Figure 3.1. The gender distribution of cholera cases by county is shown in Figure 3.1.
4 Figure 3:2 Cholera case distribution age in South Sudan 24 February 2017
Cholera case age distributionby IDP site wk 27 of 2016 to week 8 of 2017
25 23.2
20
15.5 15
11.0
10 8.4 7.8
g itiuin % Age distribution 7.1 7.4 5.5 5 3.7 2.9 1.7 1.7 1.9 1.3 0.9
0
9yrs +yrs - 14yrs 24yrs <5yrs 19yrs 29yrs 34yrs 39yrs 44yrs 49yrs 54yrs 59yrs 64yrs 69yrs ------5 70 10 20 15 25 30 35 40 45 50 55 60 65
Figure 3:3 Cholera case distribution by age and county in South Sudan 24 February 2017
Cholera case age distributionby IDP site wk 27 of 2016 to week 7 of 2107
100%
90%
80%
70%
60%
50%
40% g itiuin % Age distribution
30%
20%
10%
0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Yirol East
<5yrs 5-9yrs 10-14yrs 15-19yrs 20-24yrs 25-29yrs 30-34yrs 35-39yrs 40-44yrs 45-49yrs 50-54yrs 55-59yrs 60-64yrs 65-69yrs 70+yrs
Children under 19 years constitute nearly 60% of the total cholera cases Figure 3.2. The age distribution of cholera cases by county is shown in Figure 3.3.
Probable risk factors The probable risk factors fueling transmission include: using untreated water from the River Nile and water tankers; lack of household chlorination of drinking water; eating food from unregulated roadside food vendors or makeshift markets; open defecation/poor latrine use especially following the conflict.
Other factors 1. Due to the protracted nature of the crisis since 2013, there has been destruction of infrastructure and limited investments to improve social services to the general population as such, living conditions have deteriorated with declining access to safe water and sanitation amenities. 2. Due to the worsening, economic situation, the cost of accessing safe water from the water trucks has increased substantially thus forcing households to resort to unsafe water sources. 3. In Southern Liech, humanitarian access remained limited due to persistent hostilities that kept away partners and thus impeding the initiation of comprehensive and sustained cholera interventions to interrupt transmission and prevent widespread and protracted outbreak. Consequently, transmission has continued in Southern Liech since late September 2016 with continued case spillovers to Bentiu, Panyijiar, Awerial, and Bor South.
5 4. While WASH partners have endeavoured to improve access to safe water and sanitation in Bentiu PoC; the continued arrival of people into the PoC has remained a challenge. In addition, current transmission in Bentiu PoC is linked to an oxidation water pond that is being used for bathing, washing, swimming and sometimes to collect water for household use since its water is soft and considered more palatable by the local population. The pond therefore needs to be secured-off to stem the ongoing transmission and to prevent future outbreaks. 5. During the protracted crisis, cholera transmission hotspots have expanded to include the following: a. Internally Displaced persons – UN House PoC, Bentiu PoC, Bor PoC, Mingkaman, Wau, and Malakal, Melut, and Wau Shiluk. b. Refugee populations c. Neighbourhoods in urban settings with inadequate access to safe water and sanitation – Juba, Torit, Bor, etc. d. Towns and counties along the Nile – Nimule, Juba, Bor, Terekeka, Leer, Panyijiar, Ayod, Fangak, Pigi, Malakal etc. e. Populations on islands with nearly no access to health care and at risk for high mortality from cholera – Terekeka, Leer, Duk, Ayod, Kuei, Yirol East etc.
Table 3: Cholera laboratory test results for Juba by 24 February 2017
Culture results State New positives in Cumulative Cumulative Total tested week 8 Positive Negative Central Upper Nile 0 0 5 5 Jonglei-Duk 0 1 4 5 Jonglei-Bor South 0 4 1 5 Jubek 0 83 133 216 Terekeka 0 2 0 2 Eastern Lakes - Mingkaman 0 27 42 77 Eastern Lakes – Yirol East 4 4 6 10 Imatong 0 7 1 8 Fangak 0 16 37 45 Wau 0 0 6 6 Boma 0 0 2 2 Northern Liech 0 31 57 88 Southern Liech – Leer 0 2 0 2 Southern Liech - Panyijiar 0 1 0 1 Southern Liech – Mayendit 2 4 6 10 Central Upper Nile (Pigi) 0 3 5 8 Total tested 6 185 305 490
Table 4: Cholera Alerts Date of Details of the alert Area Action notification No alerts 10-Feb-17 At least 2 suspect cases Twic East The taskforce in Bor is planning reported from Islands in Twic verification missions to Twic East. East and Panyagor 10-Feb-17 15 suspect cases reported from Duk – Moldova and Rapid response mission 19-24 Feb 2017 the Islands of Moldova in Duk Koyom Islands visited Koyom and Moldova Islands in Duk. At least 8 suspect cases were reported in Koyom PHCU since 3 Feb 2017. The team conducted sensitization on cholera prevention and left case management supplies with JDF. No access to safe water and there are only two communal latrines constructed by Africa Rise last year.
6 21-Feb-17 Suspect cases in Pajatriei Island Pajatriei Island of Plans underway to send verification and of Baidit payam, Bor South Baidit payam response team to the Island County following the report of 2 deaths cases 22-Feb-17 Two suspect cases reported in Malakal Town Cases admitted and stabilized in MSF- MSF-Malakal Town Clinic. Malakal Town Clinic. Samples obtained Samples obtained and patients for confirmatory testing. Taskforce in stabilized on treatment. Malakal activated and cholera EPR plan updated.
Cholera Response Activities Overall coordination of the cholera response at the national level is coordinated by the National cholera taskforce to review outbreak trends and progress of implementation activities. Sub-national cholera taskforce committees are coordinating the cholera response in Northern and Southern Liech, Yirol East, Mingkaman, and Bor.
Following the identification of the two suspect cholera cases in Malakal Town, samples were obtained for confirmatory testing and follow up visits to the community were undertaken to determine the source and to identify additional suspect cholera cases. The taskforce has been activated and the response plan has been updated to guide preparedness and response actions by the taskforce that includes health and WASH cluster partners.
Rapid response teams from MoH, CHD, CUAMM, IOM, MSF-B are supporting cholera outbreak response activities in Yirol East. Rapid response teams from MoH and WHO are working with CUAMM, CHD, and HLSS to respond to the cholera outbreak in Mingkaman. The current response efforts in Eastern Lakes are aimed at addressing the underlying risk factors and improving skills for case management and infection prevention and control at existing cholera treatment facilities.
Thus, on 23 February 2017, WHO and MoH conducted cholera case management training for 25 frontline health care workers in Mingkaman IDP site in Awerial. The trainees were drawn from Cholera treatment center, Mingkaman PHCC, and neighboring health facilities.
Rapid response mission 19-24 Feb 2017 visited Koyom and Moldova Islands in Duk county, Jonglei state. At least 8 suspect cases were reported in Koyom PHCU since 3 Feb 2017. The team conducted sensitization on cholera prevention and left case management supplies with JDF. There is no access to safe water on the islands and there are only two communal latrines constructed by Africa Rise last in 2016. The mission to Koyom and Moldova Islands was supported by WHO.
On 22 February 2017, a rapid response mission was organized by MSF-B to Kuei Islands in Bor South county. There is one ‘Tukul’ (Hut) used as health facility with 3 Nurses, 3 health promoters, 1 hygiene officer, 2 clinicians, and 2 laboratory technicians – all working as volunteers. There were case management supplies donated by SMC – a national NGO. The immediate needs included training of the team on cholera protocols, securing a tent for case isolation, latrine facility, and safe water. There is no borehole on the island and only one communal latrine. These needs will be addressed in follow up visits organized by state and national taskforce.
To slow the current surge in cholera cases, WHO working with health cluster partners has secured the initial batch of 68 967 doses of oral cholera vaccine for Leer, Padeah, and Thonyor in Leer county. MedAir, an emergency operational health cluster partner will coordinate the deployment of the vaccine alongside WFP’s food distribution headcount on 27 February 2017.
WHO working with the health and WASH cluster partners has identified at least nine high-risk populations that have been prioritized for emergency complementary oral cholera vaccination. A multi-year plan for complementary oral cholera vaccination alongside improving access to safe water, sanitation, social mobilization, case management, and surveillance will be validated and launched on 9 March 2017.
Planned Activities/recommendations 1. The next weekly EPR/cholera taskforce meeting is scheduled for 1 March 2017 starting 2:00pm in the WHO Conference Hall. 2. Support the investigation and response into new alerts in Malakal Town; and Pajatriei Islands in Bor county.
7 3. Continue with the ongoing response to the outbreaks in Mingkaman, Yirol East, Bor, Southern Liech, Northern Liech, and Pigi in Central Upper Nile state. 4. Conduct oral cholera vaccination campaigns for the select high risk populations in Southern Liech state.
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 number for Vivacell calls is: 1144.
Contacts For more information, please contact
Dr. Pinyi Nyimol Mawien Dr. Alice Igale Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955604020 Tel: +211956420189
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