Acute Watery Diarrhoea in Southern Sudan

Date of Reporting: 27 March 2006

Overview As of 26 March 2006, the cumulative number of cases reported, so far, from acute watery diarrhoea in Juba is 4,648 and the cumulative number of deaths reported, so far from Juba, is 90 (case fatality rate: 1.94%). In Yei, the cumulative number of cases, reported from acute watery diarrhoea, now stands at 1,819 (through 23-03-06) and the cumulative number of deaths stand at 54 (case fatality rate: 2.97%). In other areas reported cumulative cases total 2,927 cases with 104 deaths (case fatality rate: 3.55%).

During last 48 hours, a total of 29 cases and 2 deaths from acute watery diarrhoea were reported from Juba. Overall, between 28 January to date, a total of 9,394 cases and 248 deaths with an overall case fatality rate of 2.64% was reported from this outbreak of acute watery diarrhoea in Southern Sudan.

Table-1: Total number of reported cases and deaths from Acute Watery Diarrhoea, South Sudan 28 January – 26 March 2006 Town Date the Number Number Case- Cumulative Cumulative Overall first of cases of fatality number of number of case- “ index” reported deaths rate in cases deaths fatality case was in last reported last 24 reported till reported till rate reported 24 in last hours date date hours 24 hours Yei (up 28/01/06 NA NA - 1,819 54 2.97% to 23/03) Juba 06/02/06 16 2 12.5% 4,648 90 1.94% Other* 11/02/06 NA NA NA 2,927 104 3.55% TOTAL 9,394 248 2.64% NA: not available * Not all areas have reported through 26-03-06. See text

The outbreak has now been reported in 7 of the 10 states in Southern Sudan and new locations continue to appear almost daily. As not all areas report on the same day please see table of other locations to determine the exact reporting date for individual locations. In Kajo-Kegi, Pibor Area (Pibor; Lekongole; Gumruk), Bor, Terekeka and Malakal stool specimens have tested positive for Vibrio cholerae Inaba (tests done at AMREF in Kenya). In Mongella no cases have been reported since 28-02 and laboratory specimens sent at that time were negative for Vibrio cholerae. In Torit the outbreak also seems to have peaked and the number of daily cases is now declining. In Lohutok, an area northeast of Torit where initial reports were of >700 cases and 40 deaths, MedAir has established a CTC and in the 14 days on ground have reported treating 344 cases with 2 deaths. Laboratory specimens are pending from this location.

Overall, the situation in Yei is stable and improving daily with the last report received as of 23 March indicating the outbreak has been contained and only sporadic cases are appearing in town. The outbreak in Yei was declared officially over by the Undersecretary of Health of the GoSS, Dr. Majok Yak on 14-03- 06. However from 18 to 23 March 25 new cases were reported, 22 more than the previous week. The official number of total cases and deaths is 1,819 with 54 deaths for a 2.97% CFR as of 23-03-06. Of concern is the waning of intensity of watsan interventions and the general insecurity in the outlaying areas and roads (LRA) with the emergence of new cases especially in the peripheral villages.

The situation in Juba is improving as the number of cases has consistently decreased daily over the past three weeks. However the situation will continue to be followed closely as the full rainy season has not yet arrived. Of concern is the waning of intensity of watsan interventions with no chlorination being currently done. On March 21 eleven samples of water taken from different settings have shown four of them polluted.

The reports of increasing locations in the states (EES & Jonglei State) neighboring Juba (CES) with increasing numbers of cases and deaths of laboratory confirmed (Vibrio cholerae Inaba) acute watery diarrhoea continues to pose a serious challenge to the ongoing response efforts. The spread by road from Juba to the east (in Torit area) continues at present to be significant focus area with cases in Torit town itself and to the villages to the northeast of Torit town totally now over 1300. In addition on 17-03- 06 reports were received that indicate there are cases appearing in Ikotos which is on the road heading

1 south to the border with Uganda. This location continues to report more cases and supplies are urgently needed.

In Malakal in Upper Nile State after the importation of the index case on a barge from Bor (01-Mar) the number of cases of AWD reported continues to increase daily and as of 25-03-06 has reached 573 cases with 11 deaths (CFR= 1.92%). Nearby locations outside of Malakal town which have reported cases are also increasing and include the towns of Nyilwak, Dolieb Hill, Wilnyang, Atar, Nasir and Melut. In Unity State suspicious cases in Leer are under investigation.

Situation in Juba town

The reported cases of acute watery diarrhoea, in Juba, progressively increased after the first index case was reported on 6 February 2006 (Figure-2). After 23 February 2006 (about 2.5 weeks after the onset of the outbreak), the number of cases reported daily started to decline in spite of the improvement in the daily reporting system and number of surveillance sites. This trend in declining cases has continued to the current week when the rate of decline has slowed and remains below 20 new cases / day for the last two days.

After a few high spikes at the very beginning of this outbreak, the daily case fatality rate of AWD in Juba gradually declined to below 2% however slight daily fluctuation continues to occur. Investigations have been carried out on days when the case fatality rate is high and on most days it appears that the death cases involve persons arriving at the treatment facility in late stage of disease or persons that have died in the community. The overall case fatality rate from AWD in Juba now remains below 2%.

Stool specimens obtained in Juba from Lologo camp on 03-03-06 continued to be positive (3 of 5 specimens obtained) for Vibrio cholerae Inaba with the same sensitivity pattern as the original isolates, i.e. sensitive to tetracycline and resistant to chloramphenicol, nalidixic acid, cotrimoxazole and erythromycin. The rapid test (SMART) is being utilized on patients now presenting with non-classical cholera symptoms and a high percentage, 66.6% (6/9), are still positive for cholera.

In Figure 1 the number of cases in Juba per week is graphed and in figure 2 the number of cases, deaths and CFR is plotted per day.

Figure 1:

AWD by Week Juba - Southern Sudan 2500

2000

1500

Cases 1000

500

0 1 (4-10 2 (11-17 3 (18-24 4 (25 5 (4-10 6 (11-17 7 (18-24 Feb) Feb) Feb) Feb-3 Mar) Mar) Mar) Mar)

2

Figure-2: Reported cases and deaths from acute watery diarrhoea, Juba town, 06 February - 26 March 2006 450 60 400 Cases (n = 4648) CFR Deaths (n = 90) 50 350 300 40 250 30 200 No of cases

150 20 deaths of No 100 10 50 0 0

4 7 6 3 6 9 8 10 13 1 19 22 25 28 12 15 1 21 24

Reports of Acute Watery Diarrhoea from other locations Notes: 1) In addition to Yei and Juba positive stool specimens have been obtained at Kajo-Kegi, Terekeka, Bor, Pibor and Malakal but at other locations the pathogen is not laboratory confirmed 2) Numbers of cases and deaths at locations are added to the cumulative statistics if cases have been laboratory or clinically confirmed.

• Jebel Lado Area (CES): Jebel Lado area is located approximately 15 miles to the northwest of Juba town and is divided into 2 villages each reporting cases of AWD. In total since the first suspected case appeared on 15-02 there have been 37 cases with 11 deaths (these cases have not been added to Juba statistics). There is only one CHW for both villages and persons are using home-made ORS for treatment. A team from SMoH-CES was mobilized and travelled to the location from 03-06 March 2006. At the time of the visit there were no “new cases” seen and confirmation that suspected cases were AWD was not possible and review of records indicated perhaps the cases and deaths were more likely to be malaria.

• Lui (West Equatoria State): On 27-02-06 Samaritans Purse, an NGO partner supporting the Lui hospital reported 2 cases of AWD. No deaths occurred and no further cases have been reported as of 23-03.

• Bor (Jonglei State): 11 cases of Acute Watery Diarrhea from 16-02 to 22-02 with 1 death – stool specimens sent 23-02-06 (AMREF-Nbo) are positive for Vibrio cholerae. MSF-B team has agreed with authorities that MSF-B will upgrade hospital services in Bor while Johanniter will attend to the PHC services. A report received from UNMIS on 07-03 indicated that from 16-02 to 28-02 there were a total of 31 cases of AWD in Bor with 1 death. A report received on 09-03 indicated the case load had increased to 72 with 12 new admissions in the preceding 24 hrs. MSF-B opened the CTC in Bor on 07-03-06 and are now providing accurate data. At end of 21- 03 there are 196 cumulative cases and 13 cumulative deaths reported from Bor (CFR = 6.63%). Reports indicate that AWD cases are appearing in other villages in the Bor environs. CMA has reported 19 cases of AWD from 07-03 to 22-03 in Padak and more supplies have been shipped on 23-03 through PSF. The cases in these outlaying villages are being investigated. Requests for supplies for the SMoH have been mobilized in Juba and ICRC has donated IV fluids. Reports have also been received from CARE International who supports two local implementing partners on ground (DEFROSS & SORD). Preliminary findings indicate a few scattered cases appearing in the Toch (Duk County) and Maar (Twic East County). Investigations by local partners are ongoing. Training has been provided to CARE medical coordinator who in turn will train national staff on ground in Duk and Twic East Counties.

• Pibor (Jonglei State): MSF-B investigated cases and is providing support. On a lorry with 20 persons travelling from Juba to Pibor on 19-02 one child died on way (<5) of diarrhoea and dehydration. Second child (9yo) admitted to Pibor with AWD. A CTC was established in Pibor

3 with mobile teams travelling daily to Lekongole and Gumuruk. An update from MSF-B team as of 19-03 indicated a total of 174 cases and 3 deaths (2 deaths were not at the facility) in Pibor including 2 cases at the Pibor IDP camp. At Lekongole (near Pibor) the MSF-B health facility has reported 2 case of AWD. At Gumuruk (also covered by MSF-B) 35 cases with 3 deaths (all in the community) were reported as of 19-03. In Gumuruk environs there are suspect cases with deaths reported outside the town center and MSF-B has been requested to investigate and to provide further support. MSF-B has set-up a second CTC in Gumuruk ASAP. In total 211 cases with 6 deaths have been reported by MSF-B in the Pibor area since the beginning of the outbreak. A peace conference was scheduled to begin on 20-03-06 in Gumuruk.

• Terekeka (CES): ADRA investigated reported cases of AWD (First case appeared on 18-02 and to 01-03 there are a total of 50 cases with three (3) deaths). Stool specimens from 4 cases obtained and AMREF lab reported 3 of 4 specimens as positive for Vibrio cholerae. ADRA reported cases appearing in the villages surrounding Terekeka town although the situation in town is controlled. Report as of 13-03 indicated there are now 63 cases with 3 deaths in Terekeka and the situation is stable.

• Kajo-Kegi (also called Mundari is in CES): The first case of AWD was reported on 14-02-06 after which due to a security problem (LRA activity) the MSF-CH team at the civil hospital was relocated and no further reports were received. However on 01-03 MSF returned to the field and reported 3 further cases of AWD (two laboratory confirmed Vibrio cholerae) at Kajo-Kegi hospital and one (1) suspect case from Mondolokok IDP camp (north of Mundari). These cases all reported during epi week 10.

• Torit (East Equatoria State): The first case of AWD was reported by AVSI, an NGO partner supporting Torit civil hospital. Due to the severity of the situation on 26-02 Merlin (with financial support from ECHO) joined the AVSI team to provide further assistance in surveillance, case management and supplies. To date (26-03) 371 cases have been admitted to Torit Civil hospital with 18 deaths. A visit by UNMIS on 03-02 reported 150 cases with 10 deaths admitted to the military hospital since 16 February to date. However a joint review by civil and military hospital personnel revised the number of total reported cases at the military hospital to be 35 cases with 2 deaths (No formal records are maintained at the military hospital). Thus the total case load in Torit is 406 cases with 20 deaths (CFR = 4.93%). Oxfam-GB is helping with the watsan interventions and has conducted training on use of chlorine.

• Lopit area (East Equatoria State): Located to the north and east of Torit town on the east side of the mountain range. NGO partners on ground (NCA, AIC= African Inland Church and Diguna= German NGO) have reported >160 cases of AWD in 4-5 villages on 03-03. An early assessment was initiated on 06-03-06 from Torit by Merlin and the SMoH which indicated 100(+) cases in the surrounding villages (Idali, Longairo, Lolere and Lofrika). By 09-03 the situation was reported as rapidly changing and a MedAir team proceeded to Lohutok. A report from 10-03 indicated >700 cases with 40 deaths reported by the community in five separate villages visited (Lacharok, Logonowati, Imehejek, Lohobohobo and Arihilo (also called Lohitijo). A CTC at Lacharok has been set-up by MedAir. Further supplies have been mobilized at both Loki and Juba level. In Juba ICRC has given IV fluids and transport was completed. New reports indicate the daily case load is rapidly decreasing. Since the CTC and ORTs were set up MedAir has recorded 344 cases with 2 deaths (CFR = 0.58%).

• Ikotos (East Equatoria State): A new area with cases of AWD was reported 17-03-06 by the NGO partner, AVSI at Ikotos in Torit County, East Equatoria State. This town is on the route to Uganda. There were 30 cases reported with 1 death. The report was verified by a staff of Torit hospital who had been involved in the outbreak at that location and is considered valid. Health services in the area are minimal and a request for supplies/human resources has been made. A tent is urgently needed as the health facility is very inadequate. WHO has alerted WHO in Uganda so appropriate steps by the Uganda MoH can be taken. Up to 25-03 Merlin has recorded 92 with 2 deaths. There is still an urgent need for supplies.

• Lafon (East Equatoria State): Reports received in Torit regarding AWD cases in Lafon appearing on 11-02 with 8 patients and 2 deaths. An assessment visit was carried out on 06-03- 06 which indicated there were NO cases of AWD in Lafon village or the immediate 7 villages which surround Lafon. There were no suspect deaths noted in the past month.

4 • Mongella (CES): North of Juba on road to Terekeka. Assessment by SMoH/Medair confirmed cases of AWD in town (IDP camp not visited) with total of 14 cases and 5 deaths from 11-27 Feb. One stool specimen obtained and sent to Nbo for identification. Although the case load is not high the PHC facility in the area is in need of chlorine, ORS, gloves, IV cannulas and Ringers Lactate) WHO and IFRC have mobilized supplies which were handed over to the SMoH to be sent to the location. Results of a stool specimen obtained on 28-02 were negative for V. cholerae.

• Tijor Villages (CES): Tijor is located 53 miles north of Juba and slightly north of Rokon town within Rokon payam, Juba County, CES. The chief of the area investigated and has reported a total of 10 cases with 7 deaths from 5 villages in Tijor area (Tijor center 2cases/2deaths; Guru lotogu 3cases/2deaths; Yari 1case/1 death and Gimora 1 case/0deaths). The area has a few PHC units with staff however no supplies are available. The people are using traditional medicines. SMoH personnel called the medical staff (CHWs/medical assistants) to Juba to provide an update which showed an increase in cases to 27 total cases with 12 deaths. The staff were trained on case management and surveillance and returned to the area on 08-03-06 with supplies donated by UNICEF and WHO. Since the last report of 04-02 one further death was reported. The SMoH team has arrived at site on 09-03 and reported they found 9 further cases in Liggi village. Reports received as of 14-03 indicate the total number of cases has increased to 85 with a CFR of 25.9%.

• Mingkaman (Lakes State-Awerial County): Located on the west side of the Nile approximately across and slightly to the south on the opposite side of the river from Bor. Reports received indicate 16 cases with 6 deaths from AWD. A further investigation to the area was mobilized for 11-03 with SMoH and UNICEF and written report received 13-03 indicated the situation on the ground was stable although health conditions are very poor as NO health facilities are present in the area. Ten probable cases were reported of which 8 cases died secondary to dehydration. The SMoH (CES) is mobilizing staff from the Terekeka facility to move to the area and provide care to those affected. Supplies and transport are being mobilized. On 27-03 a reports were received from a community health worker of the Carter Centre about 22 cases and 8 deaths in Deng (Awerial). A team will be sent as soon as possible to confirm this information.

• Malakal (Upper Nile State): The fist case of AWD was reported on 01-03-06 in a patient arriving on a barge from Bor. Since that time a CTC has been established at the football stadium and is supported by MSF-H. MDM is prepared to open a second CTC in the Bam area of town (an area with a high number of cases) if there is need. The Malakal city water supply has been chlorinated by the Ministry with assistance from partners. Goal is carrying-out tracing of cases and performing household disinfection. 7 of 8 stool specimens sent were confirmed by laboratory (AMREF-Nairobi) as Vibrio cholerae inaba and the sensitivity pattern is the same as isolates from Juba. To 25-03 the total of reported cases from Malakal is 573 with 11 deaths. On 24-03 ICRC sent 10 tones of IV fluids to Malakal.

• Wilnyang (Upper Nile): In Wilnyang (Panyikango County) a collection of cases has been reported by WVI and through 19-03 19 cases with 2 deaths have been reported.

• Nyilwak (Shilluk Kingdom-Upper Nile State): On 12-03 WVI reported from Nyilwak (which is located approximately 50 km to west of Malakal) 6 cases of AWD with the first case appearing on 11-03. Activities have begun in surveillance, case management and prevention. A report received as of 19-03 indicated the cumulative cases now are 29 with 2 deaths.

• Dolieb Hill (Upper Nile State): There have been 9 reported cases in this village nearby Malakal. MoH wth assistance of Goal will initiate a mobile clinic if the need increases.

• Atar (Upper Nile): Cases from Atar were reporting to Wilnyang and the MoH investigated to find 18 cases with 3 deaths at that location. On 25-03 MSF-H reported two more cases.

• Nasir (Upper Nile): To 25-03 6 cases with 0 deaths have been reported.

• Leer: This town is in Unity State but located on the Nile. MSF-H has reported 6 suspicious cases which are not as yet confirmed but investigations are ongoing.

5 Table 2. Total number of reported cases and deaths from AWD in other locations, Southern Sudan. Juba and Yei not included.

Name First Lab Total Total Date of Partners on Site Case Test Cases Deaths last Report update Jebel Lado 15-02 No 37- not 11- not 07-03 SMoH assessment did NOT confirmed confirmed verify this rumor Kajo-Kegi 14-02 3(+) 6 0 12-03 KK-Civil Hosp/MSF-CH stool Vibrio Lekongole 23-02 No 2 0 19-03 MSF-B/SMoH-JS Gumuruk 05-03 35 3** 19-03 MSF-B/SMoH-JS Pibor 22-02 Stool 174 3* 19-03 MSF-B/SMoH-JS Vibrio Bor Town 16-02 Stool 196 18 21-03 SMoH-JS/UN- Vibrio partners/Johanniter/MSF-B Padak (Bor 07-03 No 19 0 22-03 CMA area) Terekeka 18-02 3 of 4 63 3 13-03 SMoH/ADRA stool Vibrio Mongella 11-02 Neg 14 5 01-03 SMoH/Medair Lui 27-02 No 2 0 20-03 SP/local authorities Lafon*** 11-02 No 0 0 06-03 SMoH Torit Town 18-02 Pend 371 18 26-03 SMoH/AVSI/ Merlin/UNMIS

16-02 No 35 2 08-03 Military Hospital Total 406 20 Totals Lopit Area 22-02 No >700 40 (comm. AIC/NCA/ SMoH (Lohutok) (minimal # Rpt recorded) 01-03 Yes 344 2 24-03 MedAir Tirangore - 113 2 25-03 Merlin Ikotos 06-03 92 2 25-03 MoH/AVSI/NCA/Merlin Jebelein ? No 17 (not 0 27-02 Military (SPLA camp confirm) rd to Nimule) Tijor (Rokon) Late Feb No 85 22(CFR= 14-03 SMoH 25.9%) Mingkaman 05-03 No 10 8 13-03 SMoH Malakal 01-03 7 of 8 573 11 25-03 MoH/MSF-H (+) for /Goal/ICRC/IRC/multiple Vibrio Wilnyang 12-03 - 19 2 19-03 MoH/WVI Nyilwak 11-03 - 29 2 19-03 MoH/WVI Doleib Hill - 9 (not NA 15-03 MoH/Goal confirm) Melut 17-03 - 26 NA 19-03 MoH Atar 18-03 - 20 3 25-03 MoH/MSF-H Nasir - 6 0 25-03 MoH/MSF-H Leer 6 (not 15-03 MoH/MSF-H confirm)

* two deaths at Pibor were not at health facility: one child died on lorry from Juba & another death was in the community -see text

** all three deaths were in the community

*** Assessment at Lafon indicated no cases- see text

6 Pattern of Current Transmission The outbreak of AWD in Yei town was declared over after approximately six weeks since it unfolded on 28 January 2006. The peak of the outbreak was reached somewhere between 1 to 7 February 2006. Further spread of the disease amongst the susceptible population has been contained although new cases and deaths are reported especially from the outlaying villages and health facilities. Insecurity (LRA) in outlaying villages has caused a decrease in monitoring of the peripheral situation.

In Juba the outbreak began one week later possibly introduced by a road traveller from Yei to Juba. The evolution of the outbreak of AWD in Juba suggests that the outbreak has peaked as a result of intensive public health interventions as new cases reported daily have levelled off. Preliminary evaluation of data suggests that the main mode of transmission in this outbreak is person-to-person.

Other areas with cases of AWD began appearing in the fourth week of the outbreak directly connected to Juba by either river or road. The number of new areas affected continues to grow and at least 6 states in Southern Sudan are involved (seven if the suspicious cases in Leer-Unity State are confirmed). It is important to note that the outbreak although contained at individual locations is not over. Please see below the graph showing the progression of cases from Yei to Juba to other locations followed by a graph showing the progression of cases to the different states in Southern Sudan.

Cases of AWD by epidemiological week Southern Sudan

3000

2500

2000 Other 1500 Juba

Cases Yei 1000

500

0 56789101112 Epidemiological week

*Please note data from other areas are not all confirmed cases so the exact values may vary slightly

Acute Watery Diarrhoea Outbreak in Southern Sudan Cases by epidemiological and outbreak week Year 2006

2500

2000 Central Eq S Eastern Eq S 1500 Jonglei S Western Eq S 1000 Lakes S No of cases of No Upper Nile S Unity S 500

0 28 Jan - 03 04 - 10 Feb 11 - 17 Feb 18 - 24 Feb 25 Feb - 03 04 - 10 Mar 11 - 17 Mar 18 - 24 Mar Feb Mar Outbreak Wk Outbreak Wk Outbreak Wk Outbreak Wk Outbreak Wk Outbreak Wk Outbreak Wk Outbreak Wk 1 2 3 4 5 6 7 8

7 Actions Undertaken Public health response operations are underway, jointly undertaken by the MoH of the Government of Southern Sudan, the FMoH, WHO and other UN and NGO partners, for outbreak containment and limiting the spread of the disease amongst the susceptible population:

• Coordination: A task force has been formed with the Undersecretary of the MOH of the GoSS in the chair to coordinate overall public health response to this outbreak.

• Surveillance: Actions undertaken to strengthen surveillance and reporting system include: − Using the standard case definition for reporting of all suspected cases of AWD − Nine (9) fixed surveillance sites are now operational in Juba reporting cases of all suspected cases of acute watery diarrhoea (AWD). − Line listing of all reported cases, meeting the case definition, and data analysis of the line listed data are continuing on a daily basis in order to better understand the changing epidemiological pattern and transmission trend of this outbreak − Mapping of all incoming data are also continuing to identify high risk areas for targeting chlorination and aggressive hygiene promotion interventions − Epidemiological investigation to gather more valid information on epicentre as well as the source of this outbreak was completed on 01 March 2006 − Systematic collection of stool samples for laboratory testing is continuing in order to understand the circulating pattern as well as the antibiotic sensitivity pattern of the pathogen causing this outbreak.

• Case management: Actions undertaken to strengthen uniform case management include: − Distribution of case management guidelines to all health services providers; − Three (3) Cholera Treatment Centres have been set up in Juba town combined with two other existing facilities (police and military hospitals) to improve access to proper treatment and as the case load is decreasing one centre (Kator) will be closed soon − Estimation of needs for essential drugs and emergency supplies for case management of AWD has been completed and based on past consumption pattern of rehydration supplies, a “critical stock value” for replenishment of depleted supplies has been determined towards more efficient management of medical supplies chain for AWD;

• Environmental control measures: Actions undertaken to strengthen environmental control measures include the followings:: − Chlorination of river water (used by tanker trucks and individuals filling jerry cans) and the city distribution system continues although after 8 weeks of intensive efforts interventions are now beginning to wan. − Jerry can chlorination continues at boreholes although with time this becoming very sporadic − Tanker trucks, boreholes/handpumps, and the city network continue to be chlorinated although less consistently then in the initial response. − Sanitation and hygiene control efforts continue but at a much reduced rate − Monitoring of residual chlorine levels in the various water supplies (tankering, boreholes, and network) also has become less regular. − Collection points at the river have been organized so that water retrieval occurs upstream from clothes washing, bathing and swimming. − Hygiene promotion activities which included taxi and radio broadcasts as well as home visits have all tapered off. Over 125,000 people have been visited by hygiene promoters in Juba town and in the adjoining areas during the height of the campaign.

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Summary - Cumulative Report Cases AWD in Juba (All facilities)

Date Total Case past Total Deaths Cumulative Cumulative CFR % 24 hrs (all past 24 hrs (all Cases in JUBA Deaths in JUBA facilities) facilities) 06-Feb 06 2 1 2 1 50 07-02 1 0 3 1 33.3 08-02 7 1 10 2 20 09-02 24 0 34 2 5.88 10-02 25 2 59 4 6.78 11-02 Sat 9 0 68 4 5.88 12-02 Sun 22 1 90 5 5.56 13-02 50 5 140 10 7.14 14-02 108 8 248 18 7.26 15-02 115 6 363 24 6.61 16-02 198 5 561 29 5.17 17-02 328 7 889 36 4.05 18-02 Sat 176 2 1065 38 3.56 19-02 Sun 381 3 1446 41 2.84 20-02 422 4 1868 45 2.41 21-02 315 2 2183 47 2.15 22-02 350 2 2533 49 1.93 23-02 274 (+27 2 (+ 2 Gumbo 2834 53 1.98 Gumbo previously previously unrecorded) unrecorded) 24-02 217 3 3051 56 1.83 25-02 Sat 155 2 3206 58 1.80 26-02 Sun 73 5 3279 63 1.92 27-02 139 2 3418 65 1.90 28-02 121 2 (+ 1) 3539 68 1.88 01-03 121 0 3660 68 1.86 02-03 122 2 3782 70 1.85 03-03 104 5 3886 75 1.93 04-03 Sat 83 2 3969 77 1.94 05-03 Sun 76 2 4045 79 1.95 06-03 49 0 4094 79 1.93 07-03 64 0 4158 79 1.90 08-03 45 2 4203 81 1.93 09-03 39 0 4242 81 1.91 10-03 31 1* 4273 82 1.92 11-03 Sat 26 1 4299 83 1.93 12-03 Sun 33 0 4334 83 1.91 13-03 35** 1 4369 84 1.92 14-03 22 1 4391 85 1.94 15-03 37 0 4428 85 1.92 16-03 28 0 4456 85 1.91 17-03 21 0 4477 85 1.90 18-03 Sat 24 1 4501 86 1.91 19-03 Sun 22 1 4523 87 1.92 20-03 20 1 4543 88 1.94 21-03 25 0 4567 88 1.93 22-03 10 0 4577 88 1.92 23-03 16 0 4593 88 1.92 24-03 26 0 4619 88 1.91 25-03 Sat 13 0 4632 88 1.90 26-03 Sun 16 2 4648 90 1.94 *death occurred on 08-03 but was reported on 10-03 **number decreased by 2 cases which on review did not meet the case definition

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