Republic of South

Cholera in Situation Report # 17 as at 23:59 Hours, 01 June 2014

Background

On 29 April 2014, a suspected case of cholera was reported from the MSF clinic at UN House/ III Protection of Civilian (PoC) camp. On 28 April 2014, he visited relatives in Gudele II where he developed severe diarrhea and vomiting. One of the contacts in the household had developed acute watery diarrhea on the 24 April 2014. Stool samples collected from his four household contacts were all laboratory confirmed. 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. A retrospective record review at the emergency medical ward of Juba Teaching Hospital (JTH) revealed seven suspected cholera cases including one death, with the first case admitted on 23 April 2014.

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

Table 1 Summary of cholera cases, 23 April - 01 June 2014 Summary of cases JTH Gurei Tongping UN Gumbo Kajo- Other Total CTC CTC CTC House ORP Keji Civil sites (Juba III) Hosp Total new admisions today 28 3 0 1 4 0 0 36 Readmissions 3 0 0 0 0 0 0 3 Total new discharges today 23 11 0 0 0 0 0 34 Total new deaths today 0 0 0 0 0 0 0 0 Total number of cases currently 82 10 0 0 4 0 0 96 admitted Leave Against Medical Advice 0 0 0 0 0 0 0 0 (LAMA) Total facility deaths since the 15 0 0 0 0 0 1 16 onset of the outbreak Community deaths since the 0 0 0 0 3 0 8 11 onset of the outbreak Cumulative deaths since the onset 15 0 0 0 3 0 9 27 of the outbreaks Cumulative cases discharged 771 138 4 11 12 1 1 938 Cumulative cases 925 148 4 14 16 1 16 1,124 *Includes cases detected in private health facilities and at community level

. On 01 June 2014, 36 new cases were admitted at the cholera treatment centers (CTC) in Juba and 34 cases discharged, leaving 96 patients on admission.

. Cases have been reported from nine Payams in Juba county with the most affected being Munuki (354, 32%). See Table 2.

1 Table 2 Distribution of cholera cases by place of residence in Juba, 23 April – 01 June 2014 Payam Week 20 Week 21 Week 22 Cases by Payam n=1,123 (%) Northern Bari 63 71 39 175 (16) Munuki 77 122 155 354 (32) Juba 26 97 45 168 (15) 19 73 156 250 (22) Kator 14 43 66 124 (11) Missing 4 23 5 33 (3) 3 2 7 12 (1) Lirya 1 0 1 2 (0.2) Lokiriri 2 1 1 4 (0.4) Mangala 0 0 1 1 (0.1) Total by epi week 209 432 476 1,123

. Figure 1 shows the most affected villages include Gumbo in Rejaf, Gudele I in Munuki, Tongping in Juba, and Gudele II in Northern Bari.

Figure 1: Cholera cases from the five most affected villages per Payam in Juba, 23 April - 01 June 2014

200 189

180

160

140

120 109

100 76 80

60 48 43 34 32 40 27 29 29 19 20 22 Number of cases of Number 14 14 17 10 10 11 10 13 12 12 20 7 6

0

Gurei Gurei Gurei

Kator

Mobil

Gabat

Giada Giada

Sirikat

Mauna

Lologo Lologo

Gumbo

Amarat

Munuki

Atlabara

Gudele Gudele 1 Gudele 2

New Site New

Tongping

Hai Game Hai

Nyakuron

Juba Town Juba

Jebel market Jebel

WalangWalang Jebel Check JebelPoint Juba Kator Rejaf Munuki Northern Bari Affected areas

. Since the beginning of the outbreak on 23 April 2014, 1,124 cumulative cholera cases including 27 deaths (16 institutional and 11 community deaths, CFR 2.4%) have been reported. The majority of the deaths reported in hospital died on arrival. Hence the need to strengthen community case detection and prompt initiation of ORS treatment while immediate referral to the nearest CTC is being organized.

. Figure 2 shows the outbreak trend since it started on 23 April 2013. Three peaks of transmission were registered on 19/05/2014, 26/05/2014 and 28/05/2014 with 26/05/2014, higher than other two.

2

Figure 2: Cholera epidemic curve, 23 April 2014 - 31 May 2014

140 Died 120 Alive

100

80

60 113 100 86 87 40 73 72 66 Number of cases of Number 59 47 52 48 20 39 44 44 43 27 25 20 13 12

0 2 1 1 1 1 1 3

21/04/2009 22/04/2010 23/04/2011 24/04/2012 25/04/2013 26/04/2014 27/04/2015 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 22/05/2014 23/05/2014 24/05/2014 25/05/2014 26/05/2014 27/05/2014 28/05/2014 29/05/2014 30/05/2014 31/05/2014 01/06/2014 17 18 19 20 21 22

Date of onset

. Of the 1,124 cholera cases reported, the majority (631, 56%) are male, and aged 20-34 years (445, 40%).

Figure 3: Distribution of cholera cases by age 23 April - 31 May 2014

200 180 M 160 F 140 120 111 100 82 73 77 80 47 41 60 51 28 40 21 38 63 70 Number of cases cases of Number 52 20 49 48 42 26 15 12 27 32 30 19 14 9 17 0 11 4

Age group

Note: This is based on age and sex information entered in the line list.

The following are some of suspected risk factors for contracting cholera in Juba: . Drinking water from unsafe sources such as:  untreated river water which in Juba is primarily supplied by water tankers,  surface water-river and ponds . Poor latrine use, lack of latrines and open defecation, 3 . Poor latrine use and open defecation . Eating foods sold on the roadside and at makeshift markets. . Poor hygiene practices at community level . Poor community handling of dead bodies and unsupervised burials.

Cholera Alerts

Table 3 Summary of cholera alerts

No Date Details of the alert Area Needs/Actions taken received 1. 01/06/2014  One suspected case of Block 25,  An investigation was conducted by cholera was reported from Kuajok, SMoH/WHO Kuajok, Warrap. A two and Kuac North  Surveillance level increased in the state a half year male from payam,  State cholera taskforce reactivated reported suffering from Gogrial  Diarrhoea disease kits provided to Kuajok Acute Watery Diarrhea died West hospital at New Side Private Clinic. County,  Discussions ongoing about the set up of a The child had travelled with Warrap CTC three other children and two State ladies from Gudele in Juba. One of the other children had developed diarrhoea, and was reported to have recovered.

2. 30/05/2014  One suspected case of ,  Case management ongoing cholera is admitted in Kajo Central  Investigation and contact tracing conducted Keji hospital. She travelled  Samples collected from contacts from Juba on 22 May and  Health education conducted in affected developed symptoms of household and on local radio cholera when she arrived in Kajo Keji. Admitted at Kajo keji civil hospital. 3. 30/05/2014  Two additional suspect Yei, Central  Taskforce has been re-activated cholera cases have been Equatoria  Isolation ward has been designated in Yei admitted in Yei Civil Civil hospital Hospital. Cumulatively  PSI contacted to provide water guard seven suspect cholera  Rapid diagnostic test positive for cholera cases including one death  Four samples from Yei arrives in the have been reported. National Reference Laboratory and will be  Six suspect cases are tested on 31/05/2014 currently admitted in Yei Civil Hospital. 4. 30/05/2014 The MoH Mangala,  No additional cases reported from the area surveillance team followed up Central  24 AWD cases improved on treatment the AWD cases reported from Equatoria Mangala two weeks ago 5. 30/05/2014 The Central Equatoria MoH Jemeza,  Samples were collected but tested in the surveillance team followed up Central hospital laboratory with no conclusive on the two AWD cases Equatoria findings reported from  No additional cases have been reported hospital form Jemeza Payam (the area where the two cases originated from).

Response actions today Case Management . The team has continued to conduct burial supervision, dead body management and disinfection of deceased households. . Three ambulances have been positioned at Juba Teaching hospital designated to transport/refer patients to the nearest cholera treatment centres (CTCs).

4 Surveillance and Laboratory . Community based surveillance and cholera awareness campaigns activities have been intensified to enable case identification and ensure prompt referral to the CTCs. . The surveillance team continues to receive and investigate all cholera alerts from the peripheral facilities and community levels. . Epidemiological analysis of the outbreak data is ongoing to inform the current response.

Social Mobilization and WASH . Ninety five (95) social mobilizers visited 1,154 households in Gudele and 1,554 others in Lologo Kasira. A social mobilizer covers an average of 16 households per day in 8 hours. During the house to house visits, 7,176 and 2,394 sachets of PUR were distributed in Gudele and Lologo respectively. Two thousand, three hundred and eight and 800 sachets of ORS were also distributed in the same area. . Information, Education and Communication (IEC) materials were distributed to schools within Juba City. These included; hand washing posters, ORS demonstration, 5 steps of cholera prevention and control and banners on Cholera signs and symptoms. . Twelve (12) drama sessions were held in Munuki New site areas, with more shows expected. . Forty (40) health workers from El Sabbah hospital were trained on cholera prevention and control. . A total of 9,360 chlorine, 1,125 bars of soap, 4800 sachets of ORS were distributed to Juba B, Rejaf and Kator areas. . In response to the alerts in Kajo Keji and Yei, 100 assorted IEC materials were delivered to the two counties. . Two hotlines remain operational: 9999 and 0952000098 for reporting cholera cases.

WASH . Hygiene and promotion messages were disseminated to households in Juba town, Ghabat, MTC, Gumbo (Adodi and Bobe) and Juba nabari. . Garbage collection and dumping is ongoing in Juba town, Ghabat and Juba nabari, MTC and Gumbo and 13 garbage dumping sites were disinfected in Juba and Ghabat areas. . A total of 3,400 sachets of PUR were distributed to 340 households and 391 bars of soap distributed to 391 households in Juba and Ghabat; 3,910 sachets of PUR and 391 bars of soap distributed in Juba nabari. . Eight (8) hand washing facilities were installed in Juba nabari and filling of hand washing stations continued in MTC. . Sixty six households were sprayed in Hai Stenu Suwiya and Adoti areas with a focus on pit latrines, rubbish places, bathing shelters and places flies converge.

Current gaps . Increasing case load at JTH and other CTC sites. . Lack of a CTC in Gumbo, which is relatively far from JTH . Community engagement needs to be strengthened in order to encourage early treatment seeking behaviour.

Planned Activities

. 20 ORT corners to be set up in major health facilities in Juba town over the course of this week.

5 . Mapping of operational presence and response capacity of health partners in PoCs across South Sudan. . Investigate all alerts of cholera and continue with active case searching. . Conduct burial supervision, disinfection of dead bodies and patients’ households.

Conclusion and Recommendation 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. Increasing case load at JTH need to be urgently addressed as the CTC’s bed and human resources capacity are being stretched.

Acknowledgements The following partners who are supporting the Ministry of Health to conduct the response:

 Case management: Medair, MSF, UNICEF and WHO  Social mobilization: ART, Medair, South Sudan Red Cross, OVCI, UNICEF and WHO  Surveillance and Laboratory: WHO  WASH: Medair, Norwegian People’s Aid, OXFAM, People In Need and UNICEF

We are very grateful 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 welcome 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.

Please send any comments and feedback to: E-mail: [email protected],

The Toll free number for alerts are: Gemtel: 9999 and Vivacell: 0952000098.

Contacts For more information please contact:

Dr. Pinyi Nyimol Mawien Dr Othwonh Thabo Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955604020 Tel: +211 0954082015

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