Republic of

Cholera in South Sudan Situation Report # 93 as at 23:59 Hours, 15-21 September 2014

Situation Update

As of 21 September 2014, a total of 6,128 cholera cases including 139 deaths (CFR 2.27%) had beenTable reported1. Summary in of South cholera Sudan cases asreported summarized in in County Tables, 23 1 April and –2.21 September 2014 New New New deaths Total cases Total Total admisions discharges Total Total cases Reporting Sites 15-21 Sept currently facility community Total cases 15-21 Sept 15-21 Sept deaths discharged 2014 admitted deaths deaths 2014 2014 JTH CTC 3 3 0 0 16 0 16 1455 1479

Gurei CTC (changed to ORP) Closed 28 July 2 0 2 365 367

Tongping CTC 0 2 1 3 69 72 Closed August Jube 3/UN House CTC Closed August 0 0 0 0 97 97

Nyakuron West CTC Closed 15 July 0 0 0 18 18

Gumbo CTC Closed 5 July 0 0 0 48 48

Nyakuron ORP Closed 5 July 0 0 0 20 20

Munuki ORP Closed 5 July 0 0 0 8 8

Gumbo ORP Closed 15 July 0 3 3 67 70

Pager PHCU 1 1 0 0 1 5 6 42 48

Other sites 0 0 0 1 15 16 1 17

Total 4 4 0 0 22 24 46 2190 2244 N.B. To prevent double counting of patients, transferred cases from ORPs to CTCs are not counted in the ORPs.

Table 2: Summary of cholera cases reported outside Juba County, 23 April –21 September 2014 New New New Total cases Total Total admisions discharges deaths Total Total cases Total States Reporting Sites currently facility community 15-21 Sept 15-21 Sept 15-21 deaths discharged cases admitted deaths deaths 2014 2014 Sept 2014 Kajo-Keji civil hospital 0 0 0 0 3 4 7 86 93 CES Yei Hospital -- 0 0 0 0 2 2 45 47

WES Lanyi- Mundri East -- 0 0 0 0 0 0 3 3

Jonglei Kolmanyang, Bor -- 0 0 0 0 0 0 1 1

Nimule Hospital 2 2 0 0 0 0 0 106 106

OTC PHCC, -- 0 0 0 10 0 10 141 151

Magwi PHCC 0 0 0 5 1 0 1 12 18

Pajok PHCC, Magwi -- 0 0 0 0 0 0 1 1

Nyolo CTC, Magwi 0 0 0 0 0 0 0 25 25

Idali PHCU, Lafon -- 0 0 0 5 1 6 90 96 Lwala PHCU, Pachidi -- 0 0 0 0 1 1 1 2 payam, Lafon Longiro PHCU,Lafon -- 0 0 0 1 0 1 15 16

Lalanga PHCU, Lafon 0 0 0 0 0 2 2 63 65 EES Hospital 4 4 0 0 8 9 17 1407 1424 Bur Mutram PHCU, -- 0 0 0 0 1 1 59 60 Bur Payam, Torit Ohiri PHCC, Bur -- 0 0 0 3 0 3 53 56 Payam, Torit Ohila PHCC, Bur -- 0 0 0 0 0 0 24 24 Payam, Torit Imurok PHCU, Imurok -- 0 0 0 2 1 3 10 13 Payam, Torit Hiyala PHCC, Torit -- 0 0 0 0 0 0 86 86 Olere PHCU, Imurok -- 0 0 0 0 0 0 4 4 Payam, Torit Osito PHCU, Bur -- 0 0 0 0 0 0 42 42 payam, Torit

1 New New New Total cases Total Total admisions discharges deaths Total Total cases Total States Reporting Sites currently facility community 15-21 Sept 15-21 Sept 15-21 deaths discharged cases admitted deaths deaths 2014 2014 Sept 2014 Ileu PHCU, Hiyala -- 0 0 0 3 7 10 147 157 payam, Torit Hileu PHCC, Himodonge Payam, -- 0 0 0 0 0 0 6 6 Torit Ofiri PHCU, Kudo -- 0 0 0 0 0 0 5 5 Payam, Torit Kudo PHCC, Kudo -- 0 0 0 1 0 1 54 55 Payam, Torit Moti PHCU, Ifwotu, -- 0 0 2 0 1 1 4 7 Torit PHCC, 3 3 0 0 1 0 1 74 75 North SSRCORPs, Nyong -- 0 0 0 0 0 0 70 70 Payam, Torit St. Theresa, Isohe, 0 7 1 2 2 2 4 93 102 Ibahure PHCC, ibahure 0 0 2 1 0 1 23 25 Payam, Lopa/Lafon Other sites -- 0 0 0 0 0 0 23 24

Kaka -- 0 0 0 0 0 0 0 1

Wau Shilluk, Malakal -- 0 0 4 15 2 17 885 906 Upper Nile Malakal PoC -- 0 0 0 2 0 2 59 61

Other sites -- 0 0 0 2 0 2 55 57

Total 9 16 1 15 60 33 93 3772 3884 x: Facilities not reporting; -- no cases reported for at least two weeks

Figure 1: South Sudan Cholera Epidemic Curve, week 17-38, 2014

1200

1000

800

No No Cases 600

400

200

0 Epidemiological week 2014 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

WES UNS EES CES Figure 2: Cholera Case Distribution by Age, Sex and State – week 38 6 5 1 4 1 3 2

No. No. cases 2 4 3 1 2 0 0 CES EES CES EES <5yrs ≥5YRS

Female Male

2 Figure 3: New Cholera Cases in Juba County during week 38, 2014

3

2 No. No. cases

1 1 1 1 1 0 0 0 0

0 Lologo Kelang Gumbo Munuki Karpeto Gwadiang JebelDinka Jibi/Karpeto Kator Northern Lobonok Rejaf Munuki Bari

Figure 4: New Cholera Cases in during week 38, 2014 2

1 No. No. cases

1 1

0 0 Malakia East Motoyo East Malakia West

Figure 5: New Cholera Cases in during week 38, 2014 3

2

No. No. cases 1 2

1

0

Natil Malibakanyit Najie (Natil) Karakamoge

3 Table 3. Cholera alerts reported between 15 – 21, August 2014 Date of Details of the alert Area Action notification 24/08/2014 Pager PHCU reported a cluster of nine Lobonok Verification conducted by the county (9) acute watery diarrhoea cases Payam, Juba, surveillance team including five (5) community deaths. CES - The WHO has supplied case management The cases have been reported from supplies and a tent to accommodate the two (2) villages (Karpeto & Pager) in - suspect cases Lobonok Payam, Juba County. By 21 WASH interventions at the community September 2014; the cases had risen level are still pending to 48 including six (6) deaths [five - A joint mission of MoH and partners community deaths & one death in the visited Lobonok during week 37 assess health facility]. - the outbreak and support the response

Surveillance and laboratory  A total of 13 new cholera cases were reported in Juba County in week 38 with the majority being reported in Juba 4 (31%), while the rest were reported from Torit (4 cases), Kapoeta North (3 cases), and Magwi (2 cases) as illustrated in Figures 3 to 5.  There were no new cholera cases reported from the rest of the counties in week 38.  As seen from Figure 1, the cholera trend is on the decline in all the five states where cholera has been confirmed.  Overall, 187 (43.4%) of the samples tested have been positive for cholera by culture.  Due to the declining cholera trend, it is recommended that all new suspect cholera cases have samples obtained for laboratory confirmation.

Case management  Management of new cholera cases is ongoing in Juba, Nimule, Torit, and Kapoeta North where new cases were reported during week 38.  Adequate supplies have been availed to support case management activities in the cholera treatment centres where the cases are being treated.

Social mobilization Social Mobilization efforts and responses are ongoing in Central Equatorial states, Eastern Equatorial State, Jonglei and Upper Nile where some AWD/Cholera cases are still being reported in some areas.

 In Central State, Mumuki and Gudele in Juba town, Lobonok payam and Kajo-Keji continue to be affected by cholera. SMOH, CRS and ACF social mobilizers and hygiene promoters are distributing aquatabs and cholera information, education and communication (IEC) materials in the villages.  In State, Save the Children continues with social mobilization on the prevention of cholera and other diarrheal disease in Torit and Lopa-Lafon. Altogether 245 households comprising 1,681 people were reached with 245 bars of soap; 490 sachets of oral rehydration salts (ORS); and 2,450 tablets of pur.  In Jonglei State social mobilization volunteers reached 1,284 people with non-food items (NFI) and cholera prevention messages. Three community meetings took place and were attended by 80 community leaders including religious, local chiefs, youth and women group leaders. - A video play was screened at Royal Junior School and reached 300 pupils and four teachers. IEC materials comprising 10 banners and 100 stickers were produced and four solar radios given to the teachers. - Radio Jonglei MF95 continues to play cholera awareness campaign messages in English, Arabic, Dinka and Nuer. - A radio talk with the Bor municipality health officer took place last Friday, during which teachers were educated on cholera control and prevention. The children also practiced and demonstrated hand washing with water and soap. - Radio Jonglei FM 95.9 continues with Radio spot messages on cholera prevention and control broadcast six times daily after every program. The messages reach listeners within Bor county. - To date 169, 502 households and 210 schools have been reached countrywide with cholera prevention and control messages. Community skills are being strengthened on safe drinking water and rehydration through ORS and sugar salt solution (SSS) with the help 1,119 social mobilizers.

WASH WASH efforts and responses are ongoing in Central and Eastern Equatoria states where some AWD cases are still being reported in some areas.

Central Equatoria State

Juba County Interventions by WASH partners continue and include:  Provision of safe drinking water in markets for hand washing.  Community mobilization, hygiene promotion, cholera awareness and prevention messages. Distribution of Aqua tablets to 76 restaurants.

Lobonok County

4  Mobilization and selection of community hygiene promoters have been conducted successfully.  Ten community hygiene volunteers were trained to disseminate key cholera messages to the community.  Awareness on cholera was undertaken in the community of Kelang area with 807 individuals reached.  Two hundred households in Kelang area were registered for NFI distribution.

Eastern Equatoria State

Torit County  House to house hygiene promotion continues in efforts to create awareness of water handling and hand-washing at critical times among the community. This is complemented by hygiene promotion through a weekly radio talk show.  Safe water supply through the water treatment units and repair of hand pumps is ongoing. Additional collection points have been set up through water trucking in order to increase safe water supply to the communities who are far from the collection points at treatment units.

Magwi County  Rehabilitation of wells and water systems at health facilities; Distribution and demonstration on proper use of water treatment reagents; House to house hygiene promotion; Distribution of Jerri cans and soap; and Training of hygiene promoters continue.

Ikwoto County  Partners continue to conduct hygiene promotion awareness, repair of water schemes and distribution of the relevant WASH NFIs.  In Lopa-Lafon, hygiene promotion was conducted and supplemented with the distribution of WASH NFIs comprising soap, aqua tabs and ORS in Lohutok and Hejuhiteng payams.  Altogether 4,306 households received soap and water treatment tablets.

Kapoeta South County  Rehabilitation of wells and hygiene promotion targeting cholera hot spots is on-going, including distribution of soap for hand washing and water treatment tablets for household use.

Gaps and needs Case management, surveillance and laboratory • Submission of updated cholera line lists to the Ministry of Health needs to be strengthened. • Cholera treatment centres should submit samples from new cases for laboratory testing. This will guide decisions on the end of outbreak declarations in the affected counties.

Social mobilization • Access to counties outside Bor remains a challenge due to poor road condition and insecurity. There are huge gaps in monitoring and supervision activities as well as dissemination cholera messages to reach target beneficiaries in locations outside Bor County and Twic East. • In Central Equatoria State, gaps include overall lack of knowledge on cholera prevention and good hygiene practices; lack of access to clean water and sanitation; lack of soap for hand washing and lack of solid waste disposal options. • In Lobonok Payam, inaccessibility of some villages due to the poor road network; inadequate health facilities; a shortage of health workers (Karpeto PHCU has only one community health worker); lack of toilets in many villages resulting to open defecation; and a high rate of illiteracy are putting the population at a high risk of cholera.

Conclusions and Recommendations Overall, cholera is on the decline countrywide. The following are the key recommendations: • Rollout targeted and comprehensive interventions to the affected villages in Lobonok Payam in Central Equatorial state and to Magwi & Kapoeta North Counties in Eastern Equatoria. • Sustain interventions to the other affected counties in the areas of case management, surveillance and laboratory, social mobilization and WASH. • Evaluate the overall response to the cholera outbreak so as to document experiences and lessons learnt for improving future response. • Update development plans to ensure that areas at high-risk for cholera are prioritised for risk communications and other evidence based interventions for improving the construction and use of appropriate sanitary facilities and improving access to safe water.

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

5 these. Send any comments and feedback to: E-mail: [email protected], The Toll free numbers for alerts are: Gemtel: 9999, Vivacell: 0952000098 and Zain: 0912000098.

Contacts For more information please contact:

Dr. John P. Rumunu Dr. Thomas Akim Ujjiga Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211955150406

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