Republic of South Sudan

Situation Report #92 on Cholera in South Sudan As at 23:59 Hours, 28 October 2016

Situation Update Cholera outbreaks have been confirmed in 8 (28.6%) of 28 states countrywide. The affected states include Imatong, Eastern Lakes, Jubek, Terekeka, Jonglei, Western Bieh, Northern Liech, and Southern Liech (Figure 1.0). Suspect cholera cases have been reported in Mayendit, Ayod, and Pigi (Table 4). Cumulatively 101 (38.5%) of the samples tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 28 October 2016 (Table 3). Jubek state has recorded 1952 cholera cases including 14 deaths (CFR 0.72 %). A total of 24 new cholera cases reported in Jubek State during week 43 of 2016 (Table 1 and Figure 1.1).

During the week, a new cluster of cases was reported in Gurei block 2, Northern Bari payam in Jubek. In response, surveillance, case management, social mobilization, hygiene promotion, and targeted oral cholera vaccination were initiated. Following the confirmation of cholera in Bentiu PoC on 21 October 2016, new cases continue to be reported among recent arrivals from Leer, Mayendit, Guit, Koch, and Panyijiar that were not vaccinated with oral cholera vaccine in 2015. During the week, a new cholera alert involving three suspect cases including one death was reported in Tayar, Ganyliel. Investigation and response activities have been initiated (Table 4).

The implementation of sustained and comprehensive investigation and response activities in Leer, Mayendit, and Ayod continues to be constrained by security concerns. Response to suspect cholera cases in Pigi is ongoing with a total of 83 suspect cholera cases including 13 deaths reported since 15 October 2016 (Table 4).

Table 1: Summary of cholera cases reported in South Sudan as of 28 October 2016

New New Total cases Total Reporting New deaths Total facility Total Total cases admissions discharges currently community Total cases Sites WK 43 deaths deaths discharged WK 43 WK 43 admitted deaths

Jubek – 24 11 - 13 8 6 14 1,925 1,952 Juba

Jonglei-Duk - - - - 5 3 8 77 85

Terekeka - - - - - 8 8 14 22

Eastern Lakes - - - - - 1 2 3 326 329 Awerial Imatong ------1 1 28 29 Pageri Western Bieh - 5 - - 2 4 - 4 210 216 Fangak Northern Liech - 11 - - 1 - - - 23 24 Rubkona Southern ------28 28 Liech - Leer

Total 40 11 - 16 18 20 38 2,631 2,685

Twenty of twenty-three (90%) ORPs set up are submitting case line list data countrywide. Cholera cases have been reported in seven special populations (Bentiu PoC, UN House PoC, Tongping UNMISS transit site, Gorom Refugee camp, Mahad IDPs, Mangatain IDPs, and among IDPs in Gumbo) in Juba. The Tongping UNMISS transit site has reported 50 cholera cases with one confirmed case and no death, while the UN House PoC has recorded 93 cholera cases with 6 confirmed cases and no death. Cholera transmission in these populations has now been contained.

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On 24 August 2016, cholera was confirmed in Mingkaman IDP settlement after two of four samples tested postive for Vibrio cholerae Inaba. The cumulative cases are 329 cholera cases including 15 confirmed cases and 3 deaths (one facility and two community) (CFR 0.91 %). On 28 October 2016, there was no new case in Mingkaman.

Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 28 October 2016

World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24-42, 2016

Map Date: 21 October, 2016 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 Canal/Pigi Aweil West 1.98 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Tonj North Ayod Leer Mayendit Ethiopia Tonj East Duk Uror Akobo Jur River Rumbek NorthPanyijiar 10.39 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Nagero Bor South Yirol West Awerial Pibor Wulu Tambura 0.91 Mvolo Legend Terekeka xx Case fatality rate (CFR) 36.4 Counties with Cholera alert Mundri WestMundri East Lafon Kapoeta North Cases per 10,000 population Ezo Ibba Maridi Kapoeta East Juba 40.1 - 50 Yambio Nzara 0.73 20.1 - 40 Kapoeta South 10.1 - 20 Torit Budi Yei Lainya 5.1 - 10 Magwi Ikotos 0.1 - 5 Kajo-Keji 3.45 Kenya No case reported Morobo Pageri River Democratic Republic of Congo Uganda

Figure 1.1: New cholera cases admitted by location in week 43 of 2016

20 18 18 16 14 11 12 10 8 5 6

Number of Cases 3 4 2 1 2 0 0 0 0 0 0 0 0 0 0 0 0 Puluk Dongchak Kator Juba Rejaf Munuki Northern Kator Nimule Terekeka New Old Thonyor Yang Bentiu Kalja Piliny Bari Fangak Fangak PoC Eastern Jonglei Jubek Imatong Terekeka Western Bieh Southern Liech Northern Liech Lakes

In Jonglei state, 85 suspected cholera cases including 8 deaths (CFR 9.41 %) have been reported from Duk County involving mainly 3 Islands namely Kawer, Long, and Moldova with the date of onset of index case on the 3rd July 2016. Of the five samples from Duk Islands that underwent culturing, one sample from Moldova Island,

2 also the most affected, was confirmed as cholera on 29 July 2016. The most recent cases reported in Duk originated from Moldova and Koyom Islands on 21st Oct 2016.

Figure 1.2: Cumulative cholera cases by payam of residence as at 28 October 2016

700

595 600

500 460

400 347 329 310 Number of Cases 300

199 200 175

83 100 36 35 22 15 17 15 7 1 1 3 2 4 2 1 1 1 3 1 3 1 1 1 1 2 11 0 Toch kalja Yang Buko Rejaf Piliny Kator Puluk Lwoki Padiat Paguir Lokiliri Pageet Nimule Munuki Uganda Nhialdu Thonyor Dhorbor Nyarjwa Mareang Terekeka Mangalla Dongchak Kolanyang Juba Town Leer Town Gondokoro Bentiu PoC Old Fangak Bentiu Town New Fangak Northern Bari Eastern LakesImatong Jonglei Jubek Terekeka Western Bieh Northern Liech Southern Liech

Terekeka has reported 22 cases of cholera including 8 deaths (CFR 36.4%) with 2 samples confirmed by the laboratory to be cholera.The most of the recent cases are from Kuda village, Lwoki payam, Nyori county on 22 September 2016. No additional cases have been reported since then.

As of 28 October 2016, a cumulative of 29 cholera cases including four laboratory confirmed cases and one death (CFR 3.45%) have been reported from Nimule in Imatong state since 15 August 2016.The afffected locations in Imatong state include Abila,Malakia and Motoyo. The last cholera case in Nimule was admitted in Nimule hospital on 29 Sept 2016 and discharged on 2 Oct 2016.

The cholera outbreak in Western Bieh state was confirmed on 22 September 2016 after two of four samples tested positive for Vibrio cholerae inaba. The initial cases were reported on 10 August 2016 in Old Fangak. The cumulative cases are 216 cholera cases including 5 confirmed cases and 4 deaths (4 facility and zero community) (CFR 1.85%). As of 28 October 2016, the affected areas include Old Fangak (175 cases); New Fangak (35q cases); Mareang (1 case); Paguir (1 cases); Toch (3 cases); and Kolanyang (1 case) (Figure 1.2).

Table 1.1: Cholera cases and deaths by state and county as of 28 October 2016 Week 43 Weeks 24-43 Cases per Cases Population New cases 10,000 No. per State County at risk W43 population cases 10,000 CFR[%] Western Bieh Fangak 139,509 5 0.36 216 15.5 1.85 Northern Liech Rubkona 126,976 11 0.87 24 1.9 - Southern Liech Leer 67,167 0 - 28 4.2 - Eastern Lakes Awerial 114,837 0 - 329 28.6 0.91 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Duk 26,180 0 - 85 32.5 9.41 Jubek Juba 471,762 24 0.51 1952 41.4 0.72 Terekeka Terekeka 177,849 0 - 22 1.2 36.4 Total 1,339,410 40 0.30 2685 20.0 1.42

In Northern Liech state, 24 cholera cases including 4 confirmed cases and no death have been reported in Bentiu Town/PoC since 29 September 2016. The cholera taskforce, chaired by MoH and constituted by Health and WASH cluster partners is coordinating the response. The new cases in Bentiu are largely reported among recent arrivals from Leer, Mayendit, Koch, Panyijiar, and Guit that did not receive oral cholera vaccine in 2015.

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In Southern Liech, two cholera cases originating from Leer Town have been confirmed. The samples tested positive for Vibrio cholerae Inaba on 11 October 2016. Cumulatively, 28 cholera cases have been reported from Leer in Southern Liech state. Since 7 October 2016, at least 35 suspect cholera cases including three deaths have been reported by UNIDO response team in Mayendit. The implementation of sustained and comprehensive response activities in Leer and Mayendit has been constrained by security concerns.

Cumulatively, 2,685 cholera cases including 38 deaths (24 facilities and 14 community) (CFR 1.42%) have been reported in South Sudan involving 8 states since the initial case was reported on 18 June 2016 for Jubek state; 3rd July 2016 in Jonglei state; 14 July 2016 for Terekeka state, 15 August 2016 for Eastern Lakes and Imatong states; 10 August 2016 for Fangak in Western Bieh state; 29 September 2016 for Rubkona in Northern Liech state; and 6 October 2016 for Leer in Southern Liech state (Figure 2.1 and Table 1.1). Jubek state has registered the highest attack rate while Terekeka reported the highest CFR (Table 1.1).

As seen from Figure 2.1 increasing community transmission was established in Juba from week 26 of 2016. Low grade transmission is ongoing in Jubek, Western Bieh, Northern Liech, and Southern Liech (Fig. 2.1).

Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 28 October 2016

350 21.1%

300 20% 16.9% 250 15% 200 315

313 CFR % 150 10% Number of cases 216 100 180 184 186 165 3.3% 5% 50 1.5% 1.4% 101 1.4% 1.6% 35 0.9% 1.0% 97 0.8% 0.3% 0.4% 0.4% 0.0% 0.0% 0.0% 0.0% 43 0.0% 0.0% 0.0% 1 22 22 31 12 24 0 1 4 0% 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Epidemiological week of onset Jonglei Jubek Terekeka Imatong Eastern Lakes

Western Bieh Northern Liech Southern Liech CFR[%]

Figure 3:1 Cholera case distribution by gender and age in Jubek State 28 October 2016 300 Cholera - age and sex distribution Jubek up to 28 Oct 2016 250

200 158 154 134 113 150 134 71 89

Number of Cases 100 54 59 48 50 107 97 102 102 77 78 39 46 58 62 21 34 21 15 10 12 0 10 15 4 8 57 3 Under 2 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Adult

Female Male

Out of the 1952 cholera cases in Jubek State, 829 (42.5%) were female, while 1123 (57.5%) were male

4 Figure 3:2 Cholera case distribution by gender and age in Jonglei State 28 October 2016

18

16

14

12

10

8 9

Number of Cases 6 10 2 4 8 1 2 1 7 5 7 2 3 2 4 7 2 1 2 1 0 Under 2 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Adult

Female Male

Data on Age missing for 11 cases

Out of the 85 cholera cases, in Jonglei State 39 (45.9 %) were female, while 46 (54.1%) were male

Figure 3:3 Cholera case distribution by gender and age in Eastern Lake State 28 October 2016

80 70 60 50 40 39 30 50 14 Number of Cases 20 25 9 11 14 6 10 9 1 4 6 16 23 30 14 20 15 7 14 3 24 0 Under 2 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60

Female Male

Out of the 329 cholera cases, in Eastern Lake State 142 (43%) were female, while 187 (57 %) were male.

Figure 3:4 Cholera case distribution by gender and age in Western Bieh State 28 October 2016

50 45 Cholera - age and sex distribution Western Bieh up to 28 Oct 2016 40 35 23 30 10 25 8 4 20 4

Number of Cases 15 4 10 21 23 22 4 20 5 16 8 5 9 10 2 6 1 4 0 3 10 1 2 10 1 10 0 Under 2 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Adult Blank

Female Male

Out of the 216 cholera cases, in Western Bieh State 141 (65.3 %) were female, while 75 (34.7 %) were male.

5 Figure 3:5 Cholera case distribution by gender and age in Southern Liech State 28 October 2016

10 9 Cholera - age and sex distribution Southern Liech up to 28 Oct 8 7 0 2016 6 5 4 0 3 0 Number of Cases 2 8 1 0 1 6 0 01 02 3 2 01 0 0 01 01 01 0 01 0 Under 2 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+

Female Male

Out of the 27 cholera cases, in Southern Liech State 12 (44 %) were female, while 15 (56 %) were male.

Table 2: Case distribution by gender in South Sudan 28 October 2016 State Female Male Total cases Eastern Lakes 142 187 329 Imatong 13 16 29 Jonglei 39 46 85 Jubek 829 1,123 1,952 Terekeka 13 9 22 Western Bieh 141 75 216 Northern Liech 13 11 24 Southern Liech 12 16 28 South Sudan 1,202 1,483 2,685

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.

Laboratory updates

Table 3: Cholera laboratory test results for Juba 28 October 2016

Culture results State Positive Negative Total tested Eastern Nile 0 5 5 Jonglei 1 4 5 Jubek 64 110 174 Terekeka 2 0 2 Eastern Lakes 16 21 37 Imatong 7 1 8 Fangak 5 7 12 Wau 0 6 6 Boma 0 2 2

6 Culture results State Positive Negative Total tested Northern Liech 4 2 6 Southern Liech 2 0 2 Eastern Nile 0 3 3 (Pigi) Total tested 101 161 262

Table 4: Cholera Alerts – Date of Details of the alert Area Action notification No alerts 13-Sept-2016 COSV reported suspect cholera Haat Islands, Ayok COSV evacuated Ayod; MedAir to cases in Haat Islands, Ayok county, Southern Bieh travel to Ayod on 20 Oct 2016 county, Southern Bieh state state Assessment report expected from the team soon. 8- Oct-2016 UNIDO reported four suspect Thaker, Tutnyang, & WHO and UNICEF supported UNIDO cholera cases including one Leah Payams, Mayendit with case investigation and death North, Southern Liech management supplies to facilitate the state investigations and response to the alert. 19-Oct-16 Since 15 Oct 2016 suspect Kurwai, Pigi By 24 Oct; NHDF reported at least 94 cholera cases were reported in suspect cases 13 deaths (5 Facility Kurwai PHCU that is supported and 8 community) with 13 inpatients. by NHDF and by 19 Oct 2016 MSF-F will train NHDF staff on cholera the cases had risen to 83 case management. Supplies donated suspect cholera cases with 12 by WHO, UNICEF to support response deaths (5 health facility and 7 community) 26-Oct-16 IRC reported 3 suspect cholera Ganyliel, Tayar, Southern Partners meeting involving Mercy cases including one death in Liech corps, IRC, GAA, and ICRC organized Ganyliel. Two cases seen at on 26 Oct 2016 to initiate a Ganyliel PHCC. Initial case seen coordinated response. on 22 Oct 2016 involving a trader from Duk WHO supported ICRC to verify and respond to the cases.

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. Security concerns have remained a major impediment to the implementation of sustained and comprehensive cholera investigation and response activities in Leer, Mayendit, and Ayod.

Cholera case management is ongoing at the designated cholera treatment facilities in the seven affected states. As cases decline, laboratory surveillance has been strengthened to ensure that all suspect cholera cases undergo rapid diagnostic testing and stool culturing to confirm cholera. WHO has therefore supported the partners operating cholera treatment facilities with ample supplies for sample collection, onsite rapid diagnostic testing, and shipment to the National Public Health Laboratory for culturing.

WHO is supporting the cholera investigation and response activities in all the eight affected states and three states with alert suspect cases. Core to WHO’s support to the current cholera response is technical support to the taskforce committees by providing updated situation reports; supporting the investigation and testing of suspect cases; support towards case management activities through trainings on cholera case management protocols; recommending tailored strategies in response to emerging trends; and support for the outbreak

7 evaluation process that is already underway. WHO technical officers are currently deployed in Mingkaman; Bentiu, Bor, Malakal, Imatong, and Juba to support the ongoing response activities.

During week 43, WHO trained 18 Health Link South Sudan (HLSS) on the use of oral cholera vaccines as part of the reactive and targeted approach to emerging clusters of cholera transmission in Juba. The immediate assignment of the trained volunteers entailed conducting targeted vaccination in Gurei Block 2 and 4 where a new cluster of cholera cases emerged during the week. The training was conducted on 25 October 2016 and the training content included: presentations on the epidemiology and management of cholera; the integrated approach for cholera response in South Sudan that includes surveillance; social mobilization; oral cholera vaccination; WASH; and overall coordination and logistics; a presentation on the use of oral cholera vaccines to prevent and control cholera; and finally a demonstration on how to set up an immunization post and the administration of oral cholera vaccine.

The HLSS team subsequently conducted targeted ring vaccination with oral cholera vaccine in Gurei block 2, 4, and 7. A total of 3,311 individuals were vaccinated during the two-day campaign in block 1, 2 and 7. The coverage is estimated at 67.1% of the planned target. In addition, Gurei Nursery/Primary School and Standard Nursery/Primary School located in Block 2 were directly served. Block 7 was covered through Eloi Primary School. During the campaign, WASH supplies were simultaneously distributed. A total of 1,600 bars of soap, 14,400 tablets of Aquatab, 10,080 Sackets of PUR and 2,000 Sackets of ORS were distributed.

UNICEF continues to support the Cholera response at the community level across all relevant sectors of Health, WASH, and C4D through active partnerships with following implementing partners: Health Link South Sudan (HLSS), LiveWell, ACROSS, CAPIAD, THESO, BEDN, IMC, RUWASSA, SMC, NHDF, and ARUDA. UNICEF continues to support 20 active Oral Rehydration points across Jubek, Mingkaman, and Nimule while standby ORPs in other previously identified high risk areas are in place. This includes areas in Yei, Kajo-keji, Torit, Lafon, Ikotos, and Wau Shiluk. New ORPs and CTUs are to be set-up in Leer, New Fangak, and Pigi.

In Rubkona, UNICEF continues to support the coordination through the state cholera task force. Adequate supplies have also been prepositioned to support response in case the outbreak escalates. Health staff are being deployed next week to support the response in Bentiu. In addition, PCA with World Relief is being expedited to be able to support the facility in Kuach which receives people from Southern Liech.

In Juba, the WASH/Health teams intensified their interventions in Gurei Block 2 and 4 where a number of cases have recently been reported. Nearly 4,000 people benefitted with the distribution of WASH commodities (soap, Aquatabs, and PUR). The Gurei ORP, supported by UNICEF through HLSS, is still in place and is supporting the management and referral of cases.

Unicef has also committed to support the ORPs in Juba where transmission is still active through HLSS till the end of November 2016.

As of week 43 of 2016, ACROSS with 34 volunteers in Gorom refugee camp has visited a cumulative of 4139 households where they reached 8,166 people; visited five schools reaching 1,263 pupils; conducted 16 community meetings reaching 1,641 people; three market sessions reaching 61 market vendors; 24 water point sessions reaching 429 people; two public announcements reaching 81 people; distributed 1243 IEC materials and 20 banners; distributed 6,462 Aquatabs; 3,718 bars of soap; and 4,927 sachets of ORS.

As of week 43 of 2016, HLSS with 37 hygiene promoters in Nyakuron, Munuki, Khor William, Gurei, Lologo 1, Mahad, Gumbo and Kator reached a cumulative of 55,196 households reaching 184,802 females and 171,935 males and distributed 67,990 chlorine tablets; 24,606 PuR sachets; 54,613 soaps; and 49,119 sachets of ORS sachets in Jubek. The volunteers have also visited 16 schools reaching 7,028 pupils; conducted 32 community meetings reaching 2,733 individuals; 21 market sessions reaching 1,624 market vendors; three water point sessions reaching 50 people; and distributed 962 posters and eight banners with messages on cholera prevention and control.

In Fangak, MSF France has established a 20-bed capacity CTC in Fangak town to manage cholera cases. The health and WASH clusters have mobilized additional partners – Hold the Child and ACF to support the community interventions including establishment of ORPs, community health education, hygiene promotion and support for personal hygiene and chlorination of water at water collection points.

8 In Bentiu, the weekly cholera taskforce meetings take place weekly on Wednesdays to coordinate preparedness and response activities. Activities in progress include the following:

Bentiu (PoC, Rubkona and Bentiu town) 1. ORPs set in all the health facilities in Bentiu PoC. 2. Refresher training on cholera case management, surveillance, and prevention conducted for health workers and social mobilizers. 3. Social mobilization is ongoing in Bentiu PoC and Bentiu Town. 4. Screening of new arrivals at Bentiu PoC entrance and roads entering to Rubkona and Bentiu towns is ongoing. 5. Plans have been put in place to start a CTC should the situation escalate.

In Thonyor, Southern Liech. • Active case finding and management is ongoing • Community awareness has been enhanced to interrupt transmission. • An ORP has been established at Tothriak with outreaches in Tochtel, Tochthil and Chulung villages. • Supplies from WHO and UNICEF were received two days ago support the response in Southern Liech.

Security concerns continue to be the main impediment for a sustained and comprehensive response in Leer and Mayendit.

Response Activities in Nimule, Torit, and Lafon

Overall coordination of the cholera response is undertaken by the cholera taskforce in Nimule that is chaired by the County Health Department and meets every Tuesday and reports to the cholera taskforce in Torit that meets every Wednesday.

Active case surveillance along Nimule – Uganda boarder and promotion of hand washing ongoing at the established ORP site targeting individuals entering South Sudan from across Ugandan boarder

House-to-house social mobilization activities are on-going in Nimule town through a network of trained HHPs, key messages passed include; promotion on hand washing, safe water, food hygiene, safe sanitation, cholera symptom awareness.

As of week 43, the HLSS team of 26 volunteers in Imatong has visited a cumulative of 18,737 households and reached 154,062 Females and 251,420 Males in Lopa, Loronyo, Lohutok, Hilieu, Hiyala, Imurok, Magwi, Nimule, Melijo, Parjok, Opari. A total of 180,398 chlorine tablets; 29,276 PuR sachets; 99,901 soaps, and 1,197 ORS sachets have been distributed. Public / street awareness was conducted using public address system to continue disseminating cholera preventive.

Other interventions

In Mingkaman, Cholera Task Force meeting in Mingkaman continues to be conducted twice a week to review trends and progress of interventions. Case management is ongoing at the site II CTU and 4 ORPs. House to house mobilization by home hygiene promoters and Radio messaging are still ongoing in Mingkaman.

In Mingkaman, WHO has deployed Technical Officers to support the overall coordination of cholera response activities. HLSS South Sudan is now running the CTC in Mingkaman. Cholera transmission is now contained in Mingkaman IDP settlement.

In the whole Country A total of 17 radio channels continue to air cholera messages country-wide (Juba, Yei, Kajo-Keji, Torit, Bor, Bentiu, Mingkaman and Wau) reaching 2 million audiences per day. MTN, a mobile telecommunications carrier is broadcasting key cholera messages to all its subscribers once a day.

Planned Activities 1. The next cholera coordination meeting in will be held in Juba Teaching Hospital on 31 October 2016 starting 11:00am in Juba Teaching Hospital.

9 2. The next weekly cholera taskforce meeting is scheduled for 2 November 2016 starting 2:00pm in the WHO Conference Hall. 3. Continue social mobilization activities, active case surveillance, and street announcements with open van, house to house awareness and distribution of WASH supplies by HHPs in affected and at risk areas. 4. Negotiate for security access to allow humanitarian access for partners to implement cholera investigation and response activities in Ayod, Mayendit, and Leer. 5. Respond to the new suspect cholera alerts in Kurwai, Pigi; and Tayar, Ganyliel.

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

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