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. 1 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. 3 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).