Cholera in South Sudan Situation Report # 13 As at 23:59 Hours, 28 May 2014

Cholera in South Sudan Situation Report # 13 as at 23:59 Hours, 28 May 2014

Background

On 29 April 2014, a suspected case of cholera was reported from the MSF clinic at UN House/Juba III Protection of Civilian (PoC) camp. The previous day he had visited relatives in Gudele where he developed severe diarrhoea. One of the contacts in the household had developed acute watery diarrhea on the 24 April 2014. Following field investigations and laboratory confirmation, 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 at JTH 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 - 28 May 2014 No. Summary of cases JTH Gurei Tongping UN House Other Total CTC CTC CTC (Juba III) sites A Total new admisions today 67 25 0 0 0 92 B Total new discharges today 69 16 0 0 0 85 C Total new deaths today 0 0 0 0 0 0 D Total number of cases currently admitted 103 26 0 2 0 131 E Leave Against Medical Advice (LAMA) 15 0 0 0 0 15 F Total facility deaths since the onset of 15 0 0 0 1 16 the outbreak G Community deaths since the onset of the 0 0 0 0 11 11 outbreak H Cumulative deaths since the onset of the 15 0 0 0 12 27 outbreaks J Cumulative cases discharged 604 75 3 7 1 690 K Cumulative cases 763 101 3 9 16 892 L Number of cases with laboratory 29 0 0 1 4 34 confirmation by culture *Includes cases detected in private health facilities and at community level

§ On 28 May 2014, 92 new cases were admitted at the cholera treatment centres (CTC) in Juba and 85 cases discharged leaving 131 patients on admission in the cholera treatment centres (table 1). A total of 15 cases in JTH CTC left the isolation ward without proper discharge. This highlights the need to enhance security checks at the CTC gate.

§ Cases have been reported from nine Payams in Juba county with the most affected being Munuki 279 (31%). See table 2.

1 Table 2 Cholera cases by area of origin in Juba, 23 April - 28 May 2014 Payam Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Cases by Payam (%) Munuki 0 0 0 72 125 82 279 (31) Rejaf 1 0 0 24 73 94 192 (22) Northern Bari 1 2 0 63 70 20 156 (17) Juba 0 0 0 26 95 22 143 (16) Kator 1 0 0 14 43 25 83 (9) Missing 0 1 0 4 23 0 28 (3) Gondokoro 0 0 0 3 2 0 5 (1) Lirya 0 0 0 1 0 0 1 (0.1) Lokiriri 0 0 0 2 1 1 4 (0.4) Mangala 0 0 0 0 0 1 1 (0.1) Total by epi-week 3 3 0 209 432 245 892 (100)

§ The most affected villages include Gumbo in Rejaf, Gudele I in Munuki, Tongping in Juba, and Gudele II in Northern Bari (figure 1).

Figure 1: Cholera cases from the five most affected villages per Payam, 23 April - 28 May 2014

§ Since the beginning of the outbreak on 23 April 2014, 892 cumulative cholera cases including 27 deaths (16 institutional and 11 community deaths) with CFR= 3% 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.Two peaks of transmission were registered on 19/05/2014 and 26/05/2014. 2

Figure 2: Juba cholera epidemic curve, 23 April 2014 - 28 May 2014

§ Of the 892 cholera cases reported, majority (497, 62%) are male, and aged 20-34 years (356, 41%).

Figure 3: Distribution of cholera cases by age, Juba, 23 April - 28 May 2014

Figure 4: Number of daily admissions at the Juba CTCs, 23 April - 28 May 2014

Assessment of risk factors and possible exposure is ongoing at all locations. The main risk factors for cholera in Juba are suspected to include the following: § Drinking of untreated river water which in Juba is primarily supplied by water tankers, § Poor latrine use, lack of latrines and open defecation, § Eating foods sold on the roadside and at makeshift markets. § Poor personal hygiene practices (for example hand washing) and community hygiene. § In addition, consumption of water from unsafe sources such as surface water-river and ponds, poor community handling of dead bodies and unsupervised burials are other factors that increase the risk of the Juba community to contracting cholera.

Cholera Alerts

Table 3 Summary of cholera alerts No Date Details of the alert Area Needs/Actions taken received 1. 29/05/2014 • Five suspect Yei, Central • Taskforce has been re-activated cholera cases Equatoria • Isolation ward has been designated in including one death Yei Civil hospital • The four suspect • PSI contacted to provide water guard cases are admitted • Dissemination of cholera brochures and in Yei Civil Hospital radio messages is underway • Index case died • Rapid diagnostic test positive for cholera after he developed • Three collected samples will be sent to profuse watery Juba diarrhoea on arrival • Suspected cases have been isolated in from Juba Yei civil hospital •

4 No Date Details of the alert Area Needs/Actions taken received 2. 29/05/2014 Two bodies of Yei, Central • The Yei and Juba county surveillance suspected cholera Equatoria officers are currently investigating the community deaths have report to identify further cases and list been transferred from contacts. Juba to Yei

Response actions today Case Management § In order to decongest the JTH CTC, the case management, surveillance and laboratory working group has agreed that ambulances will now transfer some of the cholera cases to the Gurei CTC.

§ The Ministry of Health working with WHO, UNICEF, and NPA are planning to set up a cholera treatment centre in Gumbo.

§ MSF Spain is currently training health workers in Melut hospital on cholera case management and has already prepositioned cholera case management kits. A follow-up mission by MSF to Kaka revealed that no additional deaths have occurred. All drinking water is being treated and all the AWD cases in Kaka PHCC were discharged.

Surveillance and Laboratory § Five suspected cholera cases including one death were reported in Yei County, Central Equatoria State. The index case travelled from Juba to Yei on 26/05/2014 and developed symptom on 28/05/2014. He was brought to Yei Civil Hospital on the morning of 29/05/2014 but died shortly after admission. The other four cases have been isolated in Yei Civil Hospital following positive cholera RDT results. The stool samples have been sent to the national reference laboratory for culture and sensitivity.

§ The national public health laboratory isolated vibrio cholerae inaba from two samples collected from JTH and Kajo Keji in Central Equatoria state. The Kajo Keji county health has been alerted to conduct further case verification and contact identification. However, antimicrobial sensitivity testing cannot be done since there are no antimicrobial discs in the laboratory.

§ On 29/05/2014, the AMREF Laboratory in Kenya released additional cholera test results. Out of the 45 additional samples tested, 24 (53%) were positive for Vibrio cholera inaba. The isolates were sensitive to Tetracycline by resistant to Ampicillin, chloramphenicol, Nalidixic acid, and Cotrimoxazole.

§ 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 § House to house cholera prevention and control campaigns continued today in Juba, Kator and Rejaf reaching a total of 2,530 households with key messages on cholera prevention through hand washing and chlorination demonstrations. These include 630 HHs from Rejaf, 700 HHs from Juba and 1200 Hs from Kator.

§ Cholera prevention and control campaigns covered 1000 households in Gudele and 400 HHs in Lologo; a total of 8,104 households reached to date in those areas.

5 § To date, 28,944 males and 22,934 females have been reached in Munuki A, B, C and Gudele I and II with cholera prevention messages. A total of 29,222 PUR sachets for water treatment and 11,845 ORS have been distributed in the area.

§ Other community mobilization activities include: o Awareness activities in Gumbo IDPs camp. OVCI during their awareness campaign got three (3) cases of suspected cholera of them children. They immediately called the ambulance and the 3 children were transferred to Juba CTC. Tents were these sick children were disinfected by the Ambulance officers. o Street announcements and distribution of about 150 pcs of IEC materials in Gumbo and Gudele. o Mobilization using music, dance and drama in Gudele I and II markets. Four (4) drama sessions were performed on cholera prevention with average attendance of 200 persons in each session. o Music shops in strategic market points shall begin broadcasting hourly messages on cholera prevention and treatment 4 stations are in the pipeline for this activity. This will focus on the main markets of Munuki, Gudele, Juba taxi park market and Konyo konyo.

§ Training of additional 162 SSRC volunteers to be deployed in Northern-Bari Payam, Juba and Kator Block.

§ Provision of 200 cholera teacher kits to UNECO for their forthcoming training in Yei.

WASH WASH is providing water, sanitation and hygiene interventions at the Juba Hospital CTC focusing on the key areas listed below:

§ Water: Provision of 7000 litres of water for drinking and other purposes including hand washing, disinfection and general cleaning. Additional 6000 litres of chlorinated water was trucked to the CTC as a contingency measure to safeguard water gap in the hospital (CTC), through water trucking. Chlorine residual monitoring is ongoing and we shall analyze the data in due course.

§ Sanitation: Septic tank latrine with three stances is now functional. Disinfection of the latrine as well as other patient waste is conducted daily. Disinfection of visitors and patients caretakers is done daily. Garbage collection is being done in the CTC, Hence Clothes, medical waste and solid waste are being disposed in an incinerator in the Hospital, the garbage collected on daily basis volume is half a tone.

§ Health and hygiene promotion: All patients discharged from the CTC received chlorine tablets for water treatment and laundry soap. They were sensitized on water treatment and hand washing as key ways to prevent re-infection with cholera. Additionally, four patient households were disinfected.

Other WASH activities

§ In Gumbo, WASH partners distributed 264 pieces of soap, 256 pieces of filter cloth, 789 ORS, and 2,640 PuR sachets. 101 garbage sites were sprayed with chlorine, 161 HHs visited and 53 people attended hygiene promotion sessions.

§ In Ghabat, 72 households were visited and 440 people reached through house-to-house mobilization activities. PUR was distributed to 74 households and 1,070 people attended hygiene promotion sessions. In schools, 337 pupils and 7 teachers received cholera prevention messages. Garbage collection activities were conducted at schools in which

6 170 pupils and teachers participated. Three hand washing stations were set up in school.

§ In MTC, 6,000 L of clean water supplied and garbage collection is ongoing.

§ In Konyo Konyo, a two-week supply of PuR was distributed to 48 restaurants and IEC materials were distributed to 56 restaurants.

§ In Gudele, Munuki and Lologo, 7,200 PuR sachets were distributed, three hand washing stations completed and hygiene promotion sessions conducted in Gudele I, II, and Munuki markets, including demonstrations on PuR use.

§ In Tongping and Juba III, cholera prevention activities continue in both PoCs, including increased hygiene promotion activity, jerry can cleanings, monitoring of water quality, spraying of latrines and bathing shelters, foot sprays at the entrance/exit.

Current gaps § Increasing case load at JTH CTC. § Increasing number of cholera cases from Gumbo, which is relatively far from JTH. § Community engagement still needs to be strengthened in order to encourage early treatment seeking behaviour.

Planned Activities § Assessments in Gumbo to identify risk factors for cholera at household level. § Further investigation of cholera alerts reported in Yei. § NPA will conduct training on social mobilization for volunteers from the areas of Bungu, Ganji, Wonduruba, Dolo, Rokon and Tijor on 4 June 2014. § The Ministry of Health in collaboration with the WHO and Medair are planning to conduct a training for all the clinical staff in the JTH CTC. The trainings are scheduled for 30 May 2014 and 2 June 2014. § Plans are underway to set up oral rehydration points in the communities to support the early initiation of treatment of suspect cases in the communities. § 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 needs to be urgently addressed as the CTC’s bed and human resources capacity are being stretched.

7 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