Republic of South Sudan

Situation Report #101 on Cholera in South Sudan As at 23:59 Hours, 29 December 2016

Situation Update Cholera outbreaks were confirmed in 9 (32%) of 28 states countrywide. The affected states include Imatong, Eastern Lakes, Jubek, Terekeka, Jonglei, Western Bieh, Northern Liech, Southern Liech; and Eastern Nile (Table 1 and Figure 1.0). Suspect cholera cases were reported in Mayendit, Panyijiar, and Ayod (Table 4). Cumulatively 139 (34.6 %) of the samples tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 29 December 2016 (Table 3). Jubek state has recorded 2,006 cholera cases including 27 deaths (CFR 1.35 %). No new cholera case was reported in Jubek State during week 51 of 2016 (Table 1 and Figure 1.1).

Table 1: Summary of cholera cases reported in South Sudan as of 29 December 2016

New New New Total cases Total Reporting Total facility Total cases Total admissions discharges deaths currently community Total deaths Sites deaths discharged cases WK 51 WK 51 WK 51 admitted deaths

Jubek – - - - - 8 19 27 1,979 2,006 Juba

Jonglei-Duk - - - - 5 3 8 84 92

Terekeka - - - - - 8 8 14 22

Eastern Lakes - - - - - 1 3 4 349 353 Awerial Imatong ------1 1 28 29 Pageri Western Bieh - - - - - 4 - 4 266 270 Fangak Northern Liech - 101 98 - 30 6 2 8 759 797 Rubkona Southern - - - - 3 - 3 86 89 Liech - Leer

Eastern Nile 5 168 - Pigi 5 163

Total 101 98 - 30 32 36 68 3,728 3,826

Active transmission is ongoing in Bentiu PoC where: 1. Cases have been on the increase since week 41 with 101 new cases reported in week 51. 2. Nearly 80% of the cases are children under 14 years of age (Annex 1). 3. New cases in recent arrivals from Guit, Leer, and Koch. 4. More women are affected than males possibly due to their traditional domestic chores (Annex 1). 5. The sectors neighboring the waste water pond also have the highest attack rate of cholera (Annex 1). 6. The 12 blocks which closely border this pond registered 25% of cholera cases (Annex 1). 7. The epidemic curve denotes continuous source outbreak that is consistent with exposure to water from the pond (Annex 1). 8. Tailored recommendations considering the current trends in Bentiu PoC

1 In Southern Liech (Leer and Mayendit), the response is led by UNIDO although implementation of sustained and comprehensive investigation and response activities continues to be constrained by security concerns. In Pigi, Eastern Nile state, transmission has been contained with the last four cases discharged from Kurwai PHCC on 15 November 2016. Cholera was confirmed in Pigi after two cases tested positive by culture on 2 November 2016. A least 163 cases including 6 deaths (5 health facility and one community) (CFR 2.98%) were reported since 10 October 2016. Health and WASH activities in Pigi are led by NHDF supported by WHO, UNICEF, and MSF-F.

Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 29 December 2016

World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24-49 2016

Map Date: 16 December, 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 Pigi Aweil West 1.10 2.98 1.48 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Tonj North Leer Ayod Mayendit 2.38 Ethiopia Tonj East Duk Uror Akobo Jur River Rumbek NorthPanyijiar 8.7 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Nagero Bor South Yirol West Awerial Pibor Wulu Tambura 1.14 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 1.35 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 51 of 2016

120 101

90

60

30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of Cases 0 Puluk Abuyung Dongchak Kator Juba Rejaf Munuki Northern Nimule Terekeka New Fangak Old Fangak Toch Thonyor Yang Rubchar Dhoryiel Bentiu PoC Bentiu Town Piliny Bari

Eastern Lakes Jonglei Jubek Imatong Terekeka Western Bieh Southern Liech Northern Liech

In Eastern Lakes state, cholera cases were reported in Mingkaman IDP settlement. The initial cases were confirmed on 24 August 2016, after two of four samples tested postive for Vibrio cholerae Inaba. The cumulative cases are 353 cholera cases including 17 confirmed cases and 4 deaths (one facility and three community) (CFR 1.13 %). This outbreak has been controlled with only sporadic cases being reported – the most recent being admitted on 16 December 2016.

In Jonglei state, 92 suspected cholera cases including 8 deaths (CFR 8.7 %) were reported from Duk County involving mainly the three Islands of Kawer, Long, and Moldova. The index case was reported on 3rd July 2016 from Moldova Island. Of the five samples from Duk Islands that underwent culturing, one sample from Moldova Island, also the most affected, was confirmed as cholera on 29 July 2016. The most recent cases reported in Duk originated from Koyom Island on 10 Nov 2016. No additional cases were reported since then.

2 Figure 1.2: Cumulative cholera cases by payam of residence as at 29 December 2016

900 788 800

700 606 600

500 470

400 351 358 320 Number of Cases 300 210 219 200 167 90 100 22 37 42 27 40 2 7 1 1 3 2 4 2 1 15 1 1 5 1 1 7 1 1 2 13 1 1 3 1 1 1 0 Yang Toch Buko Rejaf Piliny Kator Yamg Puluk Adok Lwoki Leer Padiat Paguir Lokiliri fangak kurwai Pageet Nimule Khaigai Munuki Uganda Rubchar Nyarjwa Thonyor Dhorbor Dhoryiel Abuyung Mareang Terekeka Mangalla Dongchak Kolanyang Leer Town Juba Town Gondokoro Bentiu PoC Old Fangak Bentiu Town New Fangak Northern Bari Dhuorguol Deng Eastern Imatong Jonglei Jubek Terekeka Western Bieh Northern Liech Southern Liech Eastern Lakes Nile

Terekeka state has reported 22 cases of cholera including 8 deaths (CFR 36.4%) with 2 samples confirmed by the laboratory to be cholera. All the deaths were reported at the onset of the outbreak from Islands on River Nile where access to health services is poor. No additional deaths occurred after the rapid response team was deployed. The most of the recent cases originated from Kuda village, Lwoki payam, Nyori county on 22 September 2016. No additional cases were reported since then.

In Nimule, Imatong state, a cumulative of 29 cholera cases including four laboratory confirmed cases and one death (CFR 3.45%) were reported from 15 August 2016.The afffected locations in Imatong state included 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. No additional cases were reported since then.

Table 1.1: Cholera cases and deaths by state and county as of 29 December 2016 Week 51 Weeks 24-51 New Cases per Cases per Population cases 10,000 10,000 State County at risk W51 population No. cases population CFR [%] Western Bieh Fangak 139,509 0 - 270 19.4 1.48 Northern Liech Rubkona 126,976 101 7.95 797 62.8 1.00 Southern Liech Leer 67,167 0 - 89 13.3 3.37 Eastern Lakes Awerial 114,837 0 - 353 30.7 1.13 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Duk 26,180 0 - 92 35.1 8.7 Jubek Juba 471,762 0 - 2,006 42.5 1.35 Terekeka Terekeka 177,849 0 - 22 1.2 36.4 Eastern Nile Pigi 125,496 0 - 168 13.4 2.98 Total 1,464,906 101 0.69 3,826 26.1 1.78

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 270 cholera cases including 13 confirmed cases and 4 deaths (4 facility and zero community) (CFR 1.48%). As of 29 December 2016, the affected areas included Old Fangak (217 cases); New Fangak (42 cases); Mareang (1 case); Paguir (1 cases); Toch (3 cases); and Kolanyang (1 case) (Figure 1.2). Three cases were reported from Old Fangak in week 48 of 2016.

In Northern Liech state, 797 cholera cases including 22 confirmed cases and eight deaths (CFR 1.00%) were 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 children under two years and in individuals that arrived from Leer, Mayendit, Koch, Panyijiar, and Guit after the 2015 oral cholera vaccine campaign in Bentiu PoC. Over 90% of cholera cases in Bentiu PoC did not receive oral cholera vaccine (Annex 1). Ongoing transmission is suspected to be associated with exposure to an unsecured water reservoir whose water is used for washing, bathing, swimming, and occasionally for domestic use. Bentiu PoC now has the highest cumulative incidence for cholera (Table 1.1).

3 In Southern Liech, two cholera cases originating from Leer Town tested positive for Vibrio cholerae Inaba on 11 October 2016. Cumulatively, 89 cholera cases were reported from Leer in Southern Liech state. Since 7 October 2016, at least 86 suspect cholera cases including three deaths were 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.

To improve access to timely rehydration, at least twenty of twenty-three (90%) oral rehydration points (ORPs) were set up and are submitting case line list data countrywide. Cholera cases were 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. The Tongping UNMISS transit site reported 50 cholera cases with one confirmed case and no death, while the UN House PoC has recorded 96 cholera cases with 6 confirmed cases and no death.

Cumulatively, 3,826 cholera cases including 68 deaths (32 facilities and 36 community) (CFR 1.78%) were reported in South Sudan involving 9 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 and state; 29 September 2016 for Rubkona in Northern Liech state; October 2016 for Leer in Southern Liech state; and 10 October 2016 for Pigi in Eastern Nile state (Figure 2.1 and Table 1.1).

As seen from Figure 2.1 there was a spike in cholera transmission in weeks 43-51 that was attributed to transmission in Bentiu PoC where most cases originate from sectors 1, 2, and 3 in blocks that are surrounding a water retention reservoir (Annex 1). Bentiu PoC now has the highest cumulative incidence for cholera.

Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 29 December 2016

350

21.1% 300 20%

250 16.9% 15% 200 316 316 150 10% CFR %

Number of cases 217 100 181 185 168 189 5% 50 3101.3% 97 3.6% 35 2.8% 2.6% 2.1% 2.0% 1 1.9% 1.4%1 .6% 1.434% 1.6% 31 1.7%1 .6%1 .6% 0.6%0 .9% 0.228% 22 12 28 1.180% 13 0 0.10%0 .0%0 .04% 0.4% 0.0%0 .0% 0.0% 5 1 0.0% 0.0% 0% 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Epidemiological week of onset Jonglei Jubek Terekeka Imatong Eastern Lakes Western Bieh Northern Liech CFR[%] Southern Liech Eastern Nile

Figure 3:1 Cholera case distribution by gender and age in Jubek State 29 December 2016

300 Cholera - age and sex distribution Jubek up to 29 Dec 2016 250

200 161 154 135 150 141 118 76 100 92 59 59 Number of Cases 110 48 50 81 100 80 107 102 39 46 58 64 35 16 22 0 21 10 17 104 138 57 3

Female Male

Out of the 2006 cholera cases in Jubek State, 851 (42.4%) were female, while 1155 (57.6%) were male

4 Figure 3:2 Cholera case distribution by gender and age in Jonglei State 29 December 2016 20 Cholera - age and sex distribution Jonglei up to 29 Dec 2016

15

10 10 1 12

Number of Cases 2 5 8 1 2 2 7 5 7 3 4 2 4 7 2 1 1 3 3 1 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 92 cholera cases, in Jonglei State 40 (43.5 %) were female, while 52 (56.5%) were male

Figure 3:3 Cholera case distribution by gender and age in Eastern Lake State 29 December 2016

100 Cholera - age and sex distribution Eastern Lakes up to 29 Dec 2016 80

60

40 39 50 27 16 Number of Cases 9 12 20 14 17 7 6 7 17 23 30 14 20 15 9 14 31 1 34 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 353 cholera cases, in Eastern Lake State 151 (42.7 %) were female, while 202 (57.2 %) were male.

Figure 3:4 Cholera case distribution by gender and age in Western Bieh State 29 December 2016

60 Cholera - age and sex distribution Western Bieh up to 29 Dec 2016 50 40 29 30 9 10 5 5 20 11 5 Number of Cases 10 22 24 22 23 5 24 14 8 12 2 10 0 6 0 0 4 5 1 21 1 21 3 1

Female Male

Out of the 268 cholera cases, in Western Bieh State 174 (65 %) were female, while 94 (35 %) were male.

5 Figure 3:5 Cholera case distribution by gender and age in Southern Liech State 29 December 2016

25 Cholera - age and sex distribution Southern Liech up to 29 Dec 2016 20

15 14 10 5 2 2

Number of Cases 4 5 3 2 2 6 9 8 4 3 13 5 2 05 10 02 01 3 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 89 cholera cases, in Southern Liech State 42 (47.2 %) were female, while 47 (52.8 %) were male.

Figure 3:6 Cholera case distribution by gender and age in Northern Liech State 29 December 2016

200 Cholera - age and sex distribution Northern Liech up to 29 Dec 2016 160

120 72 92 78 80 48

Number of Cases 3 40 5 7 14 2 2 5 80 83 79 39 30 21 28 21 29 6 9 40 12 23 52 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 797 cholera cases, in Northern Liech State 454 (57 %) were female, while 343 (43 %) were male.

Figure 3:7 Cholera case distribution by gender and age in Eastern Nile State 29 December 2016

Cholera - age and sex distribution Eastern Nile up to 29 Dec 2016 40

23 20 6 10 14 4 3

Number of Cases 7 14 13 11 16 5 6 10 13 23 25 12 21 1 0 1 0

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

Female Male

Out of the 168 line listed cholera cases, in Eastern Nile State 85 (50.6 %) were female, while 83 (49.4 %) were male.

6 Table 2: Case distribution by gender in South Sudan 29 December 2016 States Female Male Total cases Eastern Lakes 152 201 353 Imatong 13 16 29 Jonglei 40 52 92 Jubek 851 1,155 2,006 Terekeka 13 9 22 Western Bieh 176 94 270 Northern Liech 454 343 797 Southern Liech 42 47 89 Eastern Nile 85 83 168 Total deaths 1,826 2,000 3,826

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 by 29 December 2016 Culture results State New positives in Cumulative Cumulative Total tested week 51 Positive Negative Eastern Nile 0 0 5 5 Jonglei 0 1 4 5 Jubek 0 73 126 199 Terekeka 0 2 0 2 Eastern Lakes 0 17 38 55 Imatong 0 7 1 8 Fangak 0 13 29 39 Wau 0 0 6 6 Boma 0 0 2 2 Northern Liech 6 22 47 49 Southern Liech 0 2 0 2 Eastern Nile (Pigi) 0 2 5 7 Total tested 00 139 263 402

Table 4: Cholera Alerts – Date of Details of the alert Area Action notification No alerts 13-Sept- From 14-17 Nov, the MedAir Wiechdeng, Ayok MedAir responded to suspect cholera 2016 team responded to 78 suspect county, Southern cases in Wiechdeng by setting up a 10 cholera cases including 15 Bieh state bed CTU. deaths in Wiechdeng, Ayod. Recent assessments by MedAir show One case tested positive on there is no active transmission in Pagil; cholera RDT. Haat; and Wiechdeng.

7 8- Oct-2016 UNIDO reported 86 suspect Bhor, Thaker, UNIDO is the healthcare partner cholera cases including three Tutnyang, Madol responding to suspect cases in deaths 1, Leah, Dablual, Mayendit. Security concerns have Rubchay, and constrained comprehensive and Malkuer Payams, sustained interventions. Mayendit North, Southern Liech state 26-Oct-16 In Panyijiar 242 suspect cholera cases Ganyliel, Tayar, Nyal, Facility and community based response is ongoing including 3 deaths were reported in Panyijiar, Southern with cases being managed in Ganyliel PHCC with Ganyliel (115 cases); Nyal (127 cases); Liech support from IRC and Nyal PHCC. Laboratory Tayar. Of these, 58 cases including confirmation of cases is still pending. three deaths reported by Ganyliel PHCC. The initial case seen on 22 Oct 2016 involving a trader from Duk. Cases have also been reported in Nyal PHCC (70 cases in total since 27 Oct 2016).

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 and Mayendit.

Cholera case management is ongoing at the designated cholera treatment facilities in the nine affected states. As cases decline in the affected areas, 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 nine affected states and the two 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 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.

UNICEF continues to support the Cholera response at the community level across all relevant sectors of Health, WASH, and communication through active partnerships with following implementing partners: Health Link South Sudan (HLSS), LiveWell, ACROSS, CAPIAD, THESO, BEDN, IMC, RUWASSA, SMC, NHDF, UNIDO, World Relief, and ARUDA.

Security concerns continue to be the main impediment for a sustained and comprehensive response in Leer and Mayendit. In Panyijiar; at least 242 suspect cases including three deaths were reported in Ganyliel (115 cases); Nyal (127 cases); and Tayar. WHO and UNICEF have supported IRC, UNIDO, and Sign of Hope to respond to the suspect cases.

In Fangak, MSF France is running a CTC in Fangak town where cholera cases are being managed. 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.

In Pigi; cases were managed in Kurwai PHCC by Nile Hope with support from WHO, UNICEF, and MSF-F. At least 168 cases including six deaths of cholera were reported. The cases declined and by 29 December 2016, there were no cholera cases admitted in the treatment center. The last four cases were discharged from Kurwai PHCC on 15 November 2016.

8 Recommendation and way forward for Bentiu PoC

Improving access to timely rehydration In week 49; there were four facility deaths – a trend that has not been seen in the past weeks. This most likely points to increasing cases in the community with delayed referral to the treatment centers. The following strategies should be considered to increase access to timely rehydration in the PoC: 1. The community health workers should be deployed to do house-to-house case search and initiate prompt treatment with ORS with immediate referral the designated cholera treatment centers. The community health workers should be able to dispense the ORS during the household visits. 2. Each block should have a designated community health worker with ORS that is known by the dwellers and who can be called on short notice to assess; initiate treatment; and refer suspect cases. 3. Open additional mobile clinics or ORPs in the most affected sectors to ensure good access to timely rehydration during day time. 4. All the existing clinics and pharmacies should be stocked with ample amounts of ORS to provide to suspect cases.

Surveillance and laboratory testing Since this is a population where oral cholera vaccination was implemented in 2014 and 2015; case based surveillance is recommended. Thus, in the current context, cases that meet the suspect cholera case definition should undergo an initial screening using the enhanced RDT testing technique (using enrichment of samples with alkaline peptone water before the test is conducted). This will improve the specificity for identifying the real cholera cases and thus accurately monitoring the evolution of the outbreak.

Secure-off the water retention pond Water retention pond: it is very clear that the possible source of infection to the community is the water retention pond. This water is contaminated with faecal matter due to rampant open defecation. The camp management should fence off this water source and forbid population from using it until the outbreak is over.

Targeted interventions to children as a high-risk group Nearly 80% of the cases are children: This is possibly because they swim and drink the water in the retention pond. Health education should be directed to this age-group by involving the school children in the PoC.

ORAL Cholera Vaccination (OCV) To increase immunity, there is a need for two rounds of oral cholera vaccination. The population of Bentiu PoC when the last two rounds were conducted in June 2015 was about 70,000. The current population has increased to 120,000. OCV coverage survey conducted by WHO/IOM in December 2016 showed that the OCV coverage stands at 40%. This is therefore not adequate to prevent transmission.

WASH related control activities All efforts towards improving access to safe drinking water, hygiene, and sanitation should be enhanced with regular assessments to review and update the taskforce on the following: • The amount of safe drinking water supplied per person per day by sector • Access to improved latrines per person per day by sector • Data on regular surveys to document FRC levels at the source; tap stands and household levels. • Documentation of waiting time at the tap stands to determine if there are unacceptable delays • A jerry-can cleaning and replacement drive at the tap stands in all the sectors to promote safe water chain. • Distribution of other NFIs like soap to promote and augment personal hygiene at household level. • House to house hygiene sensitization that is targeted to most affected blocks and sectors that are surrounding the water retention pond.

Social mobilization and health education for cholera control Given the current transmission levels in Bentiu PoC; a 1-2 weeklong mobilization campaign in each of the five sectors to sensitize the camp dwellers on cholera, how it is spread, the signs and symptoms, and behaviors to mitigate the risk – proper hand washing; using safe drinking water; and good sanitation. The campaign should also entail a cleaning drive in each of the sectors.

9 Planned Activities 1. The next weekly EPR/cholera taskforce meeting is scheduled for 4 January 2017 starting 2:00pm in the WHO Conference Hall. 2. 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.

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. Alice Igale Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211956420189

10 Update of Cholera outbreak as of week 50, Bentiu PoC

Highlight

822 suspected cases of cholera by 18th December, 2016 Number of cases is on the increase from 82 in week 46 to 132 in week 50. Sector 1 and 2 has highest attack rate at 13 and 11 per 1000 population respectively Annex 1: Cholera distribution in Bentiu PoC as of Blocks neighboring the retention water pond has also the29 December 2016 highest number of reported cases Annex 1.1:6 deaths Cholera mainly case distributionin the community by time (CFR in Bentiu 0.9%) PoC 29 December 2016 6 new positiveEpidemic Curve for cholera in Bentiu PoC as of 29 Dec 2016 samples positive for vibrio cholera in week 50 alone. Total of 22 positive

30cases so far. 25 th 20Index case reported on 10 October, 2016 having travelled from Leer. 15 10 WhoNo. cases are5 affected? 0 55% (451) of all cases are female possibly due to their domestic work related activities

76% (623) of all the cases of cholera areDate of onset children below 14 years.

Where do the cases of cholera live? Annex 1.2: Cholera age and sex distribution in Bentiu PoC as of 29 December 2016 All five sectors have been reporting cases. 210 Sector 1Cholera has the- age and sex distribution Northern Liech up to 29 Dec 2016 highest attack rate of 13 per 1000 population 180 Sectors which border the waste water pond also have the highest attack rate. The 150

120community says the water has a better taste and you use less soap when washing. For as 72 92 77 90long as the community continues to use this water, we will continue seeing cases since 60 Number of Cases 47 the water is contaminated.2 2 5 7 13 30 2 3 12 blocks80 83 which79 surround39 29 th21e retention27 21 basin29 account6 8 for40 25%12 (116)23 o52f all 1cases0 of 63 0 suspectedUnder 3- 5cholera 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 2 Female Male

Attack Rate of cholera cases per per 1000 population, Bentiu Annex 1.3: Cholera case distribution by sector inPoC Bentiu PoC as of 29 December 2016

15 13 11 10 8 6 6 7 5

0 No. of cases/1000 pop 1 2 3 4 5 Total Sectors 1-5

11 Annex 1.4: Cholera case distribution by sector and block in Bentiu PoC as of 29 December 2016

12