South Sudan

Integrated Disease Surveillance and Response (IDSR)

Epidemiological Update W23 2018 (May 04- Jun 10) Major Epidemiological Developments W23 2018

• Completeness for IDSR reporting at county level was 68% . Completeness for EWARS reporting from IDP sites was 83%. ______• A total of 7 alerts were reported, of which 43% have been verified. 1 alert was risk assessed & 0 required a response. ______• There is no new disease outbreak confirmed during the week. ______• There are no new suspect Rift Valley Fever (RVF) cases reported from Yirol East since week 18. A total of 57 suspect human cases including 6 confirmed; 3 probable; 26 non-cases; and 22 pending classification (with no definitive lab. test results) have been reported. Nine confirmed animal cases (cattle). ______• Suspect rabies cases continue to be reported in Bentiu PoC, Abyei town, and Aweil town. There is need to optimize the response through case management, vaccination, community engagement, and curling of stray dogs. ______• Hepatitis E continues in Bentiu PoC where a total of 79 suspect cases (13 confirmed by PCR). Current response entails surveillance, case follow up, WASH and discouraging communities from using stagnant water for domestic and recreational purposes. ______

2 Surveillance| IDSR surveillance indicators Surveillance | IDSR surveillance indicators

Table 1 | IDSR surveillance performance indicators by county (W23 2018)

Hub Reporting Performance (W23 2018) Performance (Cumulative 2018)

# counties # reports received Completeness Timeliness Completeness Timeliness

Aweil 5 5 100% 100% 84% 84% Bentiu 9 0 0% 0% 68% 49% Bor 11 7 64% 64% 45% 41% Juba 6 6 100% 100% 83% 65% Kwajok 7 5 71% 71% 99% 89% Malakal 13 4 31% 31% 26% 12% Rumbek 8 8 100% 100% 101% 92% Torit 8 7 88% 88% 96% 73% Wau 3 2 67% 67% 93% 74% Yambio 10 10 100% 100% 99% 99% South Sudan 80 54 68% 68% 74% 68%

• Completeness for IDSR reporting at county level was 68% in week 23 and cumulatively at 74% for 2018

• Timeliness for IDSR reporting at county level was 68% in week 23 and cumulatively at 68% for 2018

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1 W23 2018 (Jun 04-Jun 10) Surveillance | Trend in IDSR completeness Surveillance| Trend in IDSR completeness

Figure 1 | Trend in IDSR completeness over time1

100%

80%

60% Percent

40%

20%

0% W26 2017 W31 2017 W35 2017 W39 2017 W44 2017 W48 2017 W01 2018 W05 2018 W09 2018 W13 2018 W18 2018 W22 2018

Completeness

The1 Completenessgraph shows footnote completeness (to be drafted) for weekly reporting at county level. The national average currently stands at 74%.

2 W23 2018 (Jun 04-Jun 10) 4 Surveillance|Surveillance Maps | Mapsof IDSR of IDSR completeness completeness by by county county

Map 1a | Map of IDSR completeness by county (W23 2018) Map 1b | Map of IDSR completeness by county (2018)

Renk Manyo

Melut Fashoda Maban Abyei Pariang Malakal Abiemnhom Baliet Aweil North Panyikang Aweil East RubkonaGuit Longechuk Twic Mayom FangakCanal Pigi Aweil West Luakpiny NasirMaiwut Raja AweilGogrial SouthGogrial West East Koch Nyirol Ulang Aweil Centre Tonj North Ayod MayenditLeer Tonj East Akobo Jur River Rumbek NorthPanyijiar Duk Uror Wau Tonj SouthCueibetRumbek Centre Twic East Pochalla Rumbek EastYirol East Nagero Yirol West Bor Pibor Wulu Tambura Awerial Mvolo Terekeka Ezo Nzara MundriMundri West East Lopa LafonKapoeta North YambioIbba Maridi Kapoeta East Juba Kapoeta South Torit YeiLainya Budi Ikotos Kajo KejiMagwi Morobo

Completeness Completeness

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

• Counties that submitted IDSR reports in W23 are shown in green in map 1a 3 W23 2018 (Jun 04-Jun 10)

• Counties that did not submit IDSR reports in W23 are shown in grey5 in map 1a Surveillance|Surveillance EWARS | EW surveillanceARS surveillance indicators indicators

Table 4 | EWARS surveillance performance indicators by partner (W23 2018)

Partner Performance Reporting (W23 2018) Reporting (Cumulative 2018)

# sites # reports received Completeness Timeliness Completeness Timeliness

CMD 1 1 100% 100% 100% 100% GOAL 2 2 100% 100% 100% 87% HLSS 1 1 100% 100% 100% 100% IMA 5 4 80% 80% 73% 70% IMC 6 6 100% 100% 93% 93% IOM 12 10 83% 83% 73% 73% IRC 1 1 100% 100% 100% 100% Medair 2 2 100% 100% 100% 96% MSF-E 2 2 100% 100% 96% 74% MSF-H 2 0 0% 0% 54% 41% SMC 5 5 100% 100% 65% 65% UNIDO 1 1 100% 100% 100% 100% UNKEA 2 2 100% 100% 87% 83% World Relief 1 1 100% 100% 100% 83% Total 48 40 83% 83% 74% 71%

Timeliness and completeness for EWARN/IDP reporting stands at 83% for week 23, while cumulatively completeness and timeliness are 74% and 71% respectively for 2018

6 4 W23 2018 (Jun 04-Jun 10) Alert|Alert Alert | Alertperformance performance indicators indicators

Table 7 | Alert performance indicators by Hub Table 8 Summary of key alert indicators

Hub W23 Cumulative (2018) W23 Cumulative (2018)

# alerts % verif. # alerts % verif. # alerts % verif. # alerts % verif. 7 356 Total alerts raised Aweil 1 100% 24 100% Bentiu 1 0% 42 67% 43% 68% % verified Bor 1 100% 32 53% 0% 0% % auto-discarded Juba 3 0% 52 69% Kwajok 0 0% 28 100% 14% 4% % risk assessed Malakal 0 0% 30 63%

Rumbek 0 0% 30 63% 0% 2% % requiring a response Torit 0 0% 35 74% Wau 0 0% 18 50% Yambio 1 100% 65 57% South Sudan 7 43% 356 68%

A total of 7 alerts were reported in week 23 with 43% of the alerts in week 23 being verified; 14% were risk assessed and 0% required a response.

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1 Alert footnote (to be drafted) Alert | Event risk assessment Alert| Event risk assessment

Table 9 | Alert performance indicators by event Table 10 | Event risk assessment

Event W23 Cumulative (2018) W23 Cumulative (2018)

# alerts % verif. # alerts % verif. 0 7 Low risk

Indicator-based surveillance 2 2 Medium risk Malaria 3 33% 61 61%

AWD 1 100% 160 65% 1 3 High risk Bloody Diarr. 0 0% 90 50% Measles 2 50% 67 76% 0 1 Very high risk Meningitis 0 0% 0 0% Cholera 0 0% 6 100% Yellow Fever 0 0% 4 75% Guinea Worm 0 0% 11 82% AFP 0 0% 46 92% VHF 0 0% 1 100% Neo. tetanus 0 0% 3 67%

Event-based surveillance

EBS total 1 0% 21 76%

• During the week, malaria and suspect measles were the most frequent infectious hazards reported 8

6 W23 2018 (Jun 04-Jun 10) Alert by disease and county in W23 2018

Alerts by hazard in week 22 and week 23, 2018 • During week 23, a total of 7 alerts were 8 reported 7 wk 22 wk 23 6 • Most alerts were due 5 to malaria 4 8 emphasizing the 3 5 need for enhanced Number of Number cases 2 3 1 2 2 2 2 malaria EP&R 1 1 1 0 Acute Watery AFP Bloody Diarrhoea EBS Measles Malaria • Suspect measles Diarrhoea cases investigated in Awerial - samples Acute Watery shipped to Juba County Diarrhoea EBS Measles Malaria Total Alerts Bor 1 1 • Suspect cholera Ibba 1 1 deaths in Motot Juba 1 1 2 Ruled out by ICRC Lainya 1 1 who are running Rubkona 1 1 Motot PHCU & the Total Alerts 1 1 1 3 6 fact that there are no people in Motot currently 9 Cumulative alerts by disease for 2018

Number of Alerts by disease, South Sudan, week 1-23, 2018

100 n=364 alerts 90 80 70 60 50 89 40 78 74 30

Number of alerts Number of alerts 58 20 4 10 4 2 15 5 21 14 0 EBS AFP Malaria Cholera Measles Viral Fever Diarrhoea Yellow Fever Yellow Acute Watery Acute Guinea Worm Haemorrhagic Bloody Diarrhoea Neonatal Tetanus

The Figure shows the cumulative number of alerts triggered in 2018 by hazard and location.

10 Cumulative alerts by risk assessment stage in 2018

County OUTCOME RISK_ASSESS VERIFICATION Total Alerts Acute Watery Diarrhoea 1 77 78 AFP 1 14 15 Bloody Diarrhoea 1 88 89 Cholera 1 1 2 EBS 2 19 21 Guinea Worm 2 12 14 Neonatal Tetanus 2 2 4 Viral Haemorrhagic Fever 2 2 Yellow Fever 4 4 Measles 5 6 63 74 Cholera 3 3 Malaria 2 56 58 Total Alerts 14 9 341 364

• The Figures show the cumulative alerts by risk assessment state in 2018 • Of the 364 alerts reported in 2018; a total of 341 alerts have been verified; 9 alerts underwent risk assessment (9 alerts); and 13 alerts have a documented outcome 11 Confirmed Outbreaks South Sudan – 17 June 2018

• The map show outbreaks confirmed in 2018 • The active outbreaks include: Measles in Rumbek Center; Wau PoC AA; Rift Valley Fever in Yirol East; HEV in Bentiu PoC

" ! Rubkona " $ Mayom✦ Guit Fangak Aweil East

! Koch Aweil Center Leer

Jur River

! ! Wau $ ! ® Cueibet Rumbek Center Yirol East Measles ! Bor◾ South Rubella $

Rift Valley Fever ®

Anthrax ✦

Hepatitis E virus [HEV] " $ Juba Foodborne disease ◾

IP C - Emergency phase

IP C - Crisis phase

IP C - Stressed phase 12 Suspect Outbreaks South Sudan – 17 June 2018

• Map shows suspect outbreaks reported in 2018

Ⓜ ! & ' Pariang Abyei Ⓜ Ⓜ & Aweil North Aweil East % Ⓜ Twic Mayom Rubkona Ⓜ ! Aweil West # Fangak Ⓜ Ⓜ & Aweil South Aweil Center Mayendit !

Ⓜ Ⓜ Ⓜ Duk Wau Jur River Ⓜ

Ⓜ % Cueibet Rumbek Center Yirol East % Ⓜ Bor South Meningitis Ⓜ Pibor Ⓜ Measles ! Awerial

Rabies & #

Health effects of ' Lopa petroleum drilling

Pertussis % ! Juba Torit Cholera # " ! Acute Jaundice " Syndrome 13 Response| Summary of major ongoing outbreaks

Cumulative Interventions Date first New cases since Aetiologic agent Location (county) cases to date reported last bulletin Case Health (attack rate %) management Vaccination promotion WASH New epidemics

Ongoing epidemics Measles Rumbek Center 13/05/2018 20 39 (0.017) Yes No Yes N/A Measles Wau PoC AA 04/04/2018 0 1 (0.0025) Yes No Yes N/A RVF Yirol East 28/12/2017 0 57 (0.053) Yes N/A Yes N/A Hepatitis E Bentiu PoC 03/01/2018 9 79 (0.068) Yes No Yes Yes Rabies probable Bentiu PoC 06/12/2017 5 234 (0.200) Yes Yes Yes N/A Controlled epidemics Hepatitis E Old Fangak 15/02/2018 0 01 (0.001) Yes No Yes Yes Rubella Jur River 14/02/2018 0 76 (0.039) Yes No Yes N/A Rubella Juba 26/02/2018 0 22 (0.0037) Yes No Yes N/A Rubella Mayom 22/02/2018 0 08 (0.004) Yes No Yes N/A Measles Aweil Center 6/Jan/2018 0 22 (0.021) Yes Yes Yes N/A Measles Cueibet 14/10/2017 0 20 (0.012) Yes Yes Yes N/A Measles Aweil East 05/02/2018 0 31 (0.006) Yes Yes Yes N/A Foodborne Bor South 18/02/2018 0 434 (29) Yes Yes Yes Yes Cut. Anthrax Mayom 27/01/2018 0 2 (0.001) Yes No Yes N/A Meningitis Torit 17/01/2018 0 173 (0.107) Yes No Yes N/A

• There is no new outbreak confirmed in the week. • The other ongoing and controlled outbreaks in 2018 are shown in the table 14 MeaslesConfirmed outbreak Measles Outbreak - Rumbek in Rumbek Center Center County Measles cases by onset week and Payam in Rumbek Center wk 19-23, 2018 Age Female Male Total cases %age Cum% 12 <1yr 1 3 4 10.3% 10.3% 10 Amongpiy Biir Matangai Blank

8 1-4yrs 5 18 23 59.0% 69.2%

6 5-9yrs 4 2 6 15.4% 84.6% 4 10-14yrs 1 1 2.6% 87.2%

Number of Number cases 2 15-44yrs 5 5 12.8% 100.0% 0 Total 15 24 39 100.0% 17 18 19 20 21 22 23 Epidemiological week of rash onset in 2018 • Measles outbreak confirmed in Rumbek Center Measles cases by test results, week 19-23, 2018 14 after 3 IgM positive cases were reported 12 lgM +ve lgM-ve ND • A cumulative of 39 measles cases with no 10 deaths have been line listed since week 19 8 • Most cases are from Akuach village (2km from 6 4 Rumbek hospital) in Biir Payam. This is where

Number of Number cases 2 the index cluster originated 0 • Nearly 70% of the cases are under 0-59 17 18 19 20 21 22 23 months Epidemiological week in 2018 • Routine measles coverage for 1st quarter of

Measles cases by village and payam in Rumbek Center wk 19-23, 2018 2018 for the county was 19%

8 • As part of the response; outbreak investigation 7 completed; line listing underway; and 6 5 4 vaccination microplan targeting 44,049 children 7 3 5 5 6-59 months of age has been completed 2 4 Number of Number cases 3 1 2 2 1 1 1 1 1 1 1 1 1 1 1 • A reactive response is planned by MedAir and 0 CUAMM supported by WHO and UNICEF Akuac Arauic Mabui Akuach Riakdor Cueicok Cumcok agergum Makuriric Titcirotjot Acholthen Nyang-Kot Achol-then Malual bab Malual Mulual bap Mulual Adol Nyang • Long-term strategy for improving routine Mathiang kok Mathiang

Ministry of police of Ministry immunization has been developed by EPI-MoH Amongpiy Biir Matangai (blank) 15 Response| Suspect epidemics HEV case distribution by age & sex, Bentiu PoC Jan-June 2018 Hepatitis E, Bentiu PoC and Old Fangak 45+yrs 2.50 3.80

15-44yrs 20.30 Hepatitis E cases reported in by location, week 1-23, 2018 17.70

15 10-14yrs 3.80 3.80 14 13

Bentiu PoC Old Fangak years Age in 12 5-9yrs 3.80 15.20 11 Male Female 10 9 1-4yrs 5.10 21.50 8 7 <1yr 6 1.30 1.30 5 Number of Number cases 4 20 15 10 5 0 5 10 15 20 25 Percentage % 3 2 1 0 • At least 79 suspect case of Hepatitis E (HEV) have been 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Epidemiological weeek 2018 reported in 2018. Of the 79 suspect cases, a total of 14 cases have been PCR confirmed as HEV (13 in Bentiu PoC Hepatitis E cases reported in by Epi classification, week 1-22, 2018 & 1 in Old Fangak). No new cases identified after active 15 follow up in Fangak. 14 13 Confirmed Suspect 12 • At least 48% of the cases are 1-9 years of age; and 66% 11 10 being male. Among the females, most cases have been 9 8 7 reported in those aged 15-44 yrs (who are at risk of adverse 6 rd 5 outcomes if infected in the 3 trimester of pregnancy). Number of Number cases 4 3 2 • Use of stagnant water for domestic or recreation purposes 1 0 likely to be source of infection - communities are being 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Epidemiological week 2018 educated on the risk and draining the water is being discussed • Unicef has shared key HEV messages - for radio programs Nine HEV cases in week 23 including one RDT on [Kondial FM & Bentiu FM] and community sensitizations. • Case identification and follow up is ongoing and WASH risk positive and one pregnant female 16assessment has been planned. Response| Confirmed epidemics Ongoing epidemics - Epidemic description - RVF Eastern Lakes state

RVF case distribution by age and sex, December 2017 - May 2018 RVF cases by County and Payam, classification, Eastern Lakes wk 49, 2017 to wk 18, 2018

50-59 3.20 6.50 25

40-49 0.00 3.20 20 confirmed probable suspected 30-39 16.10 3.20 15 15 20-29 12.90 6.50 10 Age in years

10-19 9.70 12.90 Number cases/death 5 3

0-9 6.50 19.40 4 1 3 0 1 1 1 1 1 Mangar Pagarau Yali Khap Tinagau Aluakluak Panliet 20 15 10 5 0 5 10 15 20 25 Yirol east Yirol West Percentage %

RFV case distribution by classification in Yirol East, wk 49, 2017 to week 17, 2018

5 Sno. Description Number 1Suspect cases 57 4 confirmed probable suspected 2Total deaths 4

3 3Confirmed cases 6 4Probable cases 3 2

Number of cases 5Cases pending testing 22 6Non-cases 26 1 7Cases on admission 0

0 8Total human samples collected 39 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 9Total animal samples collected 28 Epidemiological week of onset in 2017 and 2018 10Positive animal cases 9

• No new suspect RVF cases reported since week 18 of 2018 • In the period 7 Decem ber 2017 to 6 April 2018, a total of 57 suspect RVF cases were reported in Eastern Lakes. • These were reclassified based on investigations and laboratory results, such that as of 6th April 2018, there were a total of six (6) RVF confirmed cases, three (3) probable, and 22 suspect RVF cases (no laboratory results). • Twenty six (26) cases were discarded as non-cases following negative laboratory results for RVF and other common causes of viral haemorrhagic fever. • A total of nine animal samples have been confirmed serologically (3IgM and 6IgG). 17 • Current response entails surveillance, laboratory testing, supportive care for suspect cases, and community sensitization on hygienic anim al handling Response| Suspect epidemics

Animal bites - suspect rabies, Bentiu PoC

Suspect rabies cases in Bentiu PoC, week 22, 2017 to week 20, 2018 Suspect rabies cases, Bentiu PoC Jan-April 2018 30 30% 25% 25 25% 23% 22% 20 20% 16% 15 15%

Cases % Cases 9% 10 10% 6% 5% Number ofdeaths Number cases/ 5 0% 0 Sec1 Sec2 Sec3 Sec4 Sec5 (blank) 22 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Sector in Bentiu PoC 2017 Epiweek 2018

Rabies case distribution by age and sex, week 49, 2017 - week 21, 2018 • During week 23, a total of 5 animal bite cases were

reported and treated in Bentiu PoC

50+ -8.00 4.00 • A cumulative of 234 animal bite cases including 4

deaths have been reported since 6 Dec 2017. 40-49 -3.00 4.00 • Sectors 3,4, &5 have reported most cases and children 30-39 Male % Female % -6.00 7.00 <19yrs constitute more than 56% of the cases with

20-29 -5.00 7.00 males affected more than females

Age in years Age in 10-19 -12.00 12.00 • Post exposure vaccination ongoing with support from MSF-H and partners. 5-9 -5.00 11.00 • WHO/ health cluster have secured antirabies vaccine 1-4 -6.00 9.00 to support the response. <1yr -0.47 0.47 • Community messaging underway via CCCM/ 15 10 5 0 5 10 15 internews/ UNMISS broadcast Percentage % • VSF arrived in the PoC to support curling of stray dogs 18 Response| Suspect epidemics

Animal bites - suspect rabies, Agok hospital, Abyei Town

Number of dog bites per month from 2016 to 2018 , Agok Sex/Age <5yrs 5+yrs Total Hospital Male 16 178 194 (53.4%) 140 Female 5 164 169 (46.6%) 120 2016 2017 2018 100 Totals 21 (5.8%) 342 (94.2%) 363 80

60 • An increase in dog bite (suspect rabies) cases continues to 40 be reported from Agok hospital in Abyei.

Number oftreated Number cases 20 • An exponential increase in suspect rabies cases has been 0 reported in 2018 when compared to the previous years with a jan feb mar apr may jun jul aug sep oct nov dec total of 437 cases reported in 2018 (week 1-21); • Current response entails surveillance - case detection and Aminal bites (susp. Rabies), Agok, Abyei - week 1-16, 2018 line listing and post exposure prophylaxis with rabies vaccine. • At a joint meeting held in Abyei Town involving MSF and FAO 40 on 7th June 2018; the following were noted: 34 35 32 31 29 30 • MSF pledged to continue treating dog bite cases 30 27 26 25 23 22 • FAO has 3,000-6,000 doses of rabies vaccine for 20 20 17 17 16 vaccinating dogs with owners in Abyei but requested 14 13 15 12 MSF to provide cold chain space for the vaccines Number of cases 10 5 • FAO also indicated they lack operational funds for 0 deploying the vaccines. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Epidemiological week 2018 • In addition, a solution needs to be found for the stray dogs to reduce the risk of bites that they pose. • There is also need for social mobilization and health 19 education to reduce the risk of exposure to dog bites Response| Suspect epidemics

Animal bites - suspect rabies, Aweil hospital, Aweil Town • Reports from Aweil continue to show that Number of dog bite cases treated in Aweil hospital, 2017-2018 dog bite cases remain a major public health 140 concern 120 • The data shown here is 2017 2018 100 obtained from Aweil hospital pediatrics 80 outpatients department 60 as a proxy of the suspect 40 rabies burden in the

Number oftreated Number cases 20 state. • In 2017; limited dog 0 Jan Feb Mar April May Jun Jul Aug sept Oct. Nov Dec vaccination was Month of treatment undertaken in UNMISS camp, Aweil. • The current statistics highlight the need for a Year Jan Feb Mar April May Jun Jul Aug sept Oct. Nov Dec Total comprehensive response that includes post 2017 37 40 55 34 86 42 81 61 88 53 56 80 713 exposure vaccination; community mobilization 2018 89 90 123 118 420 and education to minimize the risk of dog bites; dog vaccination; and curling of stray dogs 20 in the town. Issued to CMD 450 vials of SSG, 900 ampoules of Paromomycin, 6 boxes of 24 test kits of rK39 equivalent to screen 144 KA suspected cases to be used in Pagil, Gorwai and Jiech. Presented on KA as an advocacy for partners to participate in the implementation of KA control activities. Visceral Leishmaniasis | Kala-azar A graph comparing VL new cases and completeness as of week 22, 2017-2018 in South Sudan Kala-azar is endemic in Upper Nile, Unity, Jonglei, & Completeness in 2018 2017 2018 Kapoeta. Response interventions have been complicated by insecurity, population displacement, poor living conditions, 160 120 increasing food insecurity, closure of treatment facilities; and 140 low treatment completion rates. 100 120 In week 22, six health facilities reported 4 cases; all were 80

# of cases of # 100 new cases 80 60 Since the beginning of 2018, a total of 1,132 cases including 60 35 deaths (CFR 3.1%); 25 (2.2%) defaulters; 895 (79.1%) 40 new cases; 44(3.9%) PKDL; and 203(17.9%) relapses - all 40 reported from less than half of the 39 treatment centers. 20 2018 cmpleteness % 20 In the corresponding period of 2017, a total of 1,719 cases 0 0 including 29 deaths (CFR 1.7%) and 53(3.4%) defaulters 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 were reported from 21 treatment centers. Weeks

Graph:1Cummulative number of VL new cases by WEEK 22(29th May 2018 –4th June 2018).

The majority of cases in 2018 have been reported from Lankien (676), Kurwai (72), Walgak (53), Ulang (51), Malakal IDP (50), Narus (42), Pieri (36), KCH (28), Pagil (27), Doma and KMH (15), Bentiu (17) and Adong (13).

The most affected groups include, males [574 cases (50.7%)], those aged ≥15years and above [516 cases (45.6%)] and 5 - 14years [423(37.4%). A total of 184 cases (16.3%)] occurred in children <5years.

Low reporting rates currently impede meaningful trend interpretations however the major concern currently is seen from the high relapse rates; suggesting the need to improve treatment compliance through regular availability of testing and treatment kits and provision of food rations for cases on treatment. 21

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Preparedness| Cholera preventive activities

Cholera preparedness and preventive activities - Oral cholera vaccine campaigns - 2018 Total Target 1st 2nd Site populati populatio round round Total doses 1st Round dates 2nd Round dates Partners on n doses doses Aburoc 11,640 11,291 11,550 11,550 20-22May2017 Jan 17- 20 2018 MoH, WHO, Unicef, MSF-E Malakal Town 20,000 19,200 22,200 22,200 18-24Mar2017 Jan 5 - 9 2018 MoH, WHO, Unicef, MSF-E Juba 214,887 206,292 206,292 9Sep - 24Nov 2017 Apr 24-28 2018 MoH, WHO, Unicef, MSF-F & Spain Malakal PoC 24,424 23,691 34,291 34,291 68,582 19-23March 2018 Apr 17-21 2018 MoH, WHO, Unicef, IOM Wau IDPs 40,499 39,284 56,860 56,860 113,720 19-23March 2018 Apr 17-21 2018 MoH, WHO, Unicef, IOM Torit 180,169 174,764 174,764 174,764 349,528 30Jun-7Jul 2018 28Jul- 6Aug 2018 MoH, WHO, Unicef, SCI, CARE Yirol East & West 143,722 139,410 139,410 139,410 278,821 TBD TBD MoH, WHO, Unicef, LiveWell Lankien 65,000 63,050 63,050 63,050 126,100 TBD TBD MoH, WHO, Unicef, MSF-H Panyijiar 76,000 73,720 75,000 75,000 150,000 16-22May2018 TBD MoH, WHO, Unicef, IRC Totals 776,341 753,051 543,375 783,417 1,326,793

• Cholera prevention and response activities are already underway to • Oral cholera vaccine campaigns completed in mitigate the risk of cholera outbreaks in cholera transmission 2018 include: hotspots • Malakal Town (2nd round) • These efforts are critical now at the rain season is starting for the • Aburoc IDPs (2nd round) states in the Southern parts of the country. • Malakal PoC (1st & 2nd round) • The use of oral cholera vaccines alongside WASH and other • Wau PoC+IDPs (1st & 2nd round) interventions is critical to these efforts • Juba Town (1st & 2nd round) • Preventive vaccine campaigns (with oral cholera vaccines) for the • Panyijiar (1st round) first half of 2018 are listed in the table • Upcoming campaigns for 2018 • A additional 113,800 doses of oral cholera vaccines requested from • Panyijiar (2nd round) GTFCC arrived in the country on 18/04/2018. • Torit (1 st round) • GTFCC secured support from GAVI for a consultant that is in the • Yirol East and parts of Yirol West (1st round) country to finalize the cholera prevention and response plan for South • Lankien, Akobo, Pieri & Karam (1st round) Sudan • Leer Town (pre-emptive campaign) 22 Preparedness| Cholera preventive activities

Oral cholera vaccine campaigns administrative coverage - 2018 The following OCV campaigns have OCV administrative coverage [%] by site in 2018 been completed in 2018: nd 250% 1. Malakal Town (2 round) First round Second round 2. Aburoc IDPs (2nd round) 200% 3. Budi county (2nd round) st nd 150% 96.3% 96.9% 4. Malakal PoC (1 & 2 round) 5. Wau PoC+IDPs (1st & 2nd round) 100% 6. Juba (2nd round)

Administrative coverage Administrative coverage 50% 103.5% 105.3% st 87.6% 98.1% 93.0% 85.6% 7. Panyijiar (1 round) 64.5%

0% Malakal TownAburoc IDPs Malakal PoC Wau IDPs Budi county Juba Panyijiar • Pre-emptive campaign Leer Town • Due to the recent displacements in 2018 OCV campaigns First round Second round Site Target Coverage Coverage %Coverage Coverage % Leer county; the first round of pre- 1 Malakal Town 19,200 12,393 64.5% emptive campaigns is scheduled to 2 Aburoc IDPs 9,683 8,484 87.6% start during the week of 11 June 3 Malakal PoC 23,447 24,277 103.5% 22,588 96.3% 4 Wau IDPs 37,048 36337 98.1% 35887 96.9% 2018 targeting 10,000 individuals 5 Budi county 89,377 94,128 105.3% aged one year and above in Leer 6 Juba 216,852 201,737 93.0% 7 Panyijiar 75,000 64,214 85.6% Tow n. Total 470,607 124,828 92.1% 375,217 94.8% • The campaign is led by MedAir and supported by WHO and UNICEF.

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Figure 3: Geographical distribution of the Ebola virus disease cases in Equateur Province, Democratic Republic of the Congo, 22 May 2018

Preparedness| Ebola preparedness and preventive activities

Ebola DR Congo update & risk to South Sudan Situation as of 12 June 2018

Confirmed cases: 38 Probable cases: 14

Suspect cases: 3 Total cases: 55 (28 deaths CFR 50.9%)

• The MoH DR Congo declared an outbreak of Ebola virus disease on 8 May 2018 Equateur province in Northwestern DR Congo

• The epidemic is active in three health zones - Bikoro (10 confirmed cases, 11 probable, 1 suspect, & 18 deaths); Iboko (24 confirmed cases, 3 probable, 2 suspect & 7 deaths); & Wangata (4 confirmed cases and 3 deaths). • [5 HCW affected - 4 confirmed & 2 deaths].

• At least 634 contacts identified & being followed up. EVD Preparedness activities in South Sudan • Recombinant vesicular stomatitis virus–Zaire Ebola virus (rVSV-ZEBOV) vaccines were delivered to Kinshasa by • Screening of international travelers commenced at JIA WHO - The initial vaccination is targeting immediate The province of Equateur covers an area of 130 442 km2 and has an estimated population of 2 543 936 people, contacts to confirmed cases, contacts of contacts and with• 16RRT healthtraining zones andundertaken 284 health centres.on 26 TheMay affected2018 healthin areaJuba of Bikoro covers 1 075 km2 and has a frontline health workers. Since 21 May 2018, a total of population• RRT deployed of 163 065 inhabitants.to investigate It has 3suspect hospitals andEbola 19 healthcase in centres,Makpandu most of which have limited 2,295 people have been vaccinated in the three affected functionality.• Updated MedicalEVD suppliescontingency are provided by internationalplanning agencies,completed but stockoutsalong of medicalwith suppliesEVD are health zones (713 -Wangata; 1,054 -Iboko; 498-Bikoro). common. The village of Ikoko-Impenge is located 45 km from the central office of the Bikoro area and is not accessiblechecklist by road, and falls outside the telephone network. However, there is an airstrip • Regional risk is high after cases were confirmed in 8 km• fromDesignation Bikoro. an EVD isolation facility - space identified Mbandaka - major commercial hub - with road, river, & air • Updating EVD SoPs • Implementation of other preparedness interventions underway transport poses a risk to neighbouring countries.

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Health Emergency Information and Risk Assessment Page 5 WHO Health Emergency Program

Response| Suspect outbreaks being investigated Date of Disease Number County Payam Status of investigations report suspected cases (deaths)

13Mar18 meningitis 16 (00) Duk Ayueldit On 12 Mar 2018; a 3 year old male from Buongjok area, Ayueldit payam was admitted to Padiet PHCC. The health partner SMC requested for guidance on managing the case and the WHO Bor team shared the meningitis case management guidelines. Surveillance has been stepped up but no additional cases have been identified. 17Feb18 meningitis 173 (31) Torit Iyire and After rumors of strange illness in Iyire, several RRT verification and response missions have been undertaken since 20Feb18. Torit county Imurok surpassed in the alert and epidemic thresholds in week 7 and week 9 respectively. Conclusive laboratory confirmation underway. Overall coordination, case surveillance, line listing, and investigation are ongoing. Transmission declined after week 9 with the weekly attack rate falling below the alert and epidemic threshold in weeks 11-18, 2018. 10Mar18 meningitis 3 (0) Cueibet Since 10 Mar 2018, at least three suspect meningitis cases have been reported by CUAMM in Cueibet hospital. However, no samples were collected. 02Feb2018 meningitis 52 (06) Aweil South (14cases) Aweil Since 2Feb2018, at least 52 suspect cases (6 deaths) have been reported in Aweil hub. Six samples positive for Streptococcus Aweil East (18 cases) hub pneumoniae following rapid pastorex testing or showed gram positive Aweil West (11 cases) diplococci on gram stain. None of the affected counties exceeded the Aweil North (4 cases) alert threshold for meningitis. 06Jan18 meningitis 03 (00) Abyei and Twic Rumkor The two suspect cases were treated in Agok hospital on 4 Jan and 29 Jan respectively with initial diagnoses of severe malaria but final and diagnosis was bacterial meningitis. Rapid pastorex testing sample for Pan- the 2nd & 3rd suspect case from Twic and Abyei counties respectively nyok were positive for Streptococcus pneumoniae. 14Feb18 meningitis 21(03) Wau (Jur River) Udici, Since 14 Feb; 20 suspect meningitis cases have been reported from Wau (11 cases - 2deaths) and Jur River (9 cases - 1 death) counties. A suspect case Roc Roc involving a 45 year old male from Jur River was admitted in Comboni hospital Dong on 28 Feb 18. PCR testing was positive for Streptococcus pneumoniae. Another suspect case tested positive for NmA by rapid pastorex at NPHL on 27/4/18. 25 Response| Suspect outbreaks being investigated

Date of Disease Number cases County Payam Status of investigations report suspected (deaths) 16Mar2018 Measles 08(01) Mayom Riak & Lol Suspect measles cased reported from Riak payam in Nyebola village since 9 Mar 2018. Four samples were obtained by MSF-CH for testing. Maroal Three of the four samples tested were positive for rubella IgM. 16Feb18 Health effects Unspecified Pariang Pariang A newswire indicates the Mayor of Pariang in Ruweng State has appealed to the Ministry of Health to establish some health of petroleum conditions affecting people in the oil producing area. drilling bit.ly/2EIndTP #SouthSudan. Initial verification details to follow

th 31Mar2018 Suspect 12(08) Gogrial West Kuach South On 28 Mar 2018; the Director Gogrial West reported community deaths in Kuach South that were verified by the RRT on 29 Mar meningitis 2018. The clinical and lab tests on suspect cases were consistent /malaria with malaria and the cases responded to treatment with ACTs. All the deaths were 10 years and above and 50% of the deaths were 20 years and above. Given the dramatic nature of symptoms, the other differential diagnosis to keep an eye on is epidemic meningitis. No new cases reported in weeks 14 and 15. 12/Apr/18 pertussis 18(00) Fangak Bei Suspect pertussis cases have been reported by Mandeang PHCU and Kuephone PHCU in Fangak county. At least 11 suspect cases have been reported from Bei payam and another 7 suspect cases from Jiath. The response instituted by the partner CM A - entails treatm ent of cases and prophylaxis to close contacts and enhancing routine immunization for the infants. 22/05/18 cholera 2 Lopa Imehejek Two suspect cholera cases reported from Imehejek, Lopa from 22May18; the index ate cold food at a local market; direct RDT positive for cholera; all two samples negative for cholera after culturing in NPHL. 21/05/2018 measles 8 Rumbek Center Teyau Eight suspect measles cases reported from Teyau, Rum bek Centre - MMT to be dispatched for the investigation. Specimens collected for testing. 23/05/18 measles 2 Mayom Tam & Wangbur Two suspect measles cases reported from Mayom (Tam & Wangbur payams) samples sent to Juba by MSF-CH 16/05/18 measles 1 Torit Nyong One suspect measles case reported from Nyong payam in Torit. 26 Specimen collected Response| Suspect outbreaks being investigated

Date of Disease Number cases County Payam Status of investigations report suspected (deaths) 30/05/2018 Acute 01(00) Torit Torit town On 30 May 2018, a 2year and eight month child was jaundice admitted to Torit Hospital with fever, yellow eyes, and vomiting, Specimen obtained for testing and sent to Juba. 28/05/2018 Measles 2 (00) Awerial Two suspect measles cases reported and investigated in Awerial county. Samples have been collected and shipped to Juba for laboratory testing.

27 This bulle*n is produced by the Ministry of Health with Technical support from WHO Notes For more help and support, WHO and the Ministry of Health gratefully acknowledge please contact: the surveillance officers [at state, county, and health facility levels], health cluster and health pooled fund (HPF) partners who have reported the data used in this bulletin. We would also like to thank ECHO and USAID for providing Dr. Pinyi Nyimol Mawien financial support. Director General Preven5ve Health Services Ministry of Health The data has been collected with support from the EWARS Republic of South Sudan project. This is an initiative to strengthen early warning, Telephone: alert and response in emergencies. It includes an online, desktop and mobile application that can be rapidly configured and deployed in the field. It is designed with frontline users in mind, and built to work in difficult and remote operating environments. This bulletin has been Dr. Mathew Tut Moses automatically published from the EWARS application. Director Emergency Preparedness and Response (EPR) Ministry of Health More information can be found at http://ewars- Republic of South Sudan project.org Telephone: +211922202028