Republic of South Sudan
Situation Report #41 on Cholera in South Sudan As at 23:59 Hours, 1 August 2015
Situation Update As of 1 August 2015, a total of 1,411 cholera cases including 42 deaths (CFR 2.98%) have been reported in Juba and Bor Counties in Central Equatoria and Jonglei States respectively. In Juba County, 1,293 cases including 41 deaths (CFR 3.17%) have been reported from seven Payams (Table 1). In Bor, 118 cases including one death (CFR 0.85%) have been reported from Malou in Makuach Payam and other areas within the County.
The initial cases in Juba were traced back to 18 May 2015 in UN House PoC where the first cholera case was confirmed on 1 June 2015. The most affected Payams in Juba County are Kator, Rejaf, Northern Bari, and Munuki that have registered attack rates (cases per 10,000) of 221, 199, 140, and 24 respectively (Annex 1).
In Bor, the initial cases were reported from Malou in Makuach Payam. Makuach Payam is the most affected in Bor and has registered an attack rate (cases per 10,000) of 31 (Annex 1 and 2).
Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 1 August 2015 Reporting Sites New New New Total cases LAMA* Total Total Total Total cases Total cases admisions discharges deaths currently facility community deaths discharged admitted deaths deaths
CES – Juba County 13 9 0 28 208 25 16 41 1016 1293 IMC UN House PoC clinic 0 0 0 2 0 0 1 1 71 74 Juba Teaching Hospital 6 6 0 21 204 21 7 28 716 969 MedAir Gumbo CTU 6 1 0 5 0 1 0 1 76 82 MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8 HLSS Nyakuron ORP 0 0 0 0 0 0 0 0 23 23 HLSS Kator ORP 0 0 0 0 0 0 0 0 7 7 HLSS Gurei ORP 1 1 0 0 0 0 0 0 35 35 HLSS Munuki ORP 0 0 0 0 0 0 0 0 3 3 HLSS Al Sabah ORP 0 0 0 0 0 1 0 1 10 11 HLSS Lologo ORP 0 0 0 0 0 0 0 0 8 8 MSF Munuki CTC 0 1 0 0 4 0 0 0 41 45 Other sites in Juba 0 0 0 0 0 2 8 10 18 28 Jonglei State – Bor 2 1 0 2 3 1 0 1 112 118 Bor State Hospital 2 1 0 2 3 1 0 1 112 118 Total 15 10 0 30 211 26 16 42 1128 §1411 *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- Central Equatoria State; § Following data cleaning, 56 duplicate records were deleted from the database. A total of 15 new cholera cases were reported in Juba and Bor on 1 August 2015 (Table 1 and Figure 1). o 13 new cases were reported from Juba County, with the majority originating from Gumbo Shirkat. o The two new admissions in Bor state hospital originated from Hai Salam and Naknyang (Figure 1),
Figure 1: New cholera cases in Juba and Bor by residence on 1 August 2015 6 5 4 3 5 2 1 1 1 1 1 1 1 1 1 1 1 0 Number casesofNumber Nyakuron Kor Romula Shirkat Kadoro Check point Airport Gondokoro Bojur Kofuri Hai Salam Naknyang west Munuki Rejaf Juba Gondokoro Blank Northern Bari Makuach Baidit Juba Bor
1 During week 31 of 2015 (week of 1 August 2015), most of the cholera cases in Juba originated from Kor William and Lologo in Kator; Jebel Dinka, Lokuilili, and Hai Baraka in Northern Bari; Hai Jebel, Nyakuron west, and Mia sava in Munuki; and Gumbo and Shirkat in Rejaf (Figure 1.1). During week 31 of 2015, the most affected Payams in Juba County were Kator, Rejaf, Northern Bari, and Munuki that registered attack rates (cases per 10,000) of 15, 14, 9.2, and 1.3 respectively (Annex 1).
Figure 1.1: New cholera cases by residence during week 31 of 2015
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N G Juba Kator Munuki Northern Bari Rejaf Gondokoro Bor Juba Bor
Cumulatively, 1,411 cholera cases including 42 deaths (26 facility and 16 community) have been reported in Juba and Bor Counties since the initial case was reported on 26 May 2015 in Juba (Tables 1 and 2). Of the 42 deaths, nine (21%) occurred in children under five years while 27 (64%) occurred in males. In Juba County, Juba Payam has registered the highest CFR followed by Northern Bari, Munuki, Rejaf, and Kator (Annex1).
Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 1 August 2015 New cases by epidemiological week of 2015 Reporting Facility 21 22 23 24 25 26 27 28 29 30 31 Grand Total CES – Juba County 4 2 7 56 130 229 235 161 237 150 82 1293 JTH 0 2 2 32 119 208 207 116 146 93 44 969 Juba 3 IMC clinic 4 0 4 9 6 13 10 10 11 5 2 74 HLSS Nyakuron ORP 0 0 0 0 0 0 2 3 11 2 5 23 HLSS Kator ORP 0 0 0 0 0 0 0 3 1 2 1 7 MedAir Gudele ORP 0 0 0 0 0 0 0 4 3 1 8 MedAir Gumbo CTU 0 0 0 0 0 5 15 20 25 10 7 82 HLSS Gurei ORP 0 0 0 0 0 0 0 1 11 10 13 35 HLSS Munuki ORP 0 0 0 0 0 0 0 1 0 2 3 HLSS Al Shabah ORP 0 0 0 0 0 0 0 0 4 3 4 11 HLSS Lologo ORP 0 0 0 0 0 0 0 0 2 4 2 8 MSF Munuki CTC 0 0 0 0 0 0 0 0 23 18 4 45 Other sites in Juba 0 0 1 15 5 3 1 3 0 0 28 Jonglei State – Bor County 0 0 0 0 0 5 46 33 21 8 5 118 Bor State Hospital 0 0 0 0 0 5 46 33 21 8 5 118 Grand Total 4 2 7 56 130 234 281 194 258 158 87 1411
As seen from Figure 2, the initial and isolated cases were reported from UN House PoC in Juba starting on 26 May 2015. However, following epidemiological investigations on 27 May 2015, cases could be traced back to 18 May 2015. Cholera was eventually confirmed on 1 June 2015 in Juba after Vibrio cholerae inaba was isolated from the one of five samples tested in the National Public Health Laboratory.
From 6 June 2015, sustained and consistently increasing community transmission was established in Juba as seen from the multiple transmission peaks. The highest transmission peak occurred on 19 July 2015 and was attributed to a funeral in Atlabara B. This trend is attributed to sustained community transmission in Kator, Rejaf, Northern Bari, Munuki, and Juba.
2 In Bor, the initial case occurred on 26 June 2015 with increasing cases from week 26 to week 27 when the highest transmission peak was registered. In the subsequent weeks, successively shorter transmission peaks were registered, a trend that is consistent with declining community transmission.
Figure 2: Epidemic curve for cholera cases in Juba and Bor, 18 May – 1 August 2015
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70 17.9 18 16 60 14.3 14 50 12 40 10 30 8 6.2 6 20
Number Number of cases 3.8 4 10 1.9 2 1.4 1.5 1.6 CaseFatality Rate [%]
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JS CES CFR
JS: Jonglei State; CES: Central Equatoria State; CFR: Case Fatality Rate
The probable risk factors fueling transmission include: residing in a crowded IDP camp with poor sanitation and hygiene; using untreated water from the Water tankers; lack of household chlorination of drinking water; eating food from unregulated roadside food vendors or makeshift markets; open defecation/poor latrine use; and attending/eating food at a funeral.
Figure 3: Spot map for cholera cases by residence in Juba, 18 May – 1 August 2015
As of 1 August 2015, the sites reporting the majority of cases in Juba include Gumbo, New site, Juba 3 PoC, Gudele 2, Atlabara B, and Munuki with satellite cases distributed in seven Payams in Juba County (Figure 3). In Bor County, the majority of the cases originated from Malou 41 (36%) and Langbar 12 (10.4%) in Makuach Payam.
3 The most affected age groups in Juba and Bor counties are children under five and 5-9 years old. Additionally, a significant number of cases have occurred among 25-29 year olds in Juba County (Tables 3.1 and 3.2).
Table 3.1: Cholera case distribution by age in Juba County, 18 May – 1 August 2015 Cholera case distribution by age in Juba County, week 21-31, 2015
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150 114 103 100 86 79 80 45 Male 43 54 50 46 Number Number of cases 77 67 73 84 Female 49 44 15 15 40 38 25 5 11 13 10 0 19 15 11 7 5 7
Table 3.2: Cholera case distribution by age in Bor County, 18 May – 1 August 2015 Cholera case distribution by age in Bor County, week 26-31, 2015 80
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60 50 33 40 Male 30 20 Female
Number Number of cases 34 10 6 1 3 8 9 2 1 0 5 1 1 1 2 3 1 3 21 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 five years years years years years years years years years years years years
Out of the 1,287 cholera cases with known gender in Juba, 562 (44%) were female, while 725 (56%) were male while in Bor, 69 (58%) of the cases were females, while 49 (42%) were males (Table 4).
Table 4: Case distribution by gender and age in Juba and Bor Counties, 18 May – 1 August 2015 Case distribution by gender N (%) CES - Juba 1287 Female 562 (44) Male 725 (56) Jonglei state – Bor County 118 Female 69 (58) Male 49 (42) Grand Total 1405
Laboratory updates
Table 5: Cholera laboratory test results for Juba and Bor, 18 May – 1 August 2015 Number of Number of cholera Number of stool Number of cholera Health Facility RDT tests RDT positives cultures Culture positives CES – Juba 221 199 89 35
4 1 Juba Teaching Hospital 126 113 54 17 2 Juba 3 PoC clinic 69 63 22 11 3 MSF Munuki CTC 14 14 1 0 4 Other sites in Juba 12 9 10 5 5 MedAir Gumbo CTU 0 0 2 2 Jonglei state – Bor 57 49 17 8 1 Bor State Hospital 57 49 17 8 Total 278 248 106 43
As seen from Table 5, 248 (89%) of the samples have been RDT positive while 43 (41%) have been confirmed by culture after the National Public Health Laboratory isolated Vibrio cholerae inaba. Most of the culture confirmed cases have been reported from Juba 3 PoC, New site, Munuki, and Nyakuron West in Juba while in Bor, Malou has registered the highest number of confirmed cases (Figure 4).
Seven stool samples were shipped to the Central Public Health Laboratory in Uganda for testing. Vibrio cholerae Inaba serogroup, 01 serotype was isolated from one of the samples while six samples tested negative for cholera but were positive for nonpathogenic Escherichia coli. Three isolates were confirmed as positive and three negative samples tested negative on repeat testing in Uganda thus confirming earlier test results by the National Public Health Laboratory. The four isolates were sensitive to tetracycline and ciprofloxacin; intermediate for Ampicillin and chloramphenicol and resistant to Sulphamethoxazole.
Figure 4: Number of culture positives by residence in Juba and Bor, 18 May – 1 August 2015
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Kor William
MangatainIDP Nyakuron West Juba Bor
Table 6: Cholera Alerts – 23 to 1 August 2015 Date of Details of the alert Area Action notification 28-Jul-15 A community death involving a 5-year-old Lokuilili, - State and county surveillance officers notified to boy occurred in Lokuilili. He was buried Juba verify the death. on 27 July 2015 and his mother was Payam - Mother to the deceased case admitted to MSF admitted in the MSF Munuki CTC with Munuki CTC for treatment. cholera symptoms on the same day. 26-Jun-15 Nineteen suspect cholera cases were Kajo Keji, - A total of 65 acute watery diarrhoea cases have initially reported in Kajo Keji Civil hospital. CES been line listed with two cases on admission at The cases have now risen to a the hospital cumulative total of 65. - 21 samples submitted for microbiological culturing - 19 samples tested negative for cholera following microbiological culturing at the National Public Health Laboratory while two are pending - An assessment by MedAir revealed there were no active suspect cases. Refresher training on cholera undertaken and cholera case management stockpiles were replenished -
Since 25 June 2015, at least 10 alerts of suspect cholera cases have been reported outside Juba. The national and respective state cholera taskforce committees have initiated the recommended follow up actions as described in Table 6.
Planned and On-going Activities
5 1. The next national cholera taskforce meeting is scheduled for Monday 3 August 2015 at 10:00 am in the Ministry of Health Ministerial Boardroom. 2. The next cholera coordination meeting in UN House PoC is scheduled for 6 August 2015 at 11:30 am in the RRP Boardroom.
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 numbers for alerts are: Zain: 0912000098.
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
6 Annex: Cholera Data tables and Charts – 18 May 2015 to 1 August 2015
Annex 1: Cholera attack rates and case fatality rates by Payam, 18 May to 1 August 2015 New Attack rate cases in [cases per Cumulative week 31, Case 10,000] for Attack rate 2015 Total Total Populati Fatality week 31 of [cases per Location Cases Deaths on Rate [%] 2015 10,000] CES 82 1293 41 279871 3.2 2.9 46.2 Gondokoro 1 8 7115 - 1.4 11.2 Juba 7 139 11 91254 7.9 0.8 15.2 Kator 17 252 5 11395 2 14.9 221.1 Lokiliri 0 3 5995 - 5.0 Munuki 17 311 8 129133 2.6 1.3 24.1 Northern Bari 19 291 8 20753 2.7 9.2 140.2 Rejaf 20 283 7 14226 2.5 14.1 198.9 (Blank) 1 5 2 40.0 JS 5 118 1 181708 0.8 0.1 6. 5 Baidit 1 5 51042 - 1 Bor 1 5 61224 - 0.8 Kolnyang 0 1 40021 - 0.2 Makuach 2 90 1 29421 1.1 0.3 30.6 Grand Total 87 1411 42 461579 3.0 1.5 30.6
Annex 2: Cholera epidemic curves by Payam – 18 May to 1 August 2015 Cholera Epidemic Curve Juba Payam 2015
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7 Cholera Epidemic curve Northern Bari Payam 2015
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Cholera Epidemic Curve Rejaf Payam 2015
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Rejaf
Cholera Epidemic Curve Munuki Payam 2015
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Munuki
8 Cholera Epidemic Curve Kator Payam 2015
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Cholera Epidemic Curve Gondokoro Payam 2015
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Cholera Epidemic Curve Lokiliri Payam 2015
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Lokiliri
9 Cholera Epidemic Curve Makuach Payam, Bor 2015
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