Cholera Situation and Response Updates 27 October 2017

CHOLERA SITUATION AND RESPONSE UPDATES 27 OCTOBER 2017

Epidemic trends

§ Cholera transmission reported in three counties [Juba, Budi, and Kapoeta East] in the last four weeks [40-43, 2017]. § Two cholera cases were confirmed from Napotpot, Kapoeta East after more than two incubation periods without cases. Oral cholera vaccination was conducted in the county and there is currently no evidence of active transmission. § Nine cholera cases were confirmed from Juba in week 43 (table 2). § Cholera transmission in Budi has continued to decline (Table 1, Figs. 1&2). § Three suspect cholera cases (all RDT positive) reported from Mayom in the last four weeks.

Table 1: Cholera cases by county for weeks 40, 2017 to 43, 2017 Cases reported Deaths Cumulative Cumulative New Date first (attack New during County during Facility+ reported Number rate per reporting reporting Community Facility Community of cases 10,000) period period CFR% Kapoeta East 24-Apr-17 2 2,107 88 0 16 10 1.23 Juba 18-Jun-16 112 2,808 48 1 26 10 1.28 Budi 22-Jul-17 33 703 41 2 43 36 11.24

§ During the last four weeks, Juba and Budi have reported the highest number of cholera cases (Table 1). During the same period, three deaths were reported from Budi (2) and Juba (1) (Table 1).

Fig. 1|Cholera cases in Juba, Budi, & Fangak from week 39 to 42, 50 2017

40 46

30 26 Budi Juba Fangak 23 20 22

Number of cases 7 10 10 0 7 10 0 wk39 wk 40 wk 41 wk 42 Epidemiological week of onset

1 § A cumulative of 703 cases including 79 deaths [CFR 11.2%] have been reported in Budi since week 29, 2017 (Table 1 and Figure 2). Overall, males (54.8%) are more affected than females (43.4%). Male children and male young adults are more affected than their female counterparts of corresponding age (Figure 3). § The outbreak in Budi started on 28 July 2017 with the initial transmission occurring among gold-miners in Ngauro.

Fig. 2|Cholera epidemic curve, Budi county 2017

140 100% 100% 90% 120 Alive Dead CFR% 80% 100 70% 67% 80 60% 50% 60 CFR % 40% 40 30%

Number of cases/deaths 20% 20% 20 16% 17% 16% 17% 10% 9% 9% 8% 10% 0 0% 0% 0% 0% 0% 0% 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Epidemiological week of illness onset 2017

Cordaid and the County Health Department are supporting management in Ngauro CTU, Kimotong CTU, Kimotong PHCC, Vaka ORP, Nagishot PHCC, and Kakilai PHCC in Budi county.

Fig. 3|Cholera case distribution by age and sex, Budi, week 26 - 42 2017 75-79 0.10 0.00 70-74 0.10 65-69 0.40 0.00 60-64 0.100.70 55-59 0.10 1.10 50-54 1.60 2.00 45-49 2.10 2.30 40-44 2.30 3.70 35-39 3.00 2.80 30-34 7.50 3.80 25-29 6.00 4.30 20-24 7.40 4.10 15-19 5.10 6.10 10-14 3.10 2.40 5-9 4.00 3.40 <0-4 11.40 6.40 14 12 10 8 6 4 2 0 2 4 6 8 Percentage %

There are ample cholera case management kits and the cholera treatment facilities are

2 adequately staffed for the current case-loads. In addition to case management, surveillance, and WASH interventions, a cholera vaccine campaign is planned for the second week of November 2017.

In Juba, 112 cases including one death (CFR 0.89%) were reported in the last four weeks [week 40-43]. Most of the cases seen in Juba in the last four weeks originated from Rejaf, Kator, and Northern Bari payams. An oral cholera vaccine campaign has been completed in Juba targeting both high-risk locations and areas with active transmission.

Fig. 4|Cholera cases per 10,000 by county in South Sudan, 2016 and 2017 15 Yirol West - 143 Yirol East - 1 Tonj North - 144 Tonj East - Terekeka 1 - Rubkona 22 70 0 Renk - Panyijiar 38 40 4 Nyirol - 0 Mayom - Mayendit 13 10 2017 2016 1 Malakal - Magwi -1 Leer - 10 87 Kapoeta … - 66 Kapoeta … - 88 Kapoeta East - Juba 14 35 131 Fashoda - Fangak 8 8 Duk 10 47 Canal Pigi 3 11 Budi 41 - 5 Bor 4 189 Ayod - Awerial 31 74

- 20 40 60 80 100 120 140 160 180 200 cholera cases per 10,000 population

Overall cholera trends

§ Since the start of the current outbreak on 18 June 2016, a total of 21,268 cases including 437 deaths (CFR 2.05%) have been reported from 26 counties. The most affected counties include Ayod, Tonj East, Yirol East, Fashoda, Kapoeta East, and Kapoeta South (Figure 4). § The most affected populations in these locations include: Landing sites/ towns along River Nile; cattle camp dwellers; populations living on islands - no social services; and IDPs - recently displaced with inadequate access to WASH.

3 Fig. 5|Cholera cases fatality rate (%) by county in South Sudan, 2016 and 2017 Yirol West 0% Yirol East 4% Tonj North 0% Tonj East 2% Terekeka 33% 0% Rubkona 1% Raja 0% Panyijiar 3% 7% Nyirol 3% Mayom 44% 2% Mayendit 3% Malakal 0% 2017 2016 Magwi 3% Leer 3% Kapoeta … 1% Kapoeta … 0% Kapoeta East 1% Juba 1% 2% Fashoda 2% Fangak 1% 1% 6% Duk 9% Canal Pigi 0% 3% Budi 11% Bor 3% Ayod 1% 2% Awerial 1% 1% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% cholera case fatality rate - CFR [%]

Cholera case fatality rates were highest in counties with poor access to health care especially in populations living in the islands and cattle camps (Figure 5). Overall, a higher proportion of females (51.9%) are affected than males (47.5%). Children and young adults are more affected. Figure 6 shows the age and sex distribution of cases. There are no significant sex differences after adjusting for age (marginally higher number of cases in females).

Fig 6|Cholera case distribution by age and sex, June 2016 - Oct 2017 90+ 0.00 85-89 0.00 80-84 0.10 0.10 75-79 0.10 0.10 70-74 0.30 0.30 65-69 0.30 0.40 60-64 0.80 1.10 55-59 0.60 0.60 50-54 1.30 1.50 45-49 1.50 1.80 40-44 1.90 2.40 35-39 2.60 3.30 30-34 3.30 4.60 25-29 3.60 5.00 20-24 3.10 4.00 15-19 3.40 4.30 10-14 5.70 5.40 5-9 7.50 6.50 0-4 11.20 10.20

15 10 5 Percentage %0 5 10 15

4 Fig.7|Cholera Epidemic Curve for South Sudan, week 23, 2016 to week 43, 2017 2000 20%

1500 Alive Died CFR% 15%

1000 10% CFR%

500 5% Number of cases/deaths

0 0% 2628303234363840424446485052 2 4 6 8 1012141618202224262830323436384042 2016 2017

Figure 7 shows the overall cholera epidemic curve for South Sudan. The highest transmission peaks were associated with outbreaks that affected cattle camps in the following counties – Awerial, Yirol East, Duk, Bor, Uror, Ayod, Kapoeta East, Kapoeta South, and Kapoeta North. The same locations also reported high CFR due to poor access to health care especially at the onset of the outbreak. In week 43, the CFR is 14.3% since only seven cases including one death were reported from Juba county.

As seen in Table 2, cholera cases have been confirmed every year since the onset of the South Sudan crisis in 2013. The 2016/17 outbreak is the longest and largest in magnitude and geographical extent. Due to the protracted crisis, displacements, insecurity, and declining investment in WASH, access to safe drinking water and sanitation facilities has declined significantly. Access to improved sanitation facilities is less than 10% while access to safe drinking water from improved water sources is estimated at 60%.

TABLE 2|CHOLERA OUTBREAKS IN SOUTH SUDAN 2014-2017

Summary measure 2014 2015 2016/17 No. cases 6,421 1,818 21,268

No. deaths 167 47 437 CFR% 2.60% 2.59% 2.05%

No. counties affected 16 3 26 Duration (weeks) 29 19 (72) Ongoing

Outbreak start date 24/04/2016 18/05/2016 18/06/2016 Date of last case 13/11/2016 24/09/2016 Ongoing

Attack rate [per 10,000] 27 17 45.8

5 Coordination of cholera response The National cholera task force is coordinating the overall cholera response. The task force meetings convene weekly on Wednesdays from 2 pm in the WHO conference hall in Juba.

Cholera response updates The overall response to cholera in South Sudan is coordinated by the national taskforce that is Chaired by MoH with support from WHO, Unicef, and partners (Health and WASH clusters).

The weekly cholera taskforce meetings are ongoing in Juba during which, the cholera situation and the ongoing cholera prevention and response activities in the affected and high-risk areas are reviewed.

During week 43, the cholera taskforce meeting was convened in Juba on 25 October 2017 to review the current cholera situation and status of outbreak response activities. In the same way, the oral cholera vaccine working group meeting was convened on 27 October 2017. The oral cholera vaccine working group meeting reviewed and updated plans for ongoing and planned oral cholera vaccine deployments.

Table 3: Oral cholera vaccine administrative coverage by round and site for 2017

Fig. 8|Administrative coverage (%) for OCV by site in 2017 200 First Round Second Round 150 83 100 56 38 58 Coverage % 50 92 98 85 81 81 76 85 81 88 69 64 62 74 59 0

Progress of oral cholera vaccine campaigns As part of the ongoing cholera response, cholera vaccines have been deployed to complement cholera response in several high-risk populations and locations. These areas include Leer, Bor PoC, Malakal Town, Bentiu PoC, Mingkaman IDP settlement, Aburoc IDPs, Bentiu/Rubkona Town, Ayod (Pagil, Tar, Jiech, Karmun, Padek, and Kandak), Juba (Don Bosco IDPs and additional high-risk locations), Tonj East and Marial Lou payam, Kapoeta North, Kapoeta South, and Kapoeta North. Out of the 1,440,358 doses secured by WHO in 2017, a total of 1 123 023 doses have been deployed (see Table 3).

The cholera vaccine campaign has been completed for select high-risk sites in Juba where 195,965 people one year and above received oral cholera vaccine in a campaign that lasted from 19 September to 7 October 2017. The lead implementing partner for the campaign was MSF-Swiss supported by HLSS, WHO, UNICEF, and the MoH.

6 Save the Children International (SCI) working with the CHD, MoH, WHO, and Unicef, completed the third round of the oral cholera vaccine campaign in Kapoeta North (Lomeyan, Paringa, Chumakori, Lokwamor, Wokubu, Nakwa, and Riwoto). A total of 10,116 persons one year and above were reached during the campaign that lasted from 16th to 21st October 2017.

Table 2: Cholera culture test results Jun 2016 - Sept 2017 Week 43 Cumulative (2016-2017) County Positive Positive Negative Total tested Abyei 1 1 Akobo 2 2 Awerial 55 63 118 Ayod 2 6 8 Bor 4 4 8 Budi 2 1 3 Duk 11 6 17 Fangak 31 50 81 Fashoda 7 14 21 Juba 9 265 288 553 Kapoeta East 2 10 10 Kodok 1 2 3 Lankien 3 1 4 Leer 9 13 22 Magwi 7 1 8 Malakal 2 21 23 Mayendit 4 6 10 Mayom 4 7 11 Panyijiar 1 1 Pibor 5 5 Pigi 2 4 6 Renk 2 2 Rubkona 30 91 121 Terekeka 2 2 Tonj East 8 8 16 Torit 5 5 Uror 2 2 Wau 6 6 Yirol East 10 12 23 Yirol West 4 4 Kapoeta South 12 12 24 Nyirol 3 1 4 Total tested 11 493 630 1,117

7 WASH CLUSTER RESPONSE UPDATES

Beneficiaries reached by WASH cluster partners in week 42

SOCIAL MOBILISATION UPDATES

Social Mobilization, Communication and Hygiene Promotion Reporting Format (14-20 October, 2017) Locations with ongoing Partners present Ongoing Action with number of population reached with Gaps and recommended action outbreak and hot spots Cholera interventions (Payam level) Tonj East: Most affected - CCM, THESO, UNICEF Implementing partner, The Health Support Makuac, Paliang, Paweng UNICEF, WHO and Organization (THESO) has been carrying on integrated Payam, Tonj South and SMOH community engagement activities covering critical health and Marial-Lou-Tonj North. nutrition lifesaving messaging. The thematic areas include (Warrap) cholera intervention, WASH, immunization, Malaria and best feeding practices. The partner also engaged communities at household level with critical demonstrations, community meetings, water-point and market awareness, school and cattle camps intervention in cholera hotspots and all other Payams and Bomas of Tonj East, Tonj North, Tonj South and Gogrial.

As of this week, 143 community mobilizers conducted household visits and reached 15676 households (about 45,000 people) with cholera and immunization messages.

A total of 10 schools with 2891 school children were sensitized on cholera prevention and control and important of immunization. 3 community meetings were also conducted in which 300 community leaders participated and 1 FGD session was conducted with 8 participants selected from different groups representing; women group, youth groups, teachers, and religious leaders

9 Two (2) market sessions were conducted educating 250 people including water vendors and six (6) round of public announcements have also been conducted in public places reaching an estimate of about 3000 people. Kapoeta East, South and - UNICEF, SSRC, ARC The Global hand washing day have been celebrated in Narus North and partners and Kapoeta south 4 secondary and 8 primary school participated, 2 minsters (Minister of education, Physical infrastructure CHD, WASH department, Mayor of Kapoeta, 5 partners including SSRC, participated the celebration, 6 Drama, 10 songs and 4 poems done on hand washing with soap, and cholera prevention, speeches were delivered to students and citizens on importance of personal hygiene and prevention of diarrhea diseases.

Bor, Twic East, Duk and CDNF No updates shared Pibor Jonglei (Akobo, Uror and Nile Hope and CHD No updates shared - Akobo Awerial County (Payams: CHADO and CHDs CHADO continue with community interaction sessions - Alel, Dor, Puluk, Bunangok, such as household visits with critical demonstrations, Nile Magok, Abuyong) community meetings, water-point and market awareness, school and cattle camps intervention in hot spots areas in Eastern Lakes

In Awerial, 618 households and 2250 individuals have been reached with cholera key messages by 28 trained community mobilisers. 31 primary school and 1986 pupils benefited from school-based interventions on

10 cholera awareness session carryout by community mobilizers at different schools in Awerial The community mobilizers conducted 54 water point sessions reached 420 people including water vendors with Cholera and diarrheal disease educative messages including demonstration on water treatment and proper storage Also, community mobilizers conducted 36 market awareness sessions and reached 340 individuals including food vendors in the mentioned counties in the same week, the social mobilizers conducted 40 community meetings and attended by 481 people inclusive of community leaders which comprise of local chiefs, religious leaders and women and youth leaders at different payams of Eastern Lakes. Religious leaders were engaged and at the time church services, Social mobilizers reached people with effective cholera messages in over 15 churches /parishes in the counties of Eastern reaching population with lifesaving messages on cholera control and prevention

11 CHADO conducted social mobilization outreach activities in 13 Cattle camps with total of 1986 individual

UNICEF supported partner, CHADO in collaboration with WASH cluster partners that include RUWASSA, HELP and CRS commemorated Global Handwashing on 16 October, 2017, in Mingkaman, Yirol East and Yirol West reaching 28 schools with a total of 4897 school children (3454 boys and1443 girls). The partners also engaged teachers, Women groups, NGO Partners, County of Education department, County of Health department and Eastern Lakes County Authorities were the key players. The celebration was comprised a lot of activities which include matching of the primary school pupils, drama group performances and speeches. The global hand washing day is a global advocacy day dedicated to increase awareness and understanding about the importance of hand washing with soap as an effective and affordable way to prevent disease and save lives.

12 Yirol East (Payams: Adior, CHADO and CHDs CHADO trained 27 Social mobilisers/health promoters - Malek, Lekakedu, Yali have conducted a range of community engagement Pagarau Tin-agau and activities in all Payams of Yirol East, which include Adior, Nyang) Malek, Lekakedu, Yali, Pagarau Tin-agau and Nyang. As of this week below were achievements;

28 trained community mobilisers in Yirol east, who have reached, 610 households 2206 people) with key messages on cholera prevention and control on the same note they have manage to conduct, 35 community meetings (610 people participated) 43 market session with total of 533 individuals reached, have reached 34 schools with total of 4449 pupils and 57 water sessions conducted with total of 586 individuals participated. The Religious leaders were also engaged: During religious services, to reach people with effective cholera key messages in the churches /parishes with lifesaving messages on cholera control and prevention. and have reached 12 churches/parishes in the county. Yirol West (Payams: Abang, CHADO and CHD In Yirol West, CHADO had 28 trained Social - In Anuol payam the health Anuol, Yirol Centre (Town), facility needs to be mobilisers/health promoters reached,630 households Geng-Geng, Geer, Aluak supported with some NFIs Luak, Mapuordit) 2034 people) with key messages on cholera prevention materials, and hand washing facilities, safe and control, 38 community meetings (377 people drinking water, and hygiene promotion

13 participated) 26 market session with total of 324 individuals conducted, they also reached 23 school with total of 2643 pupils. 40 water sessions conducted with total of 334 individuals participated in cleaning of jerry can and demonstration of hand-washing with soap and lean water. The engagement of religious leaders: Throughout religious services, community mobilizers reached people in over 9 churches /parishes in the Yirol West with lifesaving messages on cholera prevention and control.

Juba Health link, SMoH - Gurei, Kator, Lologo, and CHD As part of Mass media, a total of 14 FM stations continue Gumbo, Nesitu with airing of radio spots and talk-shows in Juba and Yei. As of 14-20 October, 2017, 980 times radio jingles have been broadcasted reaching over 2 million people across the country.

In commemoration of Global Handwashing Day, 15th October, 2017 which was celebrated on 16th, 672 radio jingles and 1 talk-show has been broadcasted through 14 radio channels reaching an estimated 1 million with key messages on importance of handwashing across greater Equatoria region. The event was also celebrated in Don Bosco Primary schools in Gumbo attended by over 5000 people including school children, implementing partners, government officials and host community.

This week, street announcement of cholera messages has been ongoing through Five (5) Public Address Systems (PAs) in five main areas of the City namely; Rejaf, Kator, Juba, Munuki and Nyar-kenyi/Northern Bari. The PAs conducts 5 hours’ announcements per day (3 hr. morning and 2hrs evening).

UNICEF partner Health Link South Sudan continue with social mobilization activities in the catchment areas of the nine (9) ORPs in Juba City and Lokiliri. This week, 45 trained community mobilizers conducted house-to-house visits covering 4,05 households (22,087 people) with cholera messages in cholera hotspots areas that include Gurei, Kator, Lologo, Gumbo, Munuki, Khor William, Nyakuron and Nesitu. The households also reached WASH and Health supplies distributed (690 sachets of ORS, 3,647 sachets of PUR and 5,727 chlorine tabs).

Upper Nile (Maban, Melut Mobile Theater No updates shared - and Renk) Team and CHD

UNICEF supported partner, CHADO carrying out cholera intervention and Global Handwashing in Awerial, Yirol and Yirol West

Celebration of Global Handwashing Day in Narus, Kapoeta East

THESO and partners commemorating Global Handwashing event in in greater Tonj and Gogrial

Contacts Dr. Mathew Tut Dr. Joseph F. Wamala Director, Emergency Preparedness and Response Epidemiologist Ministry of Health, Ministerial ComplexJuba, Republic of South Sudan World Health Organization Email: [email protected] Ministerial Complex Juba, Republic of South Sudan Email: [email protected]