• Overall, malaria is the top cause of morbidity accounting for 55.5% of the total consultations in week 47; followed by ARI (12.2%), and AWD (9.1%). Trend in consultations and key diseases IDSR trends in absolute counts
Figure 3 | Trend in total consultations and key diseases (W39)
275000
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0 6 7 6 6 7 7 6 7 7 7 7 7 7 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2
9 9 8 4 8 3 2 6 2 5 1 9 5 3 0 4 4 1 1 5 2 2 0 3 3 3 W W W W W W W W W W W W W
Total consultations Acute Watery Diarrhoea
Malaria Acute Jaundice Syndrome (AJS)
Acute Respiratory Infection (ARI) Measles
5 W39 2017 (Sep 25-Oct 01)
Trend in consultations and key diseases IDSR Proportionate morbidity trends
Figure 3 | Trend in total consultations and key diseases (W39) Fig. 1|IDSR Proportionate morbidity trends, week 1 to 47, 2017 275000 70% 160 250000 140 60% 225000 Thousands 120 200000 50% 100 175000 40% 80 150000 r e
b 30% Morbidity % m
u 60
N 125000 20% 40 100000 10% 20 Number of consultations 75000
0% 0 50000 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344454647 Epidemiological week of reporting in 2017 25000
0 Consultations Malaria ARI AWD ABD Measles 6 7 6 6 7 7 6 7 7 7 7 7 7 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2
9 9 8 4 8 3 2 6 2 5 1 9 5 3 0 4 4 1 1 5 2 2 0 3 3 3 W W W W W W W W W W W W W In the relatively stable states, Total consultations malaria is the top cause of morbidity accounting Acute Watery Diarrhoea Malaria Acute Jaundice Syndrome (AJS) for 44.4% of the consultations in week Acute Respiratory Infection (ARI) 47 Mwith a cumulative easles 41.3% in 2017. The malaria proportionate morbidity increased from an average of 30% prior to the malaria transmission season to nearly 44.4% currently. 5 W39 2017 (Sep 25-Oct 01)
Trend in consultations and key diseases IDP Proportionate morbidity trends
Figure 3 | Trend in total consultations and key diseases (W39)
275000 Fig. 2|IDP Proportionate morbidity trends, week 01-47, 2017
250000 45% 50,000 45,000 225000 40% 40,000 35% 200000 35,000 30%
175000 30,000 25%
% of Mobidity 25,000 Consultations 150000 r 20% e
b 20,000 m u
N 15% 125000 15,000 10% 10,000 100000 5% 5,000
75000 0% 0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344454647 50000 Epi week 2017
25000 Consultations Malaria ARI AWD ABD Measles 0 6 7 6 6 7 7 6 7 7 7 7 7 7 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2
9 9 8 4 8 3 2 6 2 5 1 9 5 3 0 4 4 1 1 5 2 2 0 3 3 3 W W W W W W W W W W W W W
Total consultations Acute Watery Diarrhoea In the IDPs, ARI surpassed malaria as the top cause of morbidity in week Malaria Acute Jaundice Syndrome (AJS) 45. Hence ARI and malaria accounted for Acute Respiratory Infection (ARI) 24.9% Measlesand 20.5% of consultations in week 47.
5 W39 2017 (Sep 25-Oct 01)
Since the beginning of 2017, at least 1,131 suspect measles cases including at least 11 deaths (CFR 0.97%) have been reported. Of these, 616 suspect cases have undergone measles case-based laboratory-backed investigation. At least 323 samples have been collected, with a total of 84 measles cases being laboratory confirmed, while 321 cases and 26 cases were epidemiologically and clinically confirmed respectively. Consequently, measles outbreaks were confirmed in nine counties – Panyijiar, Aweil South, Gogrial East, Gogrial West, Wau, Juba, Torit, Yambio, and Jur River. Measles follow up campaign implemented from May 2017 in eight state hubs where 1,639,947 children six to 49 months (87%) were reached with measles vaccine.
Rainfall experience for October 2017
• Maps show rainfall for October 2017 percentage of average( less than 25% bellow is bellow normal, 75-125% is normal , greater than 125% is above normal) and standardized precipitation index(SPI) • In October 2017; all counties received either normal or below normal rains apart from Kapoeta South; Kapoeta North; Kapoeta East; and Budi that were extremely wet (SPI - map).
• Projections for November 2017 show that the Southern States are likely to receive >300mm of rainfall; areas of central South Sudan will likely receive 10mm-100mm of rainfall; while northern South Sudan will receive the least (<10mm) of rain fall. • Most malaria cases are occurring in counties in IPC crisis phase • Two counties with high malaria cases are in IPC emergency phase - • Many of the counties in Jonglei are in IPC crisis phase but malaria surveillance data is not available for those locations Counties with malaria cases exceeding the third quartile in week 45 of 2017 Malaria trends by county
1,800 Malaria trends for Terekeka county in 2017 1,600 o At least 23 countries - Awerial, Cueibet, 1,400
1,200 3rd Quartile C-sum 2017 1,000 Rumbek East, Rumbek North, Wulu, Yirol 800 600 East, Yirol West, Aweil East, Aweil North, 400
200 - Aweil South, Jur River, Gogrial East, Tonj Weeks North, Tonj South, Rubkona, Twic East, Duk,
600 Malaria trends for Kapoeta East county in 2017 Kapoeta North, Ikotos, Kapoeta East, &
500
400 Terekeka have reported increasing trends at 3rd Quartile C-sum 2017 300 or above the third quartile [see next four 200 100 slides].
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Weeks
1,200 Malaria trends for Ikotos county in 2017
1,000
800 3rd Quartile C-sum 2017
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400
200
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700 Malaria trends for Kapoeta North county in 2017
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500
3rd Quartile C-sum 2017 400
300
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100
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Weeks
Malaria trends by county and rainfall patterns Counties with malaria cases exceeding the third quartile in week 45 of 2017
500 Malaria trends for Duk county in 2017 450 In October 2017; 4 counties 400
350
300 3rd Quartile C-sum 2017 received rainfall that exceed the
250 200 third quartile of the rainfall for 150
100 50 period 2013-2016. These -
Weeks counties should be monitored for potential increase in malaria 600 Malaria trends for Twic East county in 2017 500 cases (see table)
400 3rd Quartile C-sum 2017
300 200 County 100
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Weeks Budi
2,500 Malaria trends for Awerial county in 2017 Kapoeta East
2,000
1,500 3rd Quartile C-sum 2017 Kapoeta South
1,000
500 Kapoeta North
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2,500 Malaria trends for Cueibet county in 2017
2,000
1,500 3rd Quartile C-sum 2017
1,000
500
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Malaria trends by county and Counties with malaria cases exceeding the third quartile in week 45 of 2017rainfall patterns
4,000 Malaria trends for Rumbek Center county in 2017 3,500 • During 2017, the mean rainfall 3,000 2,500 3rd Quartile C-sum 2017 in millimeters increased from 2,000 1,500 2.7 and 13 in January and 1,000
500
- February to a peak of 158-185 Weeks in July, August, and
9,000 Malaria trends for Rumbek East county in 2017 September). 8,000
7,000
6,000 3rd Quartile C-sum 2017 5,000 • The mean precipitation 4,000 3,000 reduced from 158 millimeters 2,000
1,000
- in September 2017 to 85.5 Weeks millimeters in October 2017
1,200 Malaria trends for Rumbek North County in 2017
1,000
800 3rd Quartile C-sum 2017
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200
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1,200 Malaria trends for Wulu County in 2017
1,000
800 3rd Quartile C-sum 2017
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200
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Counties with malaria cases exceeding the third quartile in week 45 of 2017 Malaria trends by county and rainfall predictions for October to December 2017 2,500 Malaria trends for Yirol East County in 2017 The rainfall outlook for Oct-Dec 2,000
1,500 3rd Quartile C-sum 2017 2017 as shared by the IGAD
1,000 climate prediction & application 500 center (ICPAC) shows that: - Weeks • Southwestern parts the country 7,000 Malaria trends for Yirol East County in 2017 will likely receive normal to 6,000 5,000 above normal rainfall (near to 3rd Quartile C-sum 2017 4,000
3,000 below normal rains in rest of
2,000
1,000 country)
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Weeks • Above normal temperatures
2,500 Malaria trends for Aweil Center County in 2017 countrywide 2,000 • 3rd Quartile C-sum 2017 The above normal rains in the 1,500
1,000 southwest will likely lead to 500 flooding, a protracted malaria
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Weeks transmission season, increased
risk of waterborne diseases 16,000 Malaria trends for Aweil East County in 2017
14,000 12,000 • In the rest of country, low rains 10,000 3rd Quartile C-sum 2017 8,000 will likely reduce quality of water 6,000 4,000 thus a possibly exaggerated risk 2,000 - of waterborne diseases Weeks
Malaria trends by county Counties with malaria cases exceeding the third quartile in week 45 of 2017and proposed mitigation measures
3,500 Malaria trends for Aweil North County in 2017
3,000 Proposed mitigation measures for
2,500
3rd Quartile C-sum 2017 areas expected to receive normal 2,000 1,500 or above normal rain: 1,000
500
- • Contingency planning, risk Weeks communication
1,400 Malaria trends for Rubkona County in 2017
1,200 • Preposition kits for malaria,
1,000
3rd Quartile C-sum 2017 800 waterborne diseases
600 400 • Enhance surveillance for malaria, 200
- AWDs Weeks • Preventive vaccination where 3,000 Malaria trends for Jur River County in 2017
2,500 applicable
2,000 3rd Quartile C-sum 2017 1,500 As for areas expected to have less 1,000
500 than normal rains, the - recommended measures entail: Weeks • Enhance WASH, water quality 5,000 Malaria trends for Gogrial East County in 2017
4,500 4,000 testing, water trucking, & water 3,500
3,000 3rd Quartile C-sum 2017
2,500 treatment
2,000
1,500 1,000 • Nutrition surveillance & 500 - prepositioning of SAM kits Weeks
Counties with malaria cases exceeding the third quartile in week 45 of 2017Malaria trends by county and proposed mitigation measures
3,000 Malaria trends for Tonj East County in 2017
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2,000 3rd Quartile C-sum 2017
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4,500 Malaria trends for Tonj North County in 2017
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3,000 Malaria trends for Tonj South County in 2017
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2,000 3rd Quartile C-sum 2017
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Malaria trends in select IDP sites
Figure 10a | Malaria trend for IDPs in Bentiu PoC 2017 70 Figure 10b | Malaria trend for IDPs in Malakal PoC, 2017
60 80
70 50 60 40 50
30 40
30 20 20 Proportionate morbidity %
10 Proportionate morbidity % 10
- - 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 Week of reporting Epi Week Third quartile Prop mob 2017 Third quartile Prop mob 2017
Figure 10c | EWARN trends for Malaria in UN House, 2017 50 Figure 10d| EWARN trends for Malaria in Renk, 2017 50 45 45 40
40 35
35 30 30 25 25 20 20
Proportionate mrobidity % 15 15 Proportionate morbidity % 10 10 5 5
- - 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Epi week Third quartile Prop mob 2017 Third quartile Prop mob 2017
Malaria trends in four of the large IDP sites - Bentiu Poc; UN House Poc; Malakal PoC; and Renk are either at or below the third quartile
patients. Currently one team is in Kapoeta South and Kapoeta East the next teams will travel to Malakal and Fangak
IMA/KalaCore in collaboration with WHO/MOH have responded to two suspected cases (both are children) of KA at Alshaba Hospital in Juba. One of the cases is positive, currently on treatment and the other negative. Strengthening coordination amongst partners, there will be KA coordination meeting on the 3rd of Nov 2017. Conduct training on the use of IEC materials and conduct KA awareness using the IEC materials in KA endemic areas. Visceral Leishmaniasis | Kala-azar
Kala-azar is endemic in Upper Nile, Unity, Jonglei, & Kapoeta. Response interventions have been complicated by insecurity, population displacement, poor living conditions, increasing food insecurity, closure of treatment facilities; and low treatment completion rates.
Since the beginning of 2017, a total of 2,722 cases including 56 deaths (CFR 2.1%); 23 (0.8%) defaulters; 2,339 (85.9%) new cases; 119(4.4%) PKDL; and 264(9.7%) relapses - all reported from less than half of the 23 treatment centers.
In the corresponding period of 2016, a total of 3,513 cases including 85 deaths (CFR 2.6%) and 65(2.0%) defaulters were reported from 21 treatment centers. rd th Graph:1Cummulative number of VL new cases by 43 (23 Oct 2017 – 29 Oct 2017). The majority of cases in 2017 have been reported from Lankien (1,181), Old Fangak (733), Kurwai (201), Chuil (103), Walgak (122), Pagil (62), Malakal IDP (96), Kapoeta (42), and Bunj (45).
The most affected groups include, males [1,322 cases (48.6%)], those aged 5 - 14years [1,112(40.9%) and ≥15years and above [922 cases (33.9%)]. A total of 519 cases (19.1%)] occurred in children <5years.
We are currently in the peak transmission season [September to December]. Hence current efforts by the taskforce entail training of health workers, and stocking ample supplies of diagnostics and medicines at all designated treatment centers.
In recent years, we have seen more than expected transmission from September to December in areas affected by conflict, displacement, severe food insecurity, and poor living conditions.
Graph: 2 Cumulative numbers of VL new cases and total cases by facilities – Week 1- to 43
3
Hepatitis E Virus (HEV)
Hepatitis E virus transmission continues to be reported in 16 350 displaced populations. Genotype 1 has been isolated 14 300 from these outbreaks since 12 250 2012. This therefore suggests 10 sub-optimal access to safe 200 water and sanitation as 8 150 transmission drivers. 6 4 100
Cumulatively, a total of 452 2 50 No. cases in Bentiu No, cases in other sites HEV cases have been reported 0 0 from Bentiu PoC in 2017 [one 3 9 152127333945515 11172329354147536 121824303642482 8 1420263238 case reported in the week]. (Fig. 19). Current response entails 2014 2015 2016 2017 behavior change communication to improve Epidemiological week hygiene, access to safe water, Awerial Lankien Bentiu and sanitation. Since the beginning of the crisis, 3,692 HEV cases including 25 deaths (CFR 0.68%) reported in Bentiu; 174 cases including seven deaths (CFR 4.4%) in Mingkaman; 38 cases including one death (CFR 2.6%) in Lankien; 3 confirmed HEV cases in Melut; 3 HEV confirmed cases in Guit;1 HEV confirmed case in Leer; and Mayom/Abyei [75 cases including 13 deaths with 7 HEV PCR positive cases. 2016 By County
2017 Acute Flaccid Paralysis | Suspected Polio In week 47, nine new AFP cases were reported [five in Eastern Equatoria; one in Unity; one in Upper Nile; one in Warrap; and one in Western Equatoria].
During 2017, a cumulative of 340 AFP cases have been reported countrywide. The annualized non- Polio AFP (NPAFP) rate (cases per 100,000 population children 0-14 years) is 4.57 per 100,000 population of children 0-14 years (target ≥2 per 100,000 children 0-14 years).
Stool adequacy was 89% in 2017, a rate that is higher than*As of the epidemiological target of ≥80 week%. 47/2017 Environmental surveillance ongoing since May # of Counties / stool adequacy rates in 2017* 2017; with 20 samples testing positive for non- polio enterovirus. State Hubs =0 >0<80 80-89% >90 Total CENTRAL EQUATORIA HUB 3 0 1 2 6 Source: South Sudan Weekly AFP Bulletin EASTERN EQUATORIA HUB 1 0 0 7 8 JONGLEI HUB 3 1 0 7 11 LAKES HUB 0 0 1 7 8
NORTHERN BAHR EL GHAZAL HUB 0 1 2 2 5
UNITY HUB 3 3 0 3 9 UPPER NILE HUB 5 3 1 3 12 WARRAP HUB 0 0 1 6 7
WESTERN BAHR EL GHAZAL HUB 0 2 0 1 3
WESTERN EQUATORIA HUB 0 0 0 10 10
Total number 15 10 6 48 79
Percent 20% 16% 8% 56% 100% *As of epidemiological week 47/2017 Mortality in the IDPs
Bentiu Proportionate Table 6 | Proportional mortality by cause of death in Cause of Death by IDP site <5yrs ≥5yrs Total deaths mortality [%] IDPs W46 2017 Hepatitis B 1 1 6 Malaria 1 1 2 13 Perinatal death 1 1 6 Sepsis 1 1 2 13 Unknown 2 2 13 Susp. TB 2 2 13 TB/HIV 2 2 13 Resp. distress 1 1 6 HIV/AIDS 3 3 19 Total deaths 3 13 16 100
Prospective mortality surveillance is ongoing in the large internally displaced population camps that are principally located in the UN Protection of Civilian sites in Bentiu, Malakal, Wau, and Juba.
Among the IDPs from these locations, mortality data was received from Akobo, Wau PoC, and UN House PoC in week 46. (Table 6). Sixteen deaths were reported during the reporting week. Bentiu PoC reported 16 (100%) deaths in the week. During the week, 3 (19%) deaths were recorded among children <5 years in (Table 6).
The causes of death in the IDP sites during the current week are shown in Table 6. The top causes of mortality in the week was HIV/AIDS. Crude and under five mortality rates in IDPs
Figure 20 | EWARN U5MR by Site - W1 2016 to W 46 of 2017 Figure 21 | EWARN Crude Mortality Rate for W1 2016 to W 46 of 2017 1.6 2.5 1.4 2.0 1.2 1.0 1.5 0.8 1.0 0.6 0.4 0.5 deaths per 10,000 per day
deaths per 10,000 per day 0.2 0.0 0.0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 2016 2017 2016 2017 Epidemiological week Epidemiological week Bentiu Juba 3 Malakal Melut Bentiu Juba 3 Malakal Threshold Wau PoC Akobo Wau Shiluk Threshold Wau PoC
The U5MR in all the IDP sites that submitted mortality data in week 46 of 2017 is below the emergency threshold of 2 deaths per 10,000 per day (Fig. 20).
The Crude Mortality Rates [CMR] in all the IDP sites that submitted mortality data in week 46 of 2017 were below the emergency threshold of 1 death per 10,000 per day (Fig. 21). Overall mortality in the IDPs in 2017
week 45Table 7 | Mortality by IDP site and cause of death as of W46, 2017
IDP site Acute watery diarrhoea GSW Heart Failure Kala-Azar Malaria Maternal death Meningitis Perinatal death Pneumonia Rabies SAM Stroke TB/HIV/AIDS Cancer Cholera HIV/AIDS Hypertention Susp. TB TB Others Total deaths Bentiu 21 10 14 2 42 4 3 32 19 1 56 3 7 10 2 11 26 23 236 522 Juba 3 3 5 18 11 20 1 1 2 15 1 2 14 33 126 Kodok 1 2 3 Malakal 2 2 7 5 2 5 6 1 1 6 64 101 Akobo 3 2 2 17 8 1 1 1 13 48 Bor POC 1 14 15 Wau PoC 9 1 1 1 1 6 19 Total deaths 36 12 21 4 79 6 3 51 52 2 58 9 8 19 2 28 2 31 43 368 834 Proportionate mortality [%] 4.3 1.4 2.5 0.5 9.5 0.7 0.4 6.1 6.2 0.2 7.0 1.1 1.0 2.3 0.2 3.4 0.2 3.7 5.2 44.1 100.0
• A total of 834 deaths have been reported from the IDP sites in 2017 Table 7.
• The top causes of mortality in the IDPs in 2017 include malaria, medical complications of malnutrition, pneumonia, perinatal complications, and TB are shown in Table 7. For more help and support, please contact:
Dr. Pinyi Nyimol Mawien Director General Preventive Health Services Ministry of Health Republic of South Sudan
Telephone: +211 955 604 020
Dr. Mathew Tut Moses Director Emergency Preparedness and Response (EPR) Ministry of Health Republic of South Sudan
Telephone: +211 956 420 189 Notes
WHO and the Ministry of Health gratefully acknowledge 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 financial support.
The data has been collected with support from the EWARS project. This is an initiative to strengthen early warning, 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 automatically published from the EWARS application.
More information can be found at http://ewars-project.org
Ministry of Health Republic of South Sudan