Republic of South Sudan
Situation Report #108 on Cholera in South Sudan As at 23:59 Hours, 17 February 2017
Situation Update A total of 12 counties in 9 (28%) of 32 states countrywide have confirmed cholera outbreaks (Table 1; Figure 1.0). The most recent cases were confirmed in Mingkaman, Eastern Lakes state on 13 February 2017. Suspect cholera cases are being investigated and responded to in Adior, Shambe, and Langmatot in Yirol East county; Panyagor in Twic East county; and Moldova in Duk county (Table 4). During week 7 of 2017, a total of 8 samples from Mingkaman in Eastern Lakes tested positive for cholera (Table 3). Cumulatively, 179 (37.8 %) samples have tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 17 February 2017 (Table 3).
Table 1: Summary of cholera cases reported in South Sudan as of 17 February 2017 New New New Total cases Total Total Total Total cases Reporting Sites admissions discharges deaths WK currently facility community Total cases deaths discharged WK 7 WK 7 7 admitted deaths deaths
Jubek – Juba - - - - 8 19 27 2,018 2,045
Jonglei-Duk - - - - 3 5 8 92 100
Jonglei-Bor 23 15 - 7 1 3 4 45 56
Terekeka - - - - - 8 8 14 22
Eastern Lakes - 32 42 - 14 2 8 10 450 474 Awerial
Imatong - Pageri - - - - - 1 1 28 29
Western Bieh - - - - - 4 - 4 266 270 Fangak
Northern Liech - - - - - 7 2 9 1,145 1,154 Rubkona
Southern Liech - - - - - 3 - 3 91 94 Leer
Southern Liech - - - - - 17 4 21 435 456 Panyijiar
Southern Liech - 1 1 - - - 5 5 204 209 Mayendit
Central Upper 5 176 Nile - Pigi 1 1 5 171
Total 57 59 - 21 50 55 105 4,959 5,085
Highlights in week 7 of 2017: 1. Eight cholera cases confirmed in Mingkaman where 32 new cases reported in the week Table 3. 2. An integrated response has been rolled out in Yirol East, Twic East, and Duk including the hard-to-reach populations on the Islands Table 4. 3. A total of 57 new cholera cases reported from Awerial, Bor South, Mayendit, and Pigi in week 7 Table 1.
1 In Northern Liech state, at least 1,154 cholera cases including 31 confirmed cases and nine deaths (CFR 0.78%) 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. Ongoing transmission is associated with exposure to water from an unsecured water reservoir; continued arrival of new people in the PoC thus straining existing WASH amenities; continued new arrivals from cholera affected areas; and the fact that its more than two years since the last oral cholera vaccine campaigns. Bentiu PoC now has the highest cumulative incidence for cholera Table 1.1. Cholera risk assessment and vaccination microplanning have been finalized to facilitate complementary vaccination using oral cholera vaccines in Bentiu PoC.
In Southern Liech, two cholera cases originating from Leer Town tested positive for Vibrio cholerae Inaba on 11 October 2016. One additional case from Ganyliel in Panyijiar tested positive for cholera on 3 January 2017; and on 31 January, two samples from Madol in Mayendit tested positive for cholera by culturing. Cumulatively, 94 cholera cases including three deaths have been line listed from Leer and at least 456 cases including 21 deaths from Panyijiar in Southern Liech state. The initial case in Panyijiar was seen on 22 October 2016 involving a trader from Duk. Facility and community based response is ongoing with most cases being managed in facilities like Duong PHCC, Ganyliel PHCC, and Nyal PHCC with support from IRC, and UNIDO.
Since 7 October 2016, at least 209 cholera cases including five deaths were reported by UNIDO and MedAir response teams in Mayendit. The MedAir CTU in Madol 1 has seen at least 89 cases aged 2 years and above since 7 January 2017. Cholera risk assessment and microplanning have been finalized to facilitate complementary vaccination using oral cholera vaccines in Panyijiar and Mayendit.
Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 17 February 2017
World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24, 2016 to 6 of 2017
Map Date: 11 February, 2017 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 0.70 2.92 1.48 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Leer Tonj NorthMayendit Ayod 4.08 1.99 Ethiopia Tonj East Duk Panyijiar Uror Akobo Jur River Rumbek North 8.7 4.29 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Bor South Nagero Yirol West Awerial 17.39 Pibor Wulu Tambura 1.24 Mvolo Legend Terekeka xx Case fatality rate (CFR) 36.36 Counties with Cholera alert Mundri WestMundri East Lafon Kapoeta North Cases per 10,000 population Ezo Ibba Maridi Kapoeta East Juba > 60 Yambio Nzara 1.32 46 - 60 Kapoeta South 31 - 45 Torit Budi Yei Lainya 16 - 30 Magwi Ikotos 0.1 - 15 Kajo-Keji 3.45 Kenya No case reported Morobo Pageri River Democratic Republic of Congo Uganda
2 Figure 1.1: New cholera cases admitted by location in week 6 and 7 of 2017
60 56
50
40 32 week 6 week 7 30 23
20 17 13 13 Number of Cases 10 3 4 2 1 1 0 Awerial Duk Bor South Rubkona Panyijiar Mayendit Pigi- canal Eastern Lakes Jonglei Northern Liech Southern Liech Central Upper Nile
In Eastern Lakes state, cholera cases were reported in Mingkaman IDP settlement and response for the suspect cases in Yirol East is ongoing. The initial cases in Mingkaman were confirmed on 24 August 2016, after two of four samples tested postive for Vibrio cholerae Inaba. The cumulative cases in Mingkaman are 474 cholera cases including 27 confirmed cases and 10 deaths (two facility and eight community) (CFR 2.11 %). However; after a lull of two weeks with only sporadic transmission since 16 December 2016, new cases were reported from 26 January 2017 with a total of 121 new cases including five deaths being reported since the beginning of 2017 (Fig 2.1). The new cases have been reported from informal settlemements in Mingkaman with inadequate no access to safe water and sanitation facilites. Current response is led by the CHD with support from CUAMM and HLSS. A MoH/WHO rapid response team was dispatched on 8 February 2017 with supplies to augment the response in Mingkaman. In Shambe, Yirol East, at least 187 suspect cholera cases including 16 deaths in reported since 1 Feb. 2017 Table 4. Initial response in Yirol East is led by the state MoH, the CHD, and CUAMM supported by WHO, UNICEF, Health and WASH cluster partners – IOM, MSF-B.
In Jonglei state, 100 cholera cases including 8 deaths (CFR 8 %) 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. Eight of the recent cholera cases in Bor hospital originated from Duk. A rapid response team dispatched with supplies to Duk on 19 Feb. 17.
Figure 1.2: Cumulative cholera cases by state and county of residence as at 17 February 2017
2500
2045 2000
1500 1151
1000 Number of Cases 456 474 500 269 209 176 94 100 1 22 3 56 29 0 FANGAK Leer Terekeka Leer Mayendit Panyijiar Leer Rubkona Juba Bor South Duk Pageri Awerial Pigi- canal Western Bieh Terekeka Southern Liech Northern Liech Jubek Jonglei Imatong Eastern Lakes Central Upper N ile
3 In Bor South, the initial suspect cholera cases were reported on 30 January 2017 by Jalle Pagam PHCC. The initial cluster involved eight suspect cholera cases including four deaths (two community deaths) – all from Kuei Islands. An initial verification and response mission was undertaken by Health and WASH partners on 31 Jan. 2017. The MoH-led and WHO-supported rapid response is currently working with the taskforce in Bor to support alert verification and response. Cholera was eventually confirmed after four samples tested positive for Vibrio cholerae on 9 Feb. 17. A total of 56 cholera cases including four confirmed cases and four deaths (CFR 7.14%) have been reported in Bor South County.
Table 1.1: Cholera cases and deaths by state and county as of 17 February 2017 Week 7 Weeks 24, 2016 to 7 of 2017 New Cases per Population cases 10,000 No. Cases per 10,000 State County at risk W7 population cases population CFR [%] Western Bieh Fangak 139,509 0 - 270 19.4 1.48 Northern Liech Rubkona 126,976 0 - 1154 90.9 0.78 Southern Liech Leer 67,167 0 - 94 14.0 3.19 Southern Liech Panyijiar 64,254 0 - 456 71.0 4.61 Southern Liech Mayendit 68,131 1 0.15 209 30.7 2.39 Eastern Lakes Awerial 114,837 32 2.79 474 41.3 2.11 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Bor South 331,611 23 0.69 56 1.7 7.14 Jonglei Duk 26,180 0 - 100 38.2 8 Jubek Juba 471,762 0 - 2,045 43.3 1.32 Terekeka Terekeka 177,849 0 - 22 1.2 36.36 Central Upper Nile Pigi 125,496 1 0.08 176 14.0 2.84 Total 1,928,902 57 0.30 5,085 26.4 2.06
Cumulatively, 5,085 cholera cases including 105 deaths (50 facilities and 55 community) (CFR 2.06%) have been 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; 11 October 2016 for Leer and 22 October 2016 for Panyijiar in Southern Liech state; 10 October 2016 for Pigi in Central Upper Nile state; 7 October 2016 for Mayendit in Southern Liech state; 30 January 2017 for Bor South in Jonglei state (Figure 2.1 and Table 1.1).
Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 17 February 2017
350 25
300 21 20 250 17 200 15
316 316 150 10 CFR [%]
Number of cases 217 100 181 185 189 7 168 4 5 5 101 50 35 3 97 3 3 3 2 3 2 2 2 2 2 2 2 1 1 2 431 31 28 1 0 1 1 221 22 121 18 131 1 1 1 231 1 0 01 0 04 0 5 1 5 5 5 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 1 2 3 4 5 6 7 Epidemiological week of onset 2016 2017 Jonglei Jubek Terekeka Imatong Eastern Lakes Western Bieh Northern Liech Southern Liech Central Upper Nile CFR[%]
4 Figure 3:1 Cholera case distribution by gender and county 17 February 2017
Cholera case gender distributionby IDP site wk 27 of 2016 to week 7 of 2107
100%
90%
35 80% 39 41 44 42 45 49 49 53 50 55 57 55 70%
60%
50%
40% e itiuin % Sex distribution
65 30% 61 59 56 58 55 51 51 47 50 45 43 45 20%
10%
0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Overall
Female Male
Overall, there are more cholera cases in females (55%) when compared to the males (45%). The gender distribution of cholera cases by county is shown in Figure 3.1.
Figure 3:2 Cholera case distribution age in South Sudan 17 February 2017 Cholera case age distributionby IDP site wk 27 of 2016 to week7 of 2017
25 23.6
20
15.6 15
10.9 10 7.8 8.2 7.1 7.3 g itiuin % Age distribution 5.5 5 3.6 2.9 1.8 1.8 1.8 1.3 0.9
0
+yrs 9yrs - 14yrs 24yrs <5yrs 19yrs 29yrs 34yrs 39yrs 44yrs 49yrs 54yrs 59yrs 64yrs 69yrs ------5 70 10 20 15 25 30 35 40 45 50 55 60 65
Figure 3:3 Cholera case distribution by age and county in South Sudan 17 February 2017
Cholera case age distributionby IDP site wk 27 of 2016 to week 7 of 2107
100%
90%
80%
70%
60%
50%
40% g itiuin % Age distribution
30%
20%
10%
0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka
<5yrs 5-9yrs 10-14yrs 15-19yrs 20-24yrs 25-29yrs 30-34yrs 35-39yrs 40-44yrs 45-49yrs 50-54yrs 55-59yrs 60-64yrs 65-69yrs 70+yrs
5 Children under 19 years constitute nearly 60% of the total cholera cases Figure 3.2. The age distribution of cholera cases by county is shown in Figure 3.3.
Probable risk factors 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.
Other factors 1. Due to the protracted nature of the crisis since 2013, there has been destruction of infrastructure and limited investments to improve social services to the general population as such, living conditions have deteriorated with declining access to safe water and sanitation amenities. 2. Due to the worsening, economic situation, the cost of accessing safe water from the water trucks has increased substantially thus forcing households to resort to unsafe water sources. In Southern Liech, humanitarian access remained limited due to persistent hostilities that kept away partners and thus impeding the initiation of comprehensive and sustained cholera interventions to interrupt transmission and prevent widespread and protracted outbreak. Consequently, transmission has continued in Southern Liech since late September 2016 with continued case spillovers to Bentiu, Panyijiar, Awerial, and Bor South. 3. While WASH partners have endeavoured to improve access to safe water and sanitation in Bentiu PoC; the continued arrival of people into the PoC has remained a challenge. In addition, current transmission in Bentiu PoC is linked to an oxidation water pond that is being used for bathing, washing, swimming and sometimes to collect water for household use since its water is soft and considered more palatable by the local population. The pond therefore needs to be secured-off to stem the ongoing transmission and to prevent future outbreaks. 4. During the protracted crisis, cholera transmission hotspots have expanded to include the following: a. Internally Displaced persons – UN House PoC, Bentiu PoC, Bor PoC, Mingkaman, Wau, and Malakal, Melut, and Wau Shiluk. b. Refugee populations c. Neighbourhoods in urban settings with inadequate access to safe water and sanitation – Juba, Torit, Bor, etc. d. Towns and counties along the Nile – Nimule, Juba, Bor, Terekeka, Leer, Panyijiar, Ayod, Fangak, Pigi, Malakal etc. e. Populations on islands with nearly no access to health care and at risk for high mortality from cholera – Terekeka, Leer, Duk, Ayod, Kuei, Yirol East etc.
Laboratory updates Table 3: Cholera laboratory test results for Juba by 17 February 2017
Culture results State New positives in Cumulative Cumulative Total tested week 7 Positive Negative Central Upper Nile 0 0 5 5 Jonglei-Duk 0 1 4 5 Jonglei-Bor South 0 4 1 5 Jubek 0 83 133 216 Terekeka 0 2 0 2 Eastern Lakes 8 27 42 77 Imatong 0 7 1 8 Fangak 0 16 37 45 Wau 0 0 6 6 Boma 0 0 2 2 Northern Liech 0 31 57 88 Southern Liech – Leer 0 2 0 2 Southern Liech - Panyijiar 0 1 0 1 Southern Liech – Mayendit 0 2 2 4 Central Upper Nile (Pigi) 0 3 5 8 Total tested 8 179 295 474
6 Table 4: Cholera Alerts Date of Details of the alert Area Action notification No alerts 26-Jan-17 Total suspected cases: 187 (102 Adior, Shambe, Current response in Yirol East is led by suspect cases including 6 Lang-Matot, and the state MoH, the CHD, CUAMM deaths from Shambe area; 61 Malek in Yirol East supported by WHO, UNICEF, Health and suspected cases from Adior; WASH cluster partners – MSF and IOM and 24 suspect cases including with cases being managed at Adior 10 community deaths from PHCC, Langmatot PHCU, and Shambe Langmatot PHCU where cholera treatment units have . been established. Sample testing is underway and ample case management supplies have been delivered to support the response. 10-Feb-17 At least 2 suspect cases Twic East The taskforce in Bor is planning reported from Islands in Twic verification missions to Twic East. East and Panyagor 10-Feb-17 15 suspect cases reported from Duk – Moldova Rapid response team dispatched with the Islands of Moldova in Duk supplies on 19 Feb. 17
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. Sub-national cholera taskforce committees are coordinating the cholera response in Northern and Southern Liech, Yirol East, Mingkaman, and Bor.
Rapid response teams from MoH, CHD, CUAMM, IOM, MSF-B have been deployed to support investigation and response activities in Yirol East. Rapid response teams from MoH and WHO are working with CUAMM, CHD, and HLSS to respond to the cholera outbreak in Mingkaman. On 19 Feb. 17 rapid response teams from Bor were dispatched with supplies to respond to the suspect cholera cases reported in Moldova Island in Duk county.
Response activities in Bor Overall response is coordinated by the taskforce chaired by the state Ministry of Health with WASH and health cluster partners as members as well as other stakeholders • CNDF distributed aqua tabs to Malou residences, 14 household visited and 20 aqua tabs distributed. • WASH cluster has started digging the pit latrine in the CTC in Bor hospital. • State MoH gave one tent to SMC for ORP centre in Jarwong. • State MoH, City Council and WHO met Director for urban Water on the distribution of clean water supply and it was agreed that the community should be prioritized to access tap water. • SMC has setup of the ORP in Jarwong to respond to the cholera outbreak • With support from WHO, a rapid response team was dispatched on 19 Feb. 17 to respond to the cholera cases on Moldova Island, Duk county. • MSF Belgium trained health workers, on water and sanitation on 15 Feb 17 in Malou and Langbaar and in Jalle, Pariak & Akuai-Deng on 16 Feb.17. • MSF donated 10 cholera beds to the CTC in Bor hospital on 16 Feb.17. • SMC sent a cholera response team with supplies to Kuei on 16 Feb.17.
Other response updates • A total of seven radio stations are airing cholera prevention and control messages countrywide. Radio Mingkaman is being used to cover Mingkaman and Yirol East. In Juba, Eye radio, Miraya, and South Sudan radio are broadcasting messages on cholera prevention and control. • During the week, IOM rapid response team deployed to support the cholera response in Yirol East. The team will be based in Shambe. • Social mobilization activities in Yirol East are currently implemented by SHDO while CARD is supporting the WASH response in the county.
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Planned Activities/recommendations 1. The next weekly EPR/cholera taskforce meeting is scheduled for 22 February 2017 starting 2:00pm in the WHO Conference Hall. 2. Ongoing support by rapid response teams to the response in Bor, Mingkaman, Yirol East, and Duk. 3. Verification of alerts in Kuei Island; and Twic East Islands. 4. Secure cholera vaccines augment the response in high-risk populations and cholera hotspots.
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
Mr. Lexson Mabrouk Dr. Alice Igale Ag. Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211956420189
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