Republic of South

Cholera in , Central State, Republic of Situation Report # 4 as at 23:59 Hours, 25 June 2015

Situation Update As of 25 June 2015, a total of 268 cholera cases including 20 deaths (CFR 7.5%) have been reported from 55 villages in eight payams of (Table 1).

The initial cases were traced back to 18 May 2015 in UN House PoC, which has reported the majority of the cases followed by New site, Gumbo, Kor William, Mangatain, Gudele 1 and Munuki.

Table 1. Summary of cholera cases reported in Juba County, 18 May – 25 June 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

UN House PoC clinic 1 0 0 6 0 0 1 1 18 27 Hai Referendum IDP clinic 0 0 0 0 0 0 1 1 0 1 Juba Teaching Hospital 24 14 1 62 28 8 2 10 121 222 Al Sabah Hospital 0 0 0 0 0 2 0 2 2 4 Morobo 2 clinic 0 0 0 0 0 0 1 1 3 4 Nyakuron PHCC 0 0 0 0 0 0 1 1 0 1 Juba Military Hospital 0 0 0 0 0 0 0 0 5 5 Luri Military 0 0 0 0 0 0 1 1 0 1 St. Kizito clinic 0 0 0 0 0 0 2 2 0 2 Mauna Medical clinic 0 0 0 0 0 0 1 1 0 1

Total 25 14 1 68 28 10 10 20 149 268 *LAMA: LEAVE AGAINST MEDICAL ADVICE

Epidemiological updates A total of 25 new cholera cases and one new death were reported in Juba on 25 June 2015. o Juba Teaching Hospital reported 24 new cases and one new death o UN House PoC clinic reported one new case o Most of the new cases were reported from Gudele 2, Tongping, Lologo, Gudele 1 and Kor William (Figure 1) o becomes the eighth payam in Juba to report cholera cases o Five new villages including Juba Prison, Hai Seminar, Lemon Gabah, Jezira, Juba Nabari and Hai Tharawa reported cholera cases for the first time thus raising the number of affected villages in Juba to 55.

Figure 1: New cholera cases by residence on 25 June 2015

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Juba Kator Munuki Northern Bari Gondokoro

1 Cumulatively, 268 cholera cases including 20 deaths (10 facility and 10 community) have been reported since the initial case was reported in Juba on 26 May 2015 (Tables 1 and 2).

Table 2: New cholera cases by facility and week in Juba, 18 May – 25 June 2015 New cases by epidemiological week of 2015 Reporting Facility 21 22 23 24 25 26 Grand Total Al Sabah hospital 4 4 Hai referendum IDP clinic 1 1 JTH 2 2 32 119 67 222 Juba 3 IMC clinic 4 4 9 5 5 27 Juba Military hospital 5 5 Morobo 2 clinic 1 3 4 Nyakuron PHCC 1 1 Luri Military 1 1 St. Kizito clinic 2 2 Mauna Medical Clinic 1 1 Grand Total 4 2 7 56 127 72 268

As seen from Figure 2, the initial and isolated cases were reported from UN House PoC 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 after Vibrio cholerae inaba was isolated from the one of five samples tested in the National Public Health Laboratory.

Since 6 June 2015, sustained and consistently increasing community transmission has been established with increasingly more suspect cases reported outside UN House PoC. There are three discernable transmission peaks with the initial peak of 15 cases occurring on 13 June 2015 while the subsequent and higher peaks occurred on 20 June and 24 June with 26 and 38 cases respectively (Figure 1).

Figure 2: Epidemic curve for suspect cholera cases in Juba, 18 May – 25 June 2015

40 Investigation adn Confirmation 35 of initial case in UN house PoC

30 Confirmation of initial case in UN house Poc 25 20

Number Number of cases 15 10 5 0 6/2/15 6/4/15 6/6/15 6/8/15 5/15/15 5/17/15 5/19/15 5/21/15 5/23/15 5/25/15 5/27/15 5/29/15 5/31/15 6/10/15 6/12/15 6/14/15 6/16/15 6/18/15 6/20/15 6/22/15 6/24/15 6/26/15 Date of onset

Alive Died The majority of suspect cholera cases in Juba have been reported from Juba 3 IDP, New site, Gumbo, Kor William, Mangatain, Gudele 1 and Munuki (Figure 3).

2 Figure 3: Spot map for suspect cholera cases by residence in Juba, 18 May – 25 June 2015

As of 25 June 2015, the sites reporting the majority of cases in Juba include UN House PoC, New site, Gumbo, Kor William, Mangatain, Gudele 1 and Munuki (Figure 4). There are satellite cases distributed in eight payams and 55 villages in Juba County.

Intensive interventions in the form of social mobilization and health education on cholera presentation and prevention, improving access to safe drinking water, latrine use and good personal and food hygiene are therefore required to prevent further escalation in Juba and spread to other counties outside Juba.

Figure 4: Cholera cases by residence in Juba, 18 May – 25 June 2015

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Gondokoro Juba Juba Nabari Kator Munuki Northern Bari Rejaf Lokiliri

Out of the 260 suspect cholera cases with known age, 37 (14%) were children less than five years of age, while 223 (86%) were individuals five years and above (Figure 5).

3 Figure 5: Suspect case distribution by age in Juba, 18 May – 25 June 2015

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Out of the 260 cholera cases with known gender, 109 (42%) were female, while 151 (58%) were male (Table 3).

Table 3: Case distribution by gender and age in Juba, 18 May – 25 June 2015 Gender and age N (%) Female 109 (42) <5yrs 12 5+yrs 97 Male 151 (58) <5yrs 25 5+yrs 126 Grand Total 260 (100)

The probable risk factors identified 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; and open defecation/poor latrine use.

Laboratory updates

Table 4: Cholera laboratory test results for Juba, 18 May – 25 June 2015 Health Facility Number of sample Number of cholera Number of cholera collected RDT positives Culture positives 1 Al Saba hospital 2 0 2 2 Juba Teaching Hospital 40 27 7 3 Juba 3 PoC clinic 22 20 9 4 Juba Military Hospital 3 2 2 5 Morobo 2 clinic 2 2 1 Total 69 51 21

A total of 69 stool samples have been collected from suspect cholera cases in Juba and submitted to the National Public Health Laboratory for testing (test results by facility shown in Table 4).

The National Public Health Laboratory has confirmed 21 cholera cases following the isolation on Vibrio cholerae inaba. Most of the culture confirmed cases have been reported from Juba 3 PoC and New site (Figure 6).

4 Figure 6: Number of culture positives by residence in Juba, 18 May – 25 June 2015

10 9 8 7 6 9 5

Number Number of cases 4 3 4 2 2 1 1 1 1 1 1 1 0 Gudele 1 Jebel Juba 3 PoC Juba Kator Mangatain Munuki New site Nyakuron Kujur Nabari IDP West

Table 5: Cholera Alerts – 23 to 26 June 2015 Date of Details of the alert Area Action notification 23-Jun-15 Suspect cholera cases , Report verified by the state surveillance team and reported from Rumbek State no suspect cases were identified by the team Town in Lakes state - 25-Jun-15 Suspect cholera case , EES State rapid response team conducted reported from Torit State investigations and obtained stool samples from the Hospital - suspect case and close contacts. The sample will be sent to Juba for Testing; RDT kits not available for onsite testing. - Refresher training on cholera conducted for the state hospital healthcare workers 26-Jun-15 Four suspect cholera , - Epidemiological investigation conducted by the cases reported in Kajo Keji CES county rapid response team; civil hospital - Three samples have been sent to Juba for culture and sensitivity. 26-Jun-15 One suspect cholera case Bor, Jonglei - Rapid diagnostic test for cholera was positive; reported by Bor State state Stool samples to be shipped to Juba for Hospital - microbiological culturing. - Epidemiological investigation to follow

- - As seen from Table 5, at least four alerts of suspect cholera cases have been reported outside Juba and are being followed up by the respective state and county rapid response teams with support from the national cholera taskforce.

5 Cholera Response Highlights 1. Urgent and lifesaving cholera response activities have been initiated by the national cholera taskforce in response to the increasing number of cases in Juba. The national cholera taskforce meeting takes place weekly. 2. The cholera response strategy is being reviewed and updated to suit the current context and to facilitate mobilization of resources to control the outbreak. 3. Oral cholera vaccination campaigns were conducted in PoC and UN House PoCs with Bentiu PoC implementing the second round, while UN House PoC carried out its first round of vaccinations. Both campaigns took place from 22 to 26 June 2015.

Urgent Response Needs 1. Intensive social mobilization and health education on cholera prevention in the transmission hotspots using multimedia channels a. Engaging all leaders – political, religious, traditional and civic groups b. Messages and talk shows on FM radios c. Use of mobile broadcasting/film vans in transmission hotspots d. Engaging institutions like schools and uniformed forces and the public in places like market areas 2. Stricter monitoring of water tanker chlorination at the Riverside and field surveillance to ensure water delivered to households conforms to the minimum free residual chlorine levels. 3. Distribution of water purification tablets to facilitate treatment of water at household level in high transmission areas. 4. Partners to support Juba Teaching Hospital cholera treatment center (CTC) and set up oral rehydration points (ORP) in Gumbo, New site, Mangatain IDP, Gudele, Nyakuron, Munuki and Kator. 5. Standby ambulances to support the transfer of cases to designated treatment centers. 6. Urgently train and deploy more home hygiene promoters to cholera hotspots for house-to-house sensitization on cholera prevention; active case finding and reporting; initiating oral rehydration treatment for new cases and referral to oral rehydration point or cholera treatment center; and distributing water purification tablets.

Planned activities 1. Finalizing sub-committee response strategies and plans to guide a coordinated response to the outbreak. 2. The next national cholera taskforce meeting is scheduled for Monday 29 June 2015 at 10:00 am in the MOH Ministerial 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 Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211955150406

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