Situation Report #32 on Cholera in South Sudan As at 23:59 Hours, 23 July 2015

Situation Update As of 23 July 2015, a total of 1,318 cholera cases including 39 deaths (CFR 2.96%) have been reported in Juba and Bor Counties in Central Equatoria and Jonglei States respectively. In Juba County, 1,208 cases including 38 deaths (CFR 3.15%) have been reported from seven Payams (Table 1). In Bor, 110 cases including one death (CFR 0.91%) 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. Most affected Payams in Juba County are Kator, Rejaf, Northern Bari, and Munuki that have registered attack rates (cases per 10,000) of 198, 184, 134, and 23 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 29 (Annex 1 and 2).

Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 23 July 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 21 13 0 38 196 22 16 38 935 1208 IMC UN House PoC clinic 1 0 0 5 0 0 1 1 64 70 Juba Teaching Hospital 10 4 0 30 193 19 7 26 656 905 MedAir Gumbo CTU 2 1 0 1 0 1 0 1 71 74 MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8 HLSS Nyakuron ORP 0 0 0 0 0 0 0 0 39 39 HLSS Kator ORP 0 0 0 0 0 0 0 0 6 6 HLSS Gurei ORP 4 4 0 0 0 0 0 0 28 28 HLSS Munuki ORP 1 1 0 0 0 0 0 0 2 2 HLSS Al Sabah ORP 1 1 0 0 0 0 0 0 8 8 HLSS Lologo ORP 1 1 0 0 0 0 0 0 10 10 MSF Munuki CTC 1 1 0 2 3 0 0 0 23 28 Other sites in Juba 0 0 0 0 0 2 8 10 20 30 Jonglei State – Bor 0 1 0 0 3 1 0 1 106 110 Bor State Hospital 0 1 0 0 3 1 0 1 106 110 Total 21 14 0 38 199 23 16 39 1041 1318 *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- Central Equatoria State A total of 21 new cholera cases were reported in Juba on 23 July 2015 (Table 1 and Figure 1). o 21 new cases were reported from Juba County, with the majority of the cases reported from Lologo, Hai Kasava, and Gurei Suk. o There were no new cases reported from Bor.

Figure 1: New cholera cases by residence on 23 July 2015

2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Kuji Number Number casesof Gurei

0 Giada Adodi Lologo Malakia New site New Gudele II Gudele Joborona Hai Game Hai Gurei souk Gurei Juba POC 3 POC Juba Hai Kasava Hai Jebel Dinka Jebel Souk Zande Souk Kor William Kor Jebel Market Jebel Hai Siminary Hai

Juba Kator Munuki Northern Bari Rejaf Juba

1 During week 30 of 2015 (week of 20 July 2015), most cholera cases originated from Lologo, Atlabara B, Malakia, Suk Jebel, and Nyakuron West (Figure 1.1).

Figure 1.1: New cholera cases by residence during week 30 of 2015

4 7 7 3 6 6 5 5 2 4 4 4 3 3 3 3 3 1 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 i l i l i i i i I i t t r t t t i k l k a a a a a a a a a a a a j e e k e 1 1 1 7 I n n n o n o o o B C 2 t r A r i y k g i e s e e s d i m m a t r a e r v v k r a l b y u g u b n d n p u b a u d u e r i a o o a b i i r o k l k u n e e e a b o o e a k a a f m k o o k s r a r o a e i l S n l b z a a a a k i n i a o e S o u K o n o b r u B c P r a r a r i l i g g l l n e l a g s m o d J m i t l S i r l o u u d s e e e l l d p w u u o n a i o a J a W G o a W a i i G J o o i u J o a D o M a K 3 G a w n l h k k u i h G o e A g o w d d k l l k Z K u J u i n a l a b l r N L l K i g S a S a a n n e e B w b b i e n K M u a u G o o o o K a m u l o a W l M G k e e M r i e y l y n o M o a e L L a l o y r L i o T a e b o e N H e G G t M r u b h a r J u J b a i l M b N N e a T n u S t H u b d o m e A o u e a H e G r J W u i b o b J H J u M e S K k J d m o H a e K u L a G J u u H K N y G G N

Juba Kator Munuki Northern Bari Rejaf Gondokoro

Cumulatively, 1,318 cholera cases including 39 deaths (23 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 39 deaths, seven (18%) have occurred in children under five years. In Juba County, Juba Payam has registered the highest CFR followed by Northern Bari, Rejaf, and Munuki (Annex1).

Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 23 July 2015 New cases by epidemiological week of 2015 Reporting Facility 21 22 23 24 25 26 27 28 29 30 Grand Total CES – Juba County 4 2 7 56 131 234 236 161 268 109 1208 JTH 0 2 2 32 119 212 208 116 150 64 905 Juba 3 IMC clinic 4 0 4 9 6 13 10 10 11 3 70 HLSS Nyakuron ORP 0 0 0 0 0 0 2 3 30 4 39 HLSS Kator ORP 0 0 0 0 0 0 0 3 1 2 6 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 26 8 74 HLSS Gurei ORP 0 0 0 0 0 0 0 1 16 11 28 HLSS Munuki ORP 0 0 0 0 0 0 0 1 0 1 2 HLSS Al Shabah ORP 0 0 0 0 0 0 0 0 5 2 7 HLSS Lologo ORP 0 0 0 0 0 0 0 0 3 7 10 MSF Munuki CTC 0 0 0 0 0 0 0 0 23 5 28 Other sites in Juba 0 0 1 15 6 4 1 3 0 0 30 Jonglei State – Bor County 0 0 0 0 0 5 46 33 21 5 110 Bor State Hospital 0 0 0 0 0 5 46 33 21 5 110 Grand Total 4 2 7 56 131 239 282 194 289 114 1318

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.

Since 6 June 2015, sustained and consistently increasing community transmission was established in Juba with increasingly more suspect cases reported outside UN House PoC. There are three discernible 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 26 June before reaching the second highest peak on 28 June. Since then, successively shorter transmission peaks have been registered. This trend is largely driven by ongoing transmission in Juba, Northern Bari, Rejaf, and Munuki Payams (Annex 2). On 19 July 2015, a total of 61 new cases in Juba County were linked to a funeral in Atlabara B.

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 have been registered, a trend that is consistent with declining community transmission.

Figure 2: Epidemic curve for suspect cholera cases in Juba, 18 May – 23 July 2015

90 20 80 17.9 18 70 16 14.3 60 14 12 50 10 40 Number Number of cases 8 30 6.1 6 CaseFatality Rate [%] 20 3.8 4 10 1.4 1.5 1.6 2 0 0 0 6/2/15 6/4/15 6/6/15 6/8/15 7/2/15 7/4/15 7/6/15 7/8/15 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 6/28/15 6/30/15 7/10/15 7/12/15 7/14/15 7/16/15 7/18/15 7/20/15 7/22/15 7/24/15

20 21 22 23 24 25 26 27 28 29 30

JS: Jonglei State; CES: Central EquatoriaJS State; CFR: Case Fatality Rate CES CFR

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 suspect cholera cases by residence in Juba, 18 May – 23 July 2015

3 As of 23 July 2015, the sites reporting the majority of cases in Juba include Gumbo, New site, Juba 3 PoC, Gudele 2, and Munuki with satellite cases distributed in seven Payams in Juba County (Figure 3). In Bor County, the majority 39 (41%) of the cases originated from Malou in Makuach Payam and later from areas like Arek, Block 8, Hai Salam, Achengdii and Langbar.

Out of the 1,195 suspect cholera cases with known age from Juba, 171 (14%) were children less than five years of age, while 1,024 (86%) were individuals aged five years and above. In Bor, 64 (58%) of the cases have occurred in children under five years of age, while 46 (42%) occurred in individuals aged five years and above (Table 3).

Table 3: Suspect case distribution by age in Juba and Bor Counties, 18 May – 23 July 2015 Case distribution by age Cases (%) CES – Juba 1195 <5yrs 171 (14) 5+yrs 1024 (86) Jonglei State – Bor County 110 <5yrs 64 (58) 5+yrs 46 (42) Grand Total 1305

Out of the 1,202 cholera cases with known gender in Juba, 524 (44%) were female, while 678 (56%) were male while in Bor, 64 (58%) of the cases were females, while 46 (42%) were males (Table 4).

Table 4: Case distribution by gender and age in Juba and Bor Counties, 18 May – 23 July 2015 Case distribution by gender N (%) CES - Juba 1202 Female 524 (44) Male 678 (56) Jonglei state – Bor County 110 Female 64 (58) Male 46 (42) Grand Total 1312

Laboratory updates

Table 5: Cholera laboratory test results for Juba and Bor, 18 May – 23 July 2015 Number of Number of cholera Number of stool Number of cholera Health Facility RDT tests RDT positives cultures Culture positives CES – Juba 210 191 80 35 1 Juba Teaching Hospital 118 105 44 17 2 Juba 3 PoC clinic 64 61 22 11 3 MSF Munuki CTC 14 14 0 0 4 Other sites in Juba 14 11 12 5 5 MedAir Gumbo CTU 0 0 2 2 Jonglei state – Bor 52 44 13 8 1 Bor State Hospital 52 44 13 8 Total 262 235 93 43

As seen from Table 5, 235 (90%) of the samples have been RDT positive while 43 (46%) 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). Of the 21 samples submitted from Kajo Keji, 19 tested negative for cholera following microbiological culturing, while the test results for two samples are pending.

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

4 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, 18 May – 23 July 2015

12 10 11 8 5 6 1 1 2 2 1 1 1 1 1 1 3 2 1 1 3 2 1 1 1 4 2

0 Arek Number Number of cases Kator Giada Malou Digala Bilpam Gumbo Kodoro Munuki Gakyom Atlabara Gudele1 Block-10 Newsite Achingdii Juba3 PoC JebelKujur JubaNabari Kor William MangatainIDP Nyakuron West

Juba Bor Table 6: Cholera Alerts – 23 to 23 July 2015 Date of Details of the alert Area Action notification 19-July-15 A total of 55 acute watery diarrhoea Atlabara Funeral visited by the state rapid response team cases reported on 19 July 2015 involving B, Juba for health education and case finding individuals who attended an overnight - At least 55 cases referred to Juba Teaching funeral in Atlabara B, Juba Hospital CTC for treatment - Premises disinfected by state rapid response team - Interviewed participants reported eating bread and roasted meat at the funeral before they - developed vomiting and diarrhoea. One of five samples collected from this cluster tested positive for cholera after Vibrio cholera - was isolated from the sample. 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 team from MedAir is on the ground to conduct case verification and support - local response efforts.

- Since 25 June 2015, at least nine 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 1. The next national cholera taskforce meeting is scheduled for Monday 27 July 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 29 July 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.

5 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 23 July 2015

Annex 1: Cholera attack rates and case fatality rates by Payam, 18 May to 23 July 2015 Attack rate Total Case Fatality [cases per Location Total Cases Deaths Population Rate [%] 10,000] CES 1208 38 279871 3.1 43.2 Gondokoro 7 7115 - 9.8 Juba 127 11 91254 8.7 13.9 Kator 225 4 11395 1.8 197.5 Lokiliri 3 5995 - 5.0 Munuki 302 7 129133 2.3 23.4 Northern Bari 277 8 20753 2.9 133.5 Rejaf 262 6 14226 2.3 184.2 (Blank) 4 2 50.0 JS 110 1 181708 0.9 6.1 Baidit 4 51042 - 0.8 Bor 4 61224 - 0.7 Kolnyang 1 40021 - 0.2 Makuach 86 1 29421 1.2 29.2 Grand Total 1318 39 461579 3.0 28.6

Annex 2: Cholera epidemic curves by Payam – 18 May to 23 July 2015 Cholera Epidemic Curve Juba Payam 2015 14

s 12 e s

a 10 c f

o 8 r

e 6 b

m 4 u

N 2

0 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 3 5 7 9 1 1 1 1 1 2 2 2 2 2 1 3 5 7 9 1 1 1 1 1 2 2 6 8 0 2 4 6 8 0 / / / / / 1 3 5 7 9 1 3 5 7 9 / / / / / 1 3 5 7 9 1 3 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Juba

7 Cholera Epidemic curve Northern Bari Payam 2015 20 s e s

a 15 c f o r 10 e b m u 5 N 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 0 6 6 6 6 6 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 2 2 1 3 5 7 9 1 3 5 7 9 6 8 0 2 4 6 8 0 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Northern Bari

Cholera Epidemic Curve Rejaf Payam 2015 16 s 14 e s

a 12 c f 10 o r 8 e b 6 m u 4 N 2

0 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 1 1 1 1 2 2 2 2 2 1 1 1 1 1 2 2 1 3 5 7 9 1 3 5 7 9 6 8 0 2 4 6 8 0 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Rejaf

Cholera Epidemic Curve Munuki Payam 2015 25 s e 20 s a c f 15 o r e b 10 m u

N 5

Munuki

8 Cholera Epidemic Curve Kator Payam 2015 70

s 60 e s a 50 c f

o 40 r e 30 b m

u 20 N 10 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 0 6 6 6 6 6 7 7 7 7 7 / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 2 2 2 2 2 3 1 3 5 7 9 1 1 1 1 1 2 2 2 2 2 1 3 5 7 9 1 1 1 1 1 2 2 6 8 0 2 4 6 8 0 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / / / / / / / / / / / / / / / / 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 1 1 1 5 5 5 5 5 1 1 1 1 1 1 1 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Kator

Cholera Epidemic Curve Gondokoro Payam 2015 2 s e s a c f o

r 1 e b m u N

Gondokoro

Cholera Epidemic Curve Lokiliri Payam 2015 3 s e s a

c 2 f o r e b

m 1 u N

Lokiliri

9 Cholera Epidemic Curve Makuach Payam, Bor 2015 10 s e 8 s a c f 6 o r e b 4 m u

N 2 0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 /1 2 4 6 8 0 /2 /4 /6 /8 0 2 4 6 8 0 2 4 /2 /2 /2 /2 /3 7 7 7 7 /1 /1 /1 /1 /1 /2 /2 /2 6 6 6 6 6 7 7 7 7 7 7 7 7

Makuach