Republic of

Situation Report #111 on Cholera in South Sudan As at 23:59 Hours, 10 March 2017

Situation Update A total of 14 counties in 9 (28%) of 32 states countrywide have confirmed cholera outbreaks (Table 1; Figure 1.0). During week 10 of 2017, a total of 13 samples from Bentiu PoC all tested negative for cholera (Table 3). Cumulatively, 187 (36.5 %) samples have tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 10 March 2017 (Table 3).

Table 1: Summary of cholera cases reported in South Sudan as of 10 March 2017

New New Total cases Total New deaths Total facility Total cases Reporting Sites admissio discharges WK currently community Total deaths Total cases WK 10 deaths discharged ns WK 10 10 admitted deaths

Jubek – Juba - - - - 8 19 27 2,018 2,045

Jonglei-Duk - - - - 3 5 8 92 100

Jonglei-Bor - - - 3 1 3 4 67 74

Terekeka - - - - - 8 8 14 22

Eastern Lakes - - - - 13 2 8 10 512 535 Awerial

Eastern Lakes - 13 - - 10 10 21 31 301 342 Yirol East

Imatong - Pageri - - - - - 1 1 28 29

Western Bieh - - - - - 4 - 4 266 270 Fangak

Northern Liech - - - - - 7 2 9 1,150 1,159 Rubkona

Southern Liech - - - - - 3 - 3 91 94 Leer

Southern Liech - - - - - 18 4 22 466 488 Panyijiar

Southern Liech ------5 5 214 219 Mayendit

Central Upper - - - 5 181 Nile - Pigi 5 176 Central Upper 2 - 12 - 16 Nile - Malakal 0 4

Total 15 - - 38 61 76 137 5,399 5,574

Highlights in week 10 of 2017: 1. A total of 15 new cholera cases reported from Yirol East (13 cases) and Malakal Town (2 cases) in week 10 of 2017 Table 3. 2. The cumulative cases in Malakal Town have risen to 16. The national cholera taskforce has approved emergency oral cholera vaccination for Malakal Town using a two-dose strategy. The target population for Malakal Town is estimated at 16,500 persons aged one year and above. MSF-E will lead the campaign in Malakal Town. 3. A total of 15 cases reported in week 10 compared to 75 cases in week 9 of 2017 Figure 1.1. 4. A stakeholder meeting was conducted in Juba from 8-9 March 2017 to develop a plan on rational use of oral cholera vaccines alongside other tools like WASH and social mobilization. The Meeting was organized by the

1 Ministry of Health and supported by WHO and the Global Taskforce for Cholera control with participants drawn from the National Cholera taskforce, Health and WASH clusters, and the Ministry of Water. 5. During the week, the International Coordinating Group (ICG) for oral cholera vaccines approved at total of 475,020 doses of oral cholera vaccines that will be used to conduct two-dose campaigns in Bentiu PoC, Mingkaman IDP settlement, and Bor PoC. The vaccines are expected to arrive in Juba on 15 March 2017.

Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 10 March 2017

Figure 1.1: New cholera cases admitted by location in week 9 and 10 of 2017

60 52

week 9 week 10 40

20 13 Number of Cases 10 6 7 1 2 0 Awerial Yirol East Bor South Rubkona Malakal Eastern Lakes Jonglei Northern Liech Central Upper Nile

The transmission in Mingkaman, Bor, Northern and Southern Liech has declined significantly Figure 2.1.

2 Figure 1.2: Cumulative cholera cases by state and county of residence as at 10 March 2017

6000 5574

5000

4000

3000

2045 Number of Cases 2000 1159 1000 488 535 342 270 219 181 22 94 74 100 29 16 0 FANGAK Terekeka Leer MayenditPanyijiar Rubkona Juba Bor South Duk Pageri Awerial Yirol EastPigi- canalMalakal Western Terekeka Southern Liech Northern Jubek Jonglei Imatong Eastern Lakes Central Upper Nile Grand Bieh Liech Total

Table 1.1: Cholera cases and deaths by state and county as of 10 March 2017 Week 10 Weeks 24, 2016 to 10 of 2017 New cases Cases per Population W10 10,000 No. Cases per 10,000 State County at risk population cases population CFR [%] Western Bieh Fangak 168,947 0 - 270 16.0 1.48 Northern Liech Rubkona 126,976 0 - 1159 91.3 0.78 Southern Liech Leer 95,731 0 - 94 9.8 3.19 Southern Liech Panyijiar 78,020 0 - 488 62.5 4.51 Southern Liech Mayendit 97,127 0 - 219 22.5 2.28 Eastern Lakes Awerial 114,837 0 - 535 46.6 1.87 Eastern Lakes Yirol East 104,694 13 1.24 342 32.7 9.06 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Bor South 331,611 0 - 74 2.2 5.41 Jonglei Duk 96,259 0 - 100 10.4 8 Jubek Juba 579,778 0 - 2,045 35.3 1.32 Terekeka Terekeka 209,902 0 - 22 1.0 36.36 Central Upper Nile Pigi 150,800 0 - 181 12.0 2.76 Central Upper Nile Malakal 214,679 2 0.09 16 0.7 0 Total 2,584,491 15 0.06 5,574 21.6 2.46

Cumulatively, 5,574 cholera cases including 137 deaths (61 facilities and 76 community) (CFR 2.46%) have been reported in South Sudan involving 14 counties in 9 states since the initial case was reported on 18 June 2016 for ; 3rd July 2016 for Duk in ; 14 July 2016 for Terekeka state, 15 August 2016 for Mingkaman in Eastern Lakes and Pageri in Imatong states; 10 August 2016 for Fangak in Western ; 29 September 2016 for Rubkona in ; 11 October 2016 for Leer; 22 October 2016 for Panyijiar in ; 10 October 2016 for Pigi in ; 7 October 2016 for Mayendit in Southern Liech state; 30 January 2017 for Bor South in Jonglei state; 3 February 2017 for Yirol East in ; and 22 February 2017 for Malakal, in Central Upper Nile state (Figure 2.1 and Table 1.1).

3 Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 10 March 2017

350 25

300 21.05 20

250 16.92 15 200 CFR [%] Number of cases 150 10

100 6.67 6.91 6.58 5.95 5.11 5 4.48 50 3.33 3.33 3.49 2.75 2.42 2.30 2.05 1.85 2.26 2.00 1.76 2.24 1.42 1.55 1.35 1.27 0.62 0.86 0.42 0.76 0.75 0.82 0.63 0.57 0.79 0.60 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 8 9 10

Epidemiological week of onset 2016 2017

Jonglei Jubek Terekeka Imatong Eastern Lakes

Western Bieh Northern Liech Southern Liech Central Upper Nile CFR[%]

Figure 3:1 Cholera case distribution by gender and county 10 March 2017

Cholera case gender distributionby IDP site wk 27 of 2016 to week 10 of 2107 100%

90%

35 37 41 80% 44 42 50 48 50 53 50 54 57 57 55 70%

60% 81

50%

e itiuin % Sex distribution 40%

65 63 59 30% 56 58 50 52 50 47 50 46 43 43 45 20%

10% 19

0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Yirol East Malakal Overall

Female Male

Overall, males and females have been affected evenly Figure 3.1. The gender distribution of cholera cases by county is shown in Figure 3.1.

4 Figure 3:2 Cholera case distribution age in South Sudan 10 March 2017 Cholera case age distributionby IDP site wk 27 of 2016 to week 10 of 2017

25 22.8

20

15.6 15

11.0

10 8.5 7.7 7.6 g itiuin % Age distribution 7.1 5.5 5 3.9 2.9 1.8 1.4 1.7 1.7 0.7

0

9yrs +yrs - 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

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.

Figure 3:3 Cholera case distribution by age and county in South Sudan 10 March 2017

Cholera case age distributionby IDP site wk 27 of 2016 to week 10 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 Yirol East Malakal

0-5yrs 5-9yrs 10-14 yrs 15-19 yrs 20-24 yrs 25-29 yrs 30-34 yrs 35-39 yrs 40-44 yrs 45-49 yrs 50-54 yrs 55-59 yrs 60-64yrs 65-69 yrs 70+yrs

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. 3. 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. 4. 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

5 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. 5. 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, Bor, Ayod, Yirol East etc.

Table 3: Cholera laboratory test results for Juba by 10 March 2017

Culture results State New positives in Cumulative Cumulative Total tested week 10 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 - Mingkaman 0 27 42 77 Eastern Lakes – Yirol East 0 4 6 10 Imatong 0 7 1 8 Fangak 0 16 37 45 Wau 0 0 6 6 Boma 0 0 2 2 Northern Liech 0 32 73 109 Southern Liech – Leer 0 2 0 2 Southern Liech - Panyijiar 0 1 0 1 Southern Liech – Mayendit 0 4 6 10 Central Upper Nile (Pigi) 0 3 5 8 Central Upper Nile (Malakal) 0 1 1 2 Total tested 0 187 339 513

Table 4: Cholera Alerts Date of Details of the alert Area Action notification No alerts 10-Feb-17 At least 2 suspect cases Twic East The Islands were visited by MSF-B who reported from Islands in Twic set up an ORP; trained HCW, donated East and Panyagor supplies and conducted awareness on cholera prevention and control. 21-Feb-17 Suspect cases in Pajatriei Island Pajatriei Island of A team visited the Island where they of Baidit payam, Bor South Baidit payam recorded 5 cases including 2 deaths and County following the report of 2 collected a sample for microbiological deaths cases culturing.

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, Bor, and Malakal Town. In Bor, the cholera taskforce meets twice a week on Mondays and Fridays at 10: 30 am at the SMOH meeting room.

The Ministry of Health with support from WHO has deployed three rapid response teams to support the cholera

6 response in Bor, Mingkaman, and Yirol East.

Following the confirmation of cholera cases in Malakal Town, the cholera taskforce has been activated and the response plan has been updated to guide preparedness and response activities. Meanwhile, the national cholera taskforce has approved emergency oral cholera vaccination for Malakal Town using a two-dose strategy. The target population for Malakal Town is estimated at 16,500 persons aged one year and above. MSF-E will lead the campaign in Malakal Town.

A stakeholder meeting conducted in Juba from 8-9 March 2017 to develop a plan on rational use of oral cholera vaccines alongside other tools like WASH and social mobilization. The Meeting was organized by the Ministry of Health and supported by WHO and the Global Taskforce for Cholera control with participants drawn from the National Cholera taskforce, Health and WASH clusters, and the Ministry of Water.

During the week, the International Coordinating Group (ICG) for oral cholera vaccines approved at total of 475,020 doses of oral cholera vaccines that will be used to conduct two-dose campaigns in Bentiu PoC, Mingkaman IDP settlement, and Bor PoC. The vaccines are expected to arrive in Juba on 15 March 2017.

Rapid response teams from MoH, CHD, CUAMM, IOM, MSF-B are supporting cholera outbreak 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. The current response efforts in Eastern Lakes are aimed at addressing the underlying risk factors and improving skills for case management and infection prevention and control at existing cholera treatment facilities.

Planned Activities/recommendations 1. The next weekly EPR/cholera taskforce meeting is scheduled for 15 March 2017 starting 2:00pm in the WHO Conference Hall. 2. Roll out a comprehensive integrated response including oral cholera vaccination in response to the cholera outbreak in Malakal Town. 3. Continue with the ongoing response to the outbreaks in Mingkaman, Yirol East, Bor, Southern Liech, Northern Liech, and Pigi in Central Upper Nile states.

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

Dr. Pinyi Nyimol Mawien Dr. Alice Igale Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955604020 Tel: +211956420189

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