Republic of South

Situation Report #89 on Cholera in As at 23:59 Hours, 12 – 18 October 2015

Situation Update During week 42 of 2015 (12-18 October 2015), three new RDT positive cholera cases were reported from County. (Figure 1)

As of 18 October 2015, a cumulative of 1,818 cholera cases including 47 deaths (CFR 2.58%) have been reported from Central State (Juba and Kajo-keji Counties) and Jonglei State (Bor County). A total of 1,622 cases including 45 deaths (CFR 2.77%) reported from seven Payams in , 57 cases including one death (CFR 1.75%) from four Payams in Kajo-keji County and 139 cases including one death (0.72%) from Makuach Payam and surrounding areas in Bor county (Tables 1 and 2).

Figure 1: Cholera cases by place of residence and RDT test result, Juba County, 12-18 October 2015 2 RDT positive RDT negative

1 Number of cases of Number

0 Lokwilili Gudele West Hai Baraka Northern Bari

Table 1. Summary of cholera cases reported in Juba and Bor Counties, 18 May – 18 October 2015 New New New Total cases Total Total Total Total cases Total cases admisions discharges deaths currently facility community deaths discharged Reporting Sites LAMA* Week 42 Week 42 Week 42 admitted deaths deaths Week 42 CES – Juba County 0 0 0 0 218 26 19 45 1358 1622 IMC UN House PoC clinic 0 0 0 0 0 0 1 1 75 76 Juba Teaching Hospital 0 0 0 0 214 22 8 30 887 1132 MedAir Gumbo CTU 0 0 0 0 0 1 0 1 97 98 MedAir Gudele ORP 0 0 0 0 0 0 0 0 8 8 HLSS Nyakuron ORP 0 0 0 0 0 0 0 0 40 40 HLSS Kator ORP 0 0 0 0 0 0 0 0 7 7 HLSS Gurei ORP 3 3 0 0 0 0 0 0 105 105 HLSS Munuki ORP 0 0 0 0 0 0 0 0 4 4 HLSS Al Sabah ORP 0 0 0 0 0 1 0 1 34 35 HLSS Lologo ORP 0 0 0 0 0 0 1 1 13 14 MSF Munuki CTC 0 0 0 0 4 0 0 0 70 74 Other sites in Juba 0 0 0 0 0 2 9 11 18 29 CES – County 0 0 0 0 0 1 0 1 56 57

Kajo Keji 0 0 0 0 0 1 0 1 56 57 Jonglei State – Bor 0 0 0 0 3 1 0 1 135 139 Bor State Hospital 0 0 0 0 3 1 0 1 135 139 Total 3 3 0 0 221 27 19 47 1549 1818 *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- State Table 2: New cholera cases by facility and week in Juba and Bor Counties, 18 May – 18 October 2015

1 New cases by epidemiological week in 2015 Reporting facility 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Grand Total Central Equatoria 168 239 150 101 77 86 45 39 32 18 8 4 0 1 3 state 1679 Juba county 160 237 149 100 77 86 45 39 32 18 8 4 0 1 3 1622 JTH 115 146 92 52 44 44 20 25 13 10 1 0 0 0 0 1132 Juba 3 IMC clinic 10 11 5 2 1 1 0 0 0 0 0 0 0 76 Medair Gudele ORP 4 3 1 0 0 0 0 0 0 0 0 0 0 0 0 8 Medair Gumbo CTU 20 25 10 8 9 4 2 0 0 0 0 0 0 0 98 MSF Munuki CTC 0 23 18 7 7 9 6 4 0 0 0 0 0 0 0 74 Other sites in Juba 3 0 0 0 1 0 0 0 0 0 0 0 0 0 29 HLSS Nyakuron ORP 3 11 2 9 3 7 1 2 0 0 0 0 0 0 0 40 HLSS Kator ORP 3 1 2 1 0 0 0 0 0 0 0 7 HLSS Gurei ORP 1 11 10 15 10 13 13 5 5 8 6 4 0 1 3 105 HLSS Munuki ORP 1 0 2 0 0 0 0 1 0 0 0 0 0 0 0 4 HLSS Al Sabah ORP 0 4 3 5 3 5 14 0 1 0 0 0 0 35 HLSS Lologo ORP 0 2 4 2 1 2 2 1 0 0 0 0 0 0 0 14 8 2 1 1 0 0 0 0 0 0 0 0 0 0 0 57 Kajo keji hospital 8 2 1 1 0 0 0 0 0 0 0 0 0 0 0 57 Jonglei state 33 21 8 9 4 4 2 4 1 1 1 0 0 0 139 Bor county 33 21 8 9 4 4 2 4 1 1 1 0 0 0 139 Bor State Hospital 33 21 8 9 4 4 2 4 1 1 1 0 0 0 139 Grand Total 201 260 158 110 81 90 47 43 33 19 8 5 0 1 3 1818

A drastic decrease trend of caseloads has been observed since week 34 in Juba, Kajo keji, and Bor counties. (Figures 2 and 2.1)

Figure 2: Epidemic curve for cholera cases in Juba and Bor, 18 May - 18 October 2015 80 20

70 17.9 18 16 60 CES 14.3 14 50 JS 12 40 CFR 10 30 8

Number of cases 6.2 6 20 3.8 4 Case Fatality Rate [%] 10 1.9 2.3 2 1.4 1.5 1.6 1.2

0 0 0 0 0 0 0 0 0 0 0 0 0

6/4/15 6/8/15 7/2/15 7/6/15 8/3/15 8/7/15 9/4/15 9/8/15

5/15/15 5/19/15 5/23/15 5/27/15 5/31/15 6/12/15 6/16/15 6/20/15 6/24/15 6/28/15 7/10/15 7/14/15 7/18/15 7/22/15 7/26/15 7/30/15 8/11/15 8/15/15 8/19/15 8/23/15 8/27/15 8/31/15 9/12/15 9/16/15 9/20/15 9/24/15 9/28/15 10/2/15 10/6/15

10/10/15 10/14/15 10/18/15 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

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

Figure 2.1: Cholera cases in Juba and Bor by week of onset, week 21-42 of 2015 350 20.0

17.9 JS 18.0 300 16.0 246 CES 250 14.3 259 239 14.0 12.0 200 168 10.0 150 150 8.0 134 100 6.0 6.0 101 Case Fatality Rate [%] Number of cases 4.0 3.4 77 50 86 18 56 1.7 1.9 2.2 2.1 2.0 2 7 1.5 1.5 1.2 45 39 8 0 1 3 4 32 4 0 ------0 - 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Week of onset

As of 18 October 2015, the sites reporting the highest number of cholera cases included Northern Bari, Muniki, , Kator, and Juba Town in Juba County. In Kajo-keji county, the most affected payams included Kangapo 2, Kangapo 1, Lire, and Liwolo. The majority of cases originated from Makuach payam in Bor County, (Figure 3).

2 Figure 3: Cholera cases by place of residence, Juba, Kajo-keji and Bor Counties, 18 May 2015 - 18 Oct 2015

As summarized in Figures 4.1, 4.2, 4.3, all age groups have been affected with majority being those aged under 10 years and 20-34 years in Juba County. In Bor, children under 10 years were the most affected. In Kajo-keji all age groups were equally affected. (Figures 3.1 and 3.2).

Figure 4.1: Cholera case distribution by age and sex in Juba County, 18 May - 18 October 2015 Cholera case distribution by age in Juba County, week 26-42, 2015

300 250 200 146 140 150 107 98 Male 99 100 83 Female 49 51 Number of cases of Number 50 100 91 98 49 83 58 59 27 50 48 31 17 10 14 13 0 22 17 12 11 8 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 fives years years years years years years years years years years years years years

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Figure 4.2: Cholera case distribution by age and sex in Kajo keji County, 15 June - 2 Aug 2015

Cholera case distribution by age in Kajo Keji County, week 26-31, 2015

8 7 6 5 1 1 1 4 6 Male 3 1 3 2 2 2 2 Female 2 4 4 4 Number of cases of Number 3 1 1 1 1 2 2 2 2 2 2 1 1 1 1 0 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 70+ fives years years years years years years years years years years years years years

Figure 4.3: Cholera case distribution by age and sex in Bor County, 26 June - 27 Sep 2015 Cholera case distribution by age in Bor County, week 27-39, 2015

90 80 70 60 37 50 Male 40 30 Female 42

Number of cases of Number 20 10 8 1 3 10 0 8 5 1 1 31 23 31 1 3 12 1 under 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 65-69 fives years years years years years years years years years years years years

Investigations carried out revealed the following probable risk factors for contacting cholera: residing in a crowded IDP camp with poor sanitation and hygiene; using untreated water from water tankers and other unsafe sources of water; lack of household chlorination of drinking water; eating unhygienic prepared food from unregulated roadside food vendors or makeshift markets; open defecation, and eating food at funerals.

Laboratory updates  All the three RDT positive cholera cases reported from Gurei ORP were found negative for vibrio cholerae after laboratory culture at the National Public Health Laboratory in Juba.  The last laboratory culture confirmed case was reported on 5 October 2015 from Juba County.  Since the beginning of the outbreak, 48 were positive for Vibrio cholerae was isolated after laboratory culture. Of the 48 positive cases, 38 were from Juba County, one from Kajo Keji County and nine from Bor County.

Planned and On-going Activities 1. The next national cholera taskforce meeting is scheduled for Monday 26 October 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

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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

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