Weekly Epidemiological Bulletin Republic of Integrated Disease Surveillance and Response (IDSR) W15| 10th to 16th April 2017

Highlights Special focus on cholera • Cumulatively, 6,774 cholera cases including 221 deaths (70 facilities and 151 • Completeness for weekly reporting was 51% IDSR sites and 75% for community) (CFR 3.25%) have been reported in South Sudan (Figs 19.2&19.3; the IDP sites. Table 4.2)

• Malaria remains the leading cause of morbidity in nonconflict areas • New cholera outbreak confirmed in Mayom and Kodok - with active while ARI is the leading cause of morbidity in the IDPs. transmission in Yirol East, Yirol West, Ayod, and Mingkaman (Figs 19.2&19.3; Table 4.2).

• A total of 31 suspect measles cases were reported from Juba, , • A new cluster of suspect cholera cases reported in Tar cattle camp near Pagil in Mayom, Jur River, and Yambio. Ayod. • A total of 18 counties in 10 (31%) of 32 states countrywide have confirmed • Active cholera transmission is ongoing in Yirol, Ayod, and Awerial. cholera outbreaks (Figs 19.2&19.3; Table 4.2).

• A total of 14 HEV cases reported from Bentiu POC in week 15. Early Warning, Alert and Response

• Suspect Guinea worm cases reported from Tonj South and Tonj East. Active responses

• Chickenpox cases continue to be reported from Wau IDPs and Bentiu Cholera PoC. Measles Kala azar Hepatitis E virus Active alerts: Public Health Priorities Guinea Worm Figure 1a | IDSR Proportional morbidity WK 15, 2017 Event! based surveillance W15 of 2017 AWD In Week 15, only Imatong state submitted event long data. Only one 10% ABD event involving one suspect measles case was reported. Investigation 2% Malaria was initiated with 72 hours. Measles ! Others 55% 32% Figure 1c | Health Facility Functionality by county in W15 2017

0%

Figure 1b | Proportional morbidity in IDPs W15 2017

10% Measles

Malaria 0% ARI

51% 28% AWD

ABD 1% Other 10%

System performance Out of the 1392 health faciltiies, 1165 (84%) are currently functional and expected to report Figure 1c. Figure 1d | IDSR Completeness by county in W15 2017 Completeness for weekly reporting was 51% for the routine surveillance (IDSR sites) and 75% for the EWARS (IDP sites) (Table 1).

During the week, nine counties attained 100% reporting completeness. A total of 28 (35%) counties attained the target completeness of at least 80% (Figures 1c).

Timeliness for weekly reporting stands at 40% for the routine reporting sites and 66% for the IDP sites (Table 1).

Table 1 | Surveillance performance in South Sudan as of W15 2017

Timelines Completeness Timeliness Completeness Total System Facilities in week 15 of 2017 Cumulative for 2017

IDSR 1165 461(40%) 590(51%) 416 (30%) 570 (41%)

EWARN 47 31(66%) 35(75%) 37(77%) 37(77%) Table 2 | Reporting Performance [Timeliness and Completeness] by Partner and County as of W15 2017

Number of health W15 2017 Partner IDSR IDSR facilities Completeness Timeliness No. Silent Counties W15 2017 Silent Counties W15 2017 Lainya Cueibet % # % # # Morobo Rumbek North ARC 3 0 0% 0 0% Budi Yirol East COSV 0 0 0% 0 0% Ikotos Payinjiar Kapoeta North Baliet GOAL 2 2 100% 2 100% Lofan Longochuk HLSS 2 2 100% 2 100% Akobo* Luakpiny/Nasir* Ayod Maban IMA 5 2 40% 2 40% Duk* Maiwut Fangak Malakal* IMC 8 6 75% 6 75% Nyirol* Melut Pibor Panyikang IOM 11 11 100% 11 100% Pochalla Renk* uror Ulang* IRC 1 1 100% 1 100% Medair 2 2 100% 2 100%

MSF-E 2 2 100% 2 100% MSF-H 4 2 50% 2 50% *Counties with EWARS reporting sites , SMC 6 2 33% 2 33% UNIDO 0 0 0% 0 0% UNKEA 2 0 0% 0 0% This week, the nine health facilities in the IDP sites that did World Relief 1 0 0% 0 0% not submit their reports are supported by WR, UNKEA, SMC, Total 47 35 75% 31 66% MSF-H, IMC, and IMA (Table 2).

This week, 21 hospitals (41%), 142 PHCCs (44%), and 427 PHCUs (42%) in 52 counties submitted their IDSR reports (Table 2). A significant improvement The best performing partner-supported facilities during from the previous weeks the week were GOAL, IRC, Medair, HLSS MSF-E, and IOM. Number of counties that did not submit any IDSR report increased from 26 in week 14 to 28 in week 15 (Table 2). However, seven of these counties submit their data through EWARS (Table 2). Consultations Twelve (12) partner-supported health facilities in the IDP sites did not submit their reports (Table 2). Table 3 | Consultations in South Sudan as of W13 2017 Trends for top causes of Morbidity Surveillance Consultations in Week 15 of 2017 Cumulative consultations for 2017 Table 4 | Top causes of morbidity in 2016 and 2017 System <5 years ≥5 years Total <5 years ≥5 years Total Cumulative cases week 1 to New cases W15 IDSR 30,777 49,251 80,028 441,501 688,985 1,130,486 System Disease week 15 of 2016 2017 2016 2017 EWARN 22,707 416,526 Malaria 17,231 22,236 327,272 336,489 ! AWD 8,301 7,111 104,821 114,458 Total 102,735 1,547,012 Meningitis 0 0 9 3 IDSR ABD 1,588 1,402 23,808 18,256 Table 4 summarizes the consultations in the IDP and IDSR reporting Measles 5 30 242 283 sites. AJS 0 0 7 15 Malaria 5,689 2,220 113,388 54,683 AWD 3,780 2,328 49,409 38,486 Malaria remains the top cause of morbidity in the IDSR reporting sites followed ARI 5,647 6,402 85,729 112,479 by Acute watery diarrhea while for the IDP sites ARI is the leading cause of EWARN ABD 398 196 6,024 3,247 morbidity followed by malaria (Figures 1a, 1b, 6a, 6b, Table 4). Measles 30 0 225 216 AJS 33 15 982 219 Meningitis 1 0 11 18 Malaria 22,920 24,456 440,660 391,172 AWD 12,081 9,439 154,230 152,944 ARI 5,647 6,402 85,729 112,479 Total ABD 1,986 1,598 29,832 21,503 Measles 35 30 467 499 AJS 33 15 989 234 Meningitis 1 0 20 21 Overall morbidity trends for 2017 Figure 6b | EWARN Priority Disease Proportionate Morbidity W52 2013 to W15 2017 Figure 6a | IDSR priority disease morbidity trends W1 to W15 2017

80% IDSR Priority Disease Morbidity trends from week 01 - 15, 2017. South Sudan 70% 70.0 500.0 60% 60.0 50% 400.0 50.0 40% 40.0 300.0 30% 20% 30.0 200.0 20.0 10% Completeness (%)

100.0 0% 10.0 15 13 08 06 03 30 ------Percentage of all consultations 12 07 02 09 04 10

0.0 0.0 ------1 2 3 4 5 6 7 8 9 10 11 12 cases per 100,000 population 2013 2014 2015 2015 2016 2016

Epidemiological Weeks %_Malaria %_ARI %_Measles Completeness ABD Malaria Measles AWD %_AJS %_AWD %_ABD Status: Urgent Malaria IDSR Malaria Incidence rate by year, 2015, 2016 and This week malaria accounted for 32% and 10% of consultations in IDSR 2017* and IDP sites respectively (Fig. 1a, 1b). The incidence (cases per 600.0 100,000) of malaria decreased from 284 in week 14 to 182 in week 15. 500.0

400.0 As the malaria season approaches, the incidence in week 15 of 2017 is comparable to the corresponding periods in 2014, 2015 and 2016. 300.0 200.0 As seen from Figs. 8a-f, analysis of malaria trends at state level showed that malaria cases were within expected levels at state hub level.(Fig 8a- 100.0 d). 0.0 cases per 100,000 population 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 The malaria incidence in the IDP sites has remained within expected Epidemiological Weeks levels. (Figs. 10a-d) 2015 2016 2017

During the week, six malaria deaths were reported from Juba, Aweil North, Tambura and Bentiu PoC (Tables 5, 6). Malaria trends by state hub Figure 8a |IDSR Malaria trends for Northern Bhar el Ghazal Figure 8b | IDSR Malaria trends for Warrap hub from week 1 to 15, 2017 hub from week 1 to 15, 2017 1200.00 1200.00

1000.00 1000.00

800.00 800.00

600.00 600.00

400.00 400.00 cases per 100,000 population 200.00 200.00 cases per 100,000 population 0.00 0.00 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological Weeks Epidemiological Weeks Third quartile 2012-2016 2017 Third quartile 2012-2016 2017

Figure 8d | IDSR Malaria trends for Lakes Wau from week 1 to Figure 8f | IDSR Malaria Incidence rate for Western ! 15, 2017 hub by year, 2015, 2016 and 2017* 700.00 500.0 600.00 400.0 500.00 400.00 300.0

300.00 200.0 200.00 100.0 100.00 cases per 100,000 population cases per 100,000 population 0.00 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological Weeks Epidemiological Weeks Third quartile 2012-2016 2017 2015 2016 2017

Malaria

Figure 8g | IDSR Malaria trends for Western Bhar el Ghazal Figure 8f | IDSR Malaria Incidence rate for Unity State by year, State from week 1 to 15, 2017 2015, 2016 and 2017* 1200.00 600.0

1000.00 500.0

800.00 400.0

600.00 300.0

400.00 200.0

200.00 100.0

cases per 100,000 population 0.00 cases per 100,000 population 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epidemiological Weeks Epidemiological Weeks Third quartile 2012-2016 2017 2015 2016 2017

*Actual disease trends may be masked by low reporting rates Malaria in IDPs

Acute Respiratory Infection (ARI)

35% Figure 11b | ARI Incidence by IDP Site in W15 2017 Figure 11 | ARI trends in IDPs W51 2013 to W15 2017 80% 30% 70% 60% 25% 50% 40% 20% 30% 20% 15% 10% … … 0% … … … 10% ! Percent of all consultations 5% E Hospital - Percent of total consultations SMC Malou Aburoc PHCU HLSS Bor Clinic 0% MSF

010305070911131517192123252729313335373941434547495153 IRC Sector 4 Clinic IMC Akobo Hospital IOM Wau PoC Clinic H Bentiu Town Clinic Medair Abayok Clinic - E Malakal Town PHCC H Bentiu PoC Hospital IMC UN House Clinic 1 - - IOM Malakal PoC Clinic SMC Arek Mobile Clinic Medair Wonthow Clinic GOAL Dethoma Camp 2 GOAL Koradar IDP clinic IOM Nazareth IDP Camp IMA Kodok Mobile Clinic IMC Malakal PoC Clinic 1 IMC Malakal PoC Clinic 2 IOM Bentiu Sector 1 PoC IOM Bentiu Sector 3 PoC IOM Bentiu Sector 5 PoC IOM Cathedral IDP Camp Epidemiological week of reporting IOM Gerger Mobile Clinic MSF IOM Ramela Mobile Clinic MSF MSF IOM Wonthou Mobile Clinic 2014 2015 IMA Delal Ajak Mobile Clinic

Figure 11b shows ARI morbidity by IDP site in Week 15 of 2017 ARI proportionate morbidity decreased from 29.06% in week 14 to 28.19% in week 15. Comparatively, the ARI proportionate morbidity in 2017 is higher than the corresponding period in 2014, 2015, and 2016.

Chickenpox

• Chicken pox cases continue to be reported from Wau PoC. • WHO has shared a guidance document on supportive • The current response is limited to symptomatic case management of chickenpox cases management of mildly ill cases and admission of • Recommended supportive management entails - using complicated cases. calamine lotion, antihistamines, and analgesics for mildly ill • Implementing partners from IDP collective sites as well as cases while complicated cases are admitted for specialized from Wau municipality are supporting the response treatment by clinicians. • IOM has line listed at least 2,222 cases while IMC has line • Calamine lotion is currently reported to be in short supply. listed an additional 800 cases Meningitis (suspected) Suspect meningitis Epi-curve showing rapid pastorex results, Bentiu PoC, week 47 of 2016 to week 12, 2017 In week 15, there was no suspect meningitis 7 case reported. 6 5 Even as the meningitis season is coming to 4 an end, partners are still urged to maintain 3 heightened surveillance, and to ensure that No. cases all patients meeting the suspect case definition 2 for meningitis are investigated and where 1 possible samples collected and notifications 0 sent to the next level for prompt action.

Cumulatively from week 47 of 2016, a total of Week of onset 18 rapid pastorex Streptococcus pneumoniae cases have been reported (Fig. 11c). Only one H.Influenzae b N. meningitidis Y/W 135 Negative S.Pneumonlae rapid pastorex Neisseria meningitidis Y/W135 case has been reported since week 47 of 2016 (Fig. 11c).

Suspect meningitis attack rates & CFR by week, Bentiu PoC Figure 11d shows the attack rates (cases per 12 30 100,000) and case fatality rates by week for 10 25 suspect meningitis cases in Bentiu PoC. While the alert threshold has been surpassed for at 8 20 least four weeks since week 47, the epidemic 6 15

threshold has not been reached. The current 4 10 CFR [%] trends are still below the epidemic threshold. cases per 100,000 2 5 Surveillance for suspect cases of meningitis is

high in Bentiu PoC and countrywide. 0 0 45 46 47 48 49 50 51 52 01 02 03 04 05 06 07 08 09 10 11 12 ------

Nearly 40% of the cases are below one year 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 2017 and 68% are below five years of age. Children Epi week of onset and young adults constitute 53% of the cases. AR Alert threshold Action threshold CFR Males constitute 61% of the total cases reported (Table 4c).

Heighten Surveillance for meningitis has been maintained across the country, especially in the Table 4c: Suspect meningitis case age & sex distribution, Bentiu PoC, wk 47, 2016 to wk 10, high risk locations Like Malakal and Bentiu 2017 PoC. Count of SN Column Labels ! The second phase of the MenAfriVac Age Female Male Total Percentage preventive campaigns are slated for the fourth <1yr 8 8 16 41% quarter of 2017 targeting the states in the 1-4yrs 2 9 11 28% region. 5-14yrs 2 3 5 13% 15-29yrs 1 3 4 10% 30+yrs 2 1 3 8% Total 15 24 39 100% Acute watery diarrhoea (AWD) IDSR Acute Watery Diarrhoea Incidence rate by year, 2015, AWD remains among the top three causes of morbidity in the 2016 and 2017* Country, this week it accounted for 10% and `10% of all 140.0 consultations in the routine reporting(IDSR) and IDP sites 120.0 respectively (Fig. 1a, 1b). 100.0 The AWD Incidence [cases per 100,000] decreased from 109 in 80.0 week 14 to 58 in week 15 from the IDSR reporting sites.(Fig. 12). 60.0

40.0 In the IDP sites, AWD morbidity has increase over the last four consecutive weeks. This week, the proportionate morbidity is 20.0

lower than the corresponding period in 2014, 2015, and 2016 cases per 100,000 population 0.0 (Fig. 13). Figure 14 shows AWD morbidity by IDP site in Week 15 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 of 2017 Epidemiological Weeks 2015 2016 2017

Acute watery diarrhoea (AWD)

Figure 14 | AWD Incidence by IDP Site in W15 2017 25% Figure 13 | AWD trends in IDPs W51 2013 to W15 2017 35% 30% 25% 20% 20% 15% 15% 10% 5% 10% … … 0% … … …

5% E Hospital - SMC Malou Percent of all consultations IMC ER PoC 1 Aburoc PHCU HLSS Bor Clinic MSF Percent of all consultations

0% IRC Sector 4 Clinic IMC Akobo Hospital IOM Wau PoC Clinic H Bentiu Town Clinic

01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 Medair Abayok Clinic - E Malakal Town PHCC H Bentiu PoC Hospital IMC UN House Clinic 1 - - SMC Arek Mobile Clinic Medair Wonthow Clinic GOAL Dethoma Camp 2 GOAL Koradar IDP clinic IOM Nazareth IDP Camp IMA Kodok Mobile Clinic IMC Malakal PoC Clinic 1 IOM Bentiu Sector 5 PoC IOM Bentiu Sector 3 PoC IOM Bentiu Sector 1 PoC IOM Cathedral IDP Camp IOM Halaka Mobile Clinic IOM Gerger Mobile Clinic MSF IOM Ramela Mobile Clinic Goa Medical Mobile Clinic MSF MSF

2014 2015 2016 2017 IOM Wonthou Mobile Clinic

Acute bloody diarrhoea (ABD) IDSR Acute Bloody Diarrhoea Incidence rate by year, 2015, 2016 ! For the fifth consecutive week, the ABD burden remained at and 2017* 25.0 2% and 1% of all consultations in the IDSR and IDP sites respectively (Fig. 1a, 1b). 20.0 For the routine reporting sites ABD incidence [cases per 15.0 100,000] decreased from 17.9 in week 14 to 11.5 in week 15 (Fig. 15). 10.0 Among the IDPs, the current ABD proportionate morbidity increased in week 15 but is still remains low compared to the 5.0 corresponding period in 2014, 2015, and 2016 (Fig. 16 and cases per 100,000 population 17). 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Figure 17 shows the number of ABD cases by IDP clinic in Epidemiological Weeks week 15 of 2017. 2015 2016 2017

Acute bloody diarrhoea (ABD) 6% Figure 17 | ABD Incidence by IDP Site in W15 2017 Figure 16 | ABD trends in IDPs W51 2013 to W15 2017 9% 8% 5% 7% 6% 4% 5% 4% 3% 3%

Percent of all consultations 2% 2% 1% … … … … … … … … … 0% … 1% Percent of all consultations E Hospital -

0% SMC Malou H Bentiu PoC IMC ER PoC 1 Aburoc PHCU - HLSS Bor Clinic MSF

010305070911131517192123252729313335373941434547495153 E Malakal Town - IRC Sector 4 Clinic MSF IOM Cathedral IDP IMC Akobo Hospital IOM Wau PoC Clinic IOM Bentiu Sector 5 IOM Bentiu Sector 1 IOM Bentiu Sector 3 H Bentiu Town Clinic MSF Medair Abayok Clinic HLSS Mingkaman IDP - IOM Wonthou Mobile IMA Delal Ajak Mobile 2014 2015 2016 2017 IMC UN House Clinic 1 IMC UNMISS PoC Clinic IOM Malakal PoC Clinic SMC Arek Mobile Clinic Medair Wonthow Clinic GOAL Dethoma Camp 2 GOAL Koradar IDP clinic IOM Nazareth IDP Camp IMA Kodok Mobile Clinic IMC Malakal PoC Clinic 1 IMC Malakal PoC Clinic 2 IOM Halaka Mobile Clinic IOM Gerger Mobile Clinic MSF IOM Ramela Mobile Clinic Gap Medical Mobile Clinic Goa Medical Mobile Clinic Table 4.1| Measles cases by location and status as at W15 of 2017

New suspect Samples Measles Suspect cases Confirmed Confirmed Outbreak status in County cases W15, tested in in 2017 Measles 2017 Rubella 2017 2017 2017 2017 In week 15, a total of 31 new suspect measles cases were reported Juba (6), Mayom (8), Jur River (9), Torit (1), and Wau IDPs 0 287 15 26 96 Confirmed

Yambio (7) (Table 4.1). Malakal PoC 0 2 0 2 Alert

Cumulatively, in 2017 a total of least 573 suspect measles Gogrial East 0 43 5 8 Alert cases including 4 deaths (CFR 0.70%) have been reported Gogrial West 0 53 15 29 Confirmed from 19 counties.. Abyei 0 12 0 7 17 Alert

Most of the cases have been reported from Wau, Gogrial East, Tonj North 0 11 0 0 0 Alert Gogrial West and Yambio counties (Figure 18.1). Aweil South 0 6 7 7 Confirmed

The majority of the cases are under five years of age (Figure Yambio 7 82 2 13 27 Alert 18.3). Cueibet 0 1 0 0 0 Alert

Since the beginning of 2017, measles outbreaks have been Mayom 8 15 0 0 0 Alert confirmed in five counties - Wau, Aweil South, Gogrial West, Nzara 0 3 0 Alert Gogrial East, and Juba (Table 4.1 and Figure 18.2). Ezo 0 1 0 0 0 Alert At least 52 measles IgM positive and 46 rubella IgM cases Table of CountiesAweil West with Suspected0 9 Outbreaks in 20171 and SpotAlert Map of Confirmed have been confirmed in 2017 (Table 4.1 and Figure 18.2). 0 Aweil Center Cases(Lab confirmed,0 Epi1 Link0 and Clinically0 0 CompatibleAlert cases)* Most counties have not attained the non-measles febrile/rash Suspected Confirmed_La Confirmed_ Suspected_with_ Number Of Number Rubella Number Of Number Of Admitted Non_Admitt Month DistrictofResidence ProvinceKajo Of-keji Residence 0 5 0 0 Alert illness rate of at least 1/100,000 (Figure 18.4). This highlights Cases b_EpiLink Lab Lab_Result Samples Cases Clinicals Discarded _Alive ed_Alive the need to enhance measles case-based investigation1 AWEIL SOUTH and NORTHERNJuba BAHR EL GHAZAL 66 0 22 4 13 6 6 29 0 Alert 0 2 1 3 sample collection. 1 GOGRIAL EAST WARRAP 5 0 5 5 5 0 0 0 0 5 Torit 1 2 0 0 39 Alert 1 GOGRIAL WEST WARRAP 11 0 7 10 11 0 1 3 3 5 The follow-up measles campaign is scheduled for1 theWAU first and WESTERNDuk BAHR EL GHAZAL 630 0 15 5 0 55 63 0 26 Alert 8 50 2 11 second week of May 2017. 2 GOGRIAL WEST WARRAP 3 0 3 3 3 0 Alert 0 0 2 1 2 JUBA CENTRALJur River EQUATORIA 89 0 2 4 0 8 0 8 0 0 0 4 1 3 2 YAMBIO WESTERNMundri West EQUATORIA 120 0 1 0 0 8 0 12 1 4 Alert 4 8 0 4 3 ABYEI WARRAP 6 0 0 5 6 2 0 5 0 0 3 JUBA CENTRALTotal EQUATORIA 315 0573 4 52 4 46 5 256 0 1 0 1 4 Non-Measles Febrile/Rash Illness3 WAU RatesWESTERN by BAHR CountyEL GHAZAL 9 / 20160 5 - 8 9 2 0 3 5 0 3 YAMBIO WESTERN EQUATORIAFig 18.2| Counties with confirmed measles outbreaks as at 21 0 0 21 21 W15 11of 2017 0 21 0 0

Measles cases by Epidemiological week and county , week 12017* -15, 2017

90 80 County level ! 70 Counties by 60 category 50 Numbe Categories 40 r Percent NM-FRI rateNumber of cases =0.00- 30 42 53% 0.00 20 NM-FRI rate >0.0110 - 2 3% 0.99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 NM-FRI rate >1.00- 5 6% 1.99 Epidemiological week in 2017

NM-FRI rateJuba >2.00 30 Gogrial West 38% Aweil South Aweil Center Malakal Total Wau 79 Jur River100% Yambio Torit * As of WeekGogrial East 14, 2017

Fig 18.4| Non-measles cases Febrile/Rash illness per 100,000 by county Fig 18.3| Measles case distribution by age group and country, week 1-15, as at W15 of 2017 2017 2016

Measles case distribution by age group and county, week 1Non-Measles Febrile/Rash-15, 2017 2017 Illness Rates by County / 2016- 100% Counties by 2017* 90% category 80% County level Numbe Counties by 70% Categories r Percent category Numbe NM-FRI rate60% = 0.00- Categories r Percent NM-FRI rate =0.00- 69 87% 42 53% 0.00 50% 0.00

Age distrib. % NM-FRI rate >0.01- 2 3% NM-FRI rate40% > 0.01- 0 0% 0.99 NM-FRI rate >1.00- 5 6% 0.99 30% 1.99 NM-FRI rate >1.00- NM-FRI rate >2.00 30 38% 20% 0 0% Total 79 100% 1.99 10% NM-FRI rate >2.00 10 13% 2016 0% Total Juba Gogrial West 79 Aweil 100% South Aweil Center Malakal Wau Jur River Yambio Torit 2017Gogrial East <1yr 1-4yrs 5-9yrs Counties by10 -14yrs 15+yrs * Ascategory of Week 14, 2017 Numbe Categories r Percent NM-FRI rate =0.00- 69 87% 0.00 NM-FRI rate >0.01- 0 0% 0.99 NM-FRI rate >1.00- 0 0% 1.99 NM-FRI rate >2.00 10 13% Total 79 100% * As of Week 12, 2017

ANALYSIS: In week 14, Six (6) health facilities reported 35 cases, 26 new cases, 8 relapses and 1 PKDL. 1 death and 2 defaulters reported. Table 2 Since the beginning of 2017, a total of 926 cases including 19 deaths (CFR 2.1%) and 6(0.6%) defaulters have been reported from 16 treatment centers however, currently 12 treatment centers are reporting. Of the 926 cases reported, 761 (82.2%) were new cases, 56(6.0%) PKDL and 109(11.8%) relapses. In the corresponding period in 2016, a total of 531 cases including 27 deaths (CFR 5.1%) and 25(4.7%) defaulters were reported from 21 treatment centers. Majority of cases were reported from Lankien (332), Old fangak (313), Kurwai (101) , Walgak (45), Malakal IDP (35), KCH (31) and Ulang (16) etc The most affected groups included, males [328 cases (54.7%)], those aged 5 - 14years [264(29.3%) and ≥15years and above [253 cases (28.5)]. A total of 93 cases (10.0%)] occurred in children <5years. Table 1 It is noted that, there is high number of relapses reported in Old Fangak and Kurwai with 60% and 25% respectively of the total cases. The numbers of cases reported in 2017 continue to be higher than those reported in 2016, almost twice despite the transmission season. However, the trend of the graph is more or less the same. There is anticipation of increase in number of cases in the coming weeks The low number of cases reported in weeks 13 was as a result of few number of health facilities reporting. WHO/MOH in collaboration with IMA and KalaCore continue to ensuring that all implementing partners have access to KA test kits and medicine and onsite monitoring of Kala azar activities to ensure proper treatment provided to patients. WHO/MOH in collaboration with IMA and KalaCore plan to conduct training and establish Visceral Leishmaniasis | Kala-azar DAT testing at the National Public Health Laboratory.

In week 15, six health facilities reported 35 cases, 26 new cases, 8 relapses and 1 PKDL including 1 death and 2 defaulters reported. Since the beginning of 2017, a total of 926 cases including 19 deaths (CFR 2.1%) and 6(0.6%) defaulters have been reported from 16 treatment centers though only 12 treatment centers are reporting currently. Of the 926 cases reported, 761 (82.2%) were new cases, 56(6%) PKDL and 109(11.8%) relapses.

In the corresponding period in 2016, a total of 531 cases including 27 deaths (CFR 5.1%) and 25(4.7%) defaulters were reported from 21 treatment centers.

Majority of cases were reported from Lankien (332), Old Fangak (313), Kurwai (101) , Malakal IDP (35), Walgak (35), KCH (31) and Ulang (16). The most affected groups include, males [328 cases (54.7%)], those aged 5 - 14years [264(29.3%) and ≥15years and above [253 cases (28.5%)]. A total of 93 cases (10.0%)] occurred in children <5years.

2 The number of cases reported in 2017 is higher than those reported in 2016

despite the fact that the 2017 transmission is yet to start season.

Hepatitis E Virus (HEV)

A total of 14 HEV cases reported from Bentiu PoC (Fig. 19) were reported in Figure 19 | HEV trends in Mingkaman, Bentiu & Lankien W10 Week 15. 2014 to W15 2017 16 350 14 300 Cumulatively, a total of 209 HEV cases have been reported from Bentiu PoC 12 250 in 2017. The transmission is linked to sub-optimal access to safe water and 10 200 sanitation. Multi-sectoral response has made some progress in reducing the 8 150 incident but control is yet to be attained due to a multiplicity of factors. (Fig. 6 19) 4 100 2 50 No. cases in Bentiu No, cases in other sites Cumulatively, from the beginning of the crisis, 3,457 HEV cases including 0 0 25 deaths (CFR 0.72%) reported in Bentiu; 174 cases including seven deaths 3 10172431384552 7 142128354249 3 10172431384552 7 (CFR 4.4%) in Mingkaman; 38 cases including one death (CFR 2.6%) in 2014 2015 2016 2017 Lankien; 3 confirmed HEV cases in Melut; 3 HEV confirmed cases in Guit;1 Epidemiological week HEV confirmed case in Leer; and Mayom/Abyei [75 cases including 13 Awerial Lankien Bentiu deaths with 7 HEV PCR positive cases.

Other diseases of public health importance Table.|Non Polio AFP rate by county as of Week 15 of 2017 !

Acute Flaccid Paralysis | Suspected Polio 2015 2016 2017 In Week 15, six new AFP cases were reported with date of onset in 2017 from Central Equatoria hub (1), hub (1), Unity hub (2), and Western Equatoria hub (2).

During 2017, a cumulative of 88 AFP cases have been reported countrywide. the annualized non-Polio AFP (NPAFP) rate (cases per 100,000 population children 0-14 years) is 3.7 per 100,000 population of children 0-14 years (target ≥2 per 100,000 children 0-14 years).

Stool adequacy was 91% in 2017, a rate that is higher than the target of ≥80%. *As of epidemiological week 14/2017 Number & Percentage of Counties by categories of NPAFP rates: Summary from above thematic maps Guinea# of Counties Worm / NPAFP | Dracunculiasis rates in 2015 # of Counties / NPAFPViral rates Haemorrhagic in 2016 # of CountiesFever / NPAFP rates in 2017* States Hubs =0 >0<1 >1<3 >3<4 >4 Total =0 >0<1 >1<3 No>3<4new suspect>4 Totalhemorrhagic =0 >0<1fever >cases1<3 >reported3<4 >from4 Totalacross the During the week, suspect Guinea worm cases were Country in the week. Central Equ Hub reported0 from1 Tonj 0 South4 (1) and1 Tonj 6East (3)0and are0 4 2 0 6 5 0 1 0 0 6 Eastern Equ Hub being0 investigated0 1. More 3than 35, 000 alerts6 have1 been1 0 2 4 8 3 0 0 0 5 8 Jonglei Hub investigated3 0 in 20173 with 4three samples3 11collected 2 out of0 1 4 3 11 6 0 0 2 3 11 which two were negative while the third is still pending. Lakes Hub 0 0 0 3 6 8 0 0 0 Animal1 7 bites8 | Suspected1 0 rabies0 2 5 8 Northern Bahr El Cumulatively0 0 in 20161 ; s3ix (6) confirmed3 5 Guinea0 worm1 1 1 2 5 0 0 3 2 5 Ghazal Hub cases were reported compared to Four (4) cases in There were no suspect rabies cases in the week. Unity Hub 2015 3 . 1 3 0 3 9 0 2 3 4 0 9 8 0 0 0 1 9 Upper Nile Hub 5 0 3 3 1 13 1 0 3 2 7 13 10 0 0 1 1 12 The Ministry of Health through the South Sudan Guinea Warrap Hub Worm 0 Eradication0 3 Program(SSGWEP) 1 4 continues7 0 to 0 1 5 1 7 2 0 1 1 3 7 Western Bahr El offer cash reward of 5,000 SSP. for reporting a Guinea 0 0 0 1 3 3 0 0 0 0 3 3 3 0 0 0 0 3 Ghazal Hub worm. Western Equ Hub 0 0 0 3 8 10 0 0 0 0 10 10 2 0 0 0 8 10 National Total 11 3 11 31 34 79 4 4 13 21 37 79 40 0 2 9 28 79 rating % 14% 3% 14% 37% 43% 100% 5% 5% 16% 27% 47% 100% 51% 0% 3% 11% 35% 100% Cholera Figure 19.2 | Cholera Epidemic curve in South Sudan as of 21 Apr 2017

• Cumulatively, 6,774 cholera cases including 221 deaths (70 450 25

facilities and 151 community) (CFR 3.25%) have been 400 21.05 20 reported in South Sudan (Figs 19.2&19.3; Table 4.2) 350

300 16.92 • New cholera outbreak confirmed in Mayom and Kodok - with 15 250 13.35 Number of cases

active transmission in Yirol East, Yirol West, Ayod, and CFR [%] 200 Mingkaman (Figs 19.2&19.3; Table 4.2). 10

150

6.67 6.91 6.32 100 • A new cluster of suspect cholera cases reported in Tar cattle 5.11 4.84 5 4.48 4.12 4.29 3.49 3.64 3.33 3.33 3.08 camp near Pagil in Ayod. 50 2.75 2.26 2.42 2.24 2.30 2.05 1.85 2.03 2.00 1.55 1.76 1.42 1.27 1.47 1.19 0.86 0.76 0.75 0.82 0.79 • A total of 18 counties in 10 (31%) of 32 states countrywide 0.62 0.42 0.63 0.57 0.60 0 - - - - 0 have confirmed cholera outbreaks (Figs 19.2&19.3; Table 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 11 12 13 14 15 16 2016 2017 4.2). Epidemiological week of onset • The transmission in Awerial (Dor), Yirol East (Tharnuar), and Jonglei Jubek Terekeka Imatong Eastern Lakes Fangak Northern Liech Southern Liech Central Upper Nile CFR[%] Ayod (Buol and Tar) is largely attributed to disease spread in affected cattle camps. Readers are referred to the cholera situation report for details on the ongoing cholera response in South Sudan

Table 4.2| Cholera cases and deaths by county as of 21 April 2017

Reporting sites Total cases Total Facility deaths Total community deaths Total deaths Juba county 2,045 8 19 27 Duk county 351 4 32 36 Bor county 87 1 4 5 Terekeka county 22 0 8 8 Awerial county 1,026 2 11 13 Yirol East 549 13 24 37 Yirol West 17 0 0 0 Pageri county 29 0 1 1 Fangak county 282 4 0 4 Ayod county 130 0 35 ! 35 Rubkona county 1176 7 2 9 Mayom county 7 0 4 4 Leer county 94 3 0 3 Panyijiar county 501 20 4 24 FigureMayendit county1.0: Cholera226 incidence0(cases per 105 ,000) and5 case fatalityPigi county rate (%) as183of 13 October5 2016 5 Kodok 30 3 1 4 Malakal 19 0 0 Total 6,774 70 151 221 Figure 19.3 | Cholera incidence (cases per 10,000) and case fatality rate (%) as of 21 Apr 2017 Mortality Table 6 | Proportional mortality by cause of death in IDPs W15 2017 Table 5 | Mortality from IDSR reports countrywide W15 2017 Bentiu Malakal Grand Total Malaria Total deaths Total deaths Proportionate COUNTY AWD <5yrs AWD ≥5yrs <5yrs <5yrs ≥5yrs Cause of Death by IDP site ≥5yrs <5yrs ≥5yrs mortality [%] Juba 8% 0 0 2 2 0 Acute watery diarrhoea 1 1 Aweil North Asthma 1 1 8% 0 0 1 1 0 Leer Burns 1 1 8% 3 0 0 3 0 Mvolo Malaria 1 1 8% 0 1 0 0 1 Tambura SAM 1 1 8% 0 0 2 2 0 Total 3 1 5 8 1 Sepsis 1 1 8% Septic shock 1 1 8%

TB/HIV/AIDS 1 1 8% In week 15, nine deaths were reported through IDSR, with three 8% deaths attributed to acute watery diarrhoea in Dindin (Leer) and Unknown 1 1 malaria while bloody diarrhoea and five due to malaria (Table 5). Epistaxis 1 1 8%

Chickenpox 1 1 8% Among the IDPs, mortality data was received from Bentiu and Malakal in week 15. (Table 6). Twelve deaths were reported from Cardiopulmonary arrest 1 1 8% the IDP sites. Bentiu PoC reported 10 deaths, the highest among Grand Total 10 1 1 12 100% the IDPs in the week. Overall, one out of the 12 deaths were children <5 years (Table 6).

The causes of death in the IDP sites during the current week are The Crude Mortality Rates [CMR] in all the IDP sites that submitted shown in Table 6. mortality data in Week 15 of 2017 were below the emergency threshold of 1 death per 10,000 per day (Fig. 21). The U5MR in all the IDP sites that submitted mortality data in Week 15 of 2017 is below the emergency threshold of 2 deaths per 10,000 per day (Fig. 20). The other causes of mortality in the week are shown in Tables 5 and 6.

Note: Mortality rates are calculated for PoC sites only and are based on the latest available population data from OCHA. They are reported from line lists and should include community and facility-based deaths. However, due to rapid in/out migration from the PoC sites, and possible under-reporting of community-level deaths, they should be interpreted carefully. ! Crude and under five mortality rates in IDPs

Figure 20 | EWARN U5MR by Site - W1 2016 to W 15 of 2017 Figure 21 | EWARN Crude Mortality Rate for W1 2016 to W 15 of 1.2 2.5 2017 1.0 2.0 0.8 1.5 0.6 1.0 0.4 0.5 0.2 0.0

deaths per 10,000 per day 0.0 1 3 5 7 9 111315171921232527293133353739414345474951 1 3 5 7 9 111315 1 3 5 7 9 111315171921232527293133353739414345474951 1 3 5 7 9 111315 deaths per 10,000 per day 2016 2017 2016 2017 Epidemiological week Epidemiological week

Bentiu Juba 3 Malakal Mingkaman Bentiu Juba 3 Malakal Mingkaman Melut Melut Akobo Wau Shiluk Threshold Akobo Wau Shiluk Threshold Wau PoC

Overall mortality in 2017

Table 7 | Mortality by IDP site and cause of death W15 2017

A total of 266 deaths

Azar have been reported - IDP site from the IDP sites in Acute watery diarrhoea GSW Heart Failure Kala Malaria Maternal death Meningitis Perinatal death Pneumonia SAM Septicemia Stroke TB/HIV/AIDS Cancer Cholera Hypertension Others Grand Total Bentiu 5 5 2 1 5 2 2 3 4 18 21 2 2 88 160 2017 Table 7. Juba 3 2 1 6 3 3 14 15 44 The top causes of Kodok 1 2 3 mortality in the IDPs Malakal 2 2 1 2 15 22 in 2017 are shown in Akobo 2 2 8 5 1 1 1 7 27 Table 7. Wau PoC 6 2 1 1 10 Grand Total 15 5 3 3 19 2 2 9 14 18 1 1 40 3 2 1 128 266 Proportionate mortality [%] 5.6 1.9 1.1 1.1 7.1 0.8 0.8 3.4 5.3 6.8 0.4 0.4 15.0 1.1 0.8 0.4 48.1 100 Data sources

This bulletin presents disease trends from the Integrated Disease Surveillance and Response (IDSR) System and the Early Warning Alert and Disease Network (EWARN).

The respective data is submitted by public health facilities serving host communities (non-conflict affected states or non IDP sites) and partner-supported facilities serving internally displaced persons (IDP) in the Republic of South Sudan.

Editorial

Editorial: Dr. Alice L. Igale, Dr. Abraham Adut, Korsuk L. Scopus, Robert M. Lasu, Rose A. Dagama, Jane Pita, Dr. Patrick, R. Otim , Gabriel Waat, Dr. Allan M. Mpairwe, Dr. Joseph F. Wamala, Dr. John P. Rumunu

Acknowledgements Contact

MoH and WHO gratefully acknowledge the support For more information, please contact: of all MoH staff in the states, WHO Field Officers, Department of Epidemics, Preparedness and Response and implementing-health cluster partners in MoH Republic of South Sudan collecting and reporting the data used in this bulletin. Email: [email protected]

Outbreak toll-free line using vivacell:1144

This bulletin is produced by the Ministry of Health with technical support from the WHO

Supported by the Global EWARS project | [email protected]