Republic of South Sudan

Situation Report #104 on Cholera in South Sudan As at 23:59 Hours, 20 January 2017

Situation Update Cholera outbreaks have been confirmed in 9 (32%) of 28 states countrywide. The affected states include Imatong, Eastern Lakes, Jubek, Terekeka, Jonglei, Western Bieh, Northern Liech, Southern Liech; and Eastern Nile (Table 1 and Figure 1.0). Suspect cholera cases were reported in Mayendit and Ayod but are not confirmed (Table 4). One sample collected by MedAir from Madol 1CTU in Mayendit tested negative for cholera by culture in week 2, 2017. Cumulatively 150 (35.7 %) of the samples tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 20 January 2017 (Table 3).

Table 1: Summary of cholera cases reported in South Sudan as of 20 January 2017 Total cases Total New New New Total Total currentl Total cases Total Reporting Sites admission discharges deaths facility communi y deaths discharge cases s WK 2 WK 2 WK 2 deaths ty deaths admitte d d Jubek – Juba 5 40 - 1 8 19 27 2,015 2,043

Jonglei-Duk - - - - 5 3 8 84 92

Terekeka - - - - - 8 8 14 22

Eastern Lakes - - 1 - - 1 3 4 349 353 Awerial

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

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

Northern Liech - 35 36 - 30 7 2 9 920 959 Rubkona

Southern Liech - - - - - 3 - 3 88 91 Leer

Southern Liech - 23 - - - 10 2 12 362 374 Panyijiar

Eastern Nile - 5 168 Pigi 5 163

Total 63 77 - 31 43 38 81 4,289 4,401

Highlights in week 2 of 2017: 1. A total of 35 cases reported from Bentiu PoC in week 2 of 2017; compared to 86 cases in week 1 of 2017 Table 1, Figure 1.1. 2. Five cases reported in UN House PoC in week 2 of 2017 compared to 23 cases in week 1 of 2017 Table 1. 3. A total of 23 cases reported from Panyijiar in week 2 of 2017 compared to 40 in week 1 of 2017 Table 1,

1 Figure 1.1. 4. There were two culture positive cases from Awerial and two positive cases from Bentiu PoC during the week. One sample from Madol in Mayendit tested negative for cholera by culture Table 3. 5. At least 48 suspect cholera cases reported in MedAir CTU in Madol 1, Mayendit, Southern Liech since 7 Jan 2017 Table 4. 6. Overall; active transmission is ongoing but declining in Northern Liech (Bentiu PoC) and Southern Liech (Leer and Panyijiar); and Jubek (UN House PoC) Figure 2.1.

In Jubek, there has been resurgence of cases in UN House PoC where at least 41 cases including 10 confirmed cases have been reported since week 52 of 2016. The majority, 39 (95%) of the cases from the recent wave of cases in UN House PoC originated from PoC 3. In response to the resurgence, a multi-cluster investigation mission was undertaken during the week. Thus, response efforts have been enhanced in UN House PoC with the WASH cluster carrying out spraying of the latrines and random quality water testing and reactivation of ORPs. In addition, HHPs have been deployed to carry out hygiene promotion. There are plans to open additional ORPs in PoC 3 and to deploy mobile communication teams in the two PoCs.

In Northern Liech state, 959 cholera cases including 24 confirmed cases and nine deaths (CFR 0.85%) were reported in Bentiu Town/PoC since 29 September 2016. The cholera taskforce, chaired by MoH and constituted by Health and WASH cluster partners is coordinating the response. Ongoing transmission is suspected to be associated with exposure to an unsecured water reservoir whose water is used for washing, bathing, swimming, and occasionally for domestic use. Bentiu PoC now has the highest cumulative incidence for cholera Table 1.1.

In Southern Liech, two cholera cases originating from Leer Town tested positive for Vibrio cholerae Inaba on 11 October 2016. One additional case from Ganyliel in Panyijiar tested positive for cholera on 3 January 2017. Cumulatively, 91 cholera cases have been line listed from Leer and at least 374 cases including 12 deaths from Panyijiar in Southern Liech state. The initial case in Panyijiar was seen on 22 October 2016 involving a trader from Duk. Facility and community based response is ongoing with most cases being managed in facilities like Duong PHCC, Ganyliel PHCC, and Nyal PHCC with support from IRC, and UNIDO.

Since 7 October 2016, at least 142 suspect cholera cases including three deaths were reported by UNIDO and MedAir response teams in Mayendit. The MedAir CTU in Madol 1 has seen at least 48 cases since 7 January 2017.

Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 20 January 2017

World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24, 2016 to 2 of 2017

Map Date: 18, January 2017 Manyo

Renk The boundaries and names shown and the designations used on this map do not imply ofcial endorsement or acceptance by the United Nations.

Sudan 0 50 100 200 Melut Kilometers Fashoda Maban Abyei Pariang Malakal Abiemnhom Baliet Aweil East Panyikang Aweil North Rubkona Fangak Guit Longochuk Twic Mayom Pigi Aweil West 0.85 2.98 1.48 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Tonj North Leer Ayod Mayendit 4.26 Ethiopia Tonj East Duk Panyijiar Uror Akobo Jur River Rumbek North 8.7 6.52 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Nagero Bor South Yirol West Awerial Pibor Wulu Tambura 1.34 Mvolo Legend Terekeka xx Case fatality rate (CFR) 36.36 Counties with Cholera alert Mundri WestMundri East Lafon Kapoeta North Cases per 10,000 population Ezo Ibba Maridi Kapoeta East Juba 40.1 - 50 Yambio Nzara 1.31 20.1 - 40 Kapoeta South 10.1 - 20 Torit Budi Yei Lainya 5.1 - 10 Magwi Ikotos 0.1 - 5 Kajo-Keji 3.45 Kenya No case reported Morobo Pageri River Democratic Republic of Congo Uganda

2 Figure 1.1: New cholera cases admitted by location in week 2 of 2017

30 23 Number of Cases

0 Juba Rubkona Panyijiar Jubek Northern Liech Southern Liech

In Eastern Lakes state, cholera cases were reported in Mingkaman IDP settlement. The initial cases were confirmed on 24 August 2016, after two of four samples tested postive for Vibrio cholerae Inaba. The cumulative cases are 353 cholera cases including 19 confirmed cases and 4 deaths (one facility and three community) (CFR 1.13 %). This outbreak has been controlled with only sporadic cases being reported – the most recent being admitted on 16 December 2016.

In Jonglei state, 92 suspected cholera cases including 8 deaths (CFR 8.7 %) were reported from Duk County involving mainly the three Islands of Kawer, Long, and Moldova. The index case was reported on 3rd July 2016 from Moldova Island. Of the five samples from Duk Islands that underwent culturing, one sample from Moldova Island, also the most affected, was confirmed as cholera on 29 July 2016. The most recent cases reported in Duk originated from Koyom Island on 10 Nov 2016. No additional cases were reported since then.

Figure 1.2: Cumulative cholera cases by payam of residence as at 20 January 2017

1000 950

900

800

700 643

600

500 470

Number of Cases 400 358 352 320 300 219 210 200 167 119 76 90 100 61 42 41 32 27 32 37 22 5 1 1 1 1 15 2 1 4 1 1 2 3 1 1 1 2 15 2 1 3 20 1 2 4 3 1 13 1 1 7 2 3 1 1 2 5 1 1 0 Kol Yai Gap Tiap NFG OFG Leer Yang Buko Rejaf Nyal Piliny Jiech Kator Puluk TOCH Adok Pariel Lwoki katith Padiat Lokiliri fangak Payam kurwai Nimule Khaigai mayom Maluak Pachak Munuki Uganda PAGUIR Rubchar Uganda Nyarjwa Thonyor Dhorbor Dhoryiel Ganyliel Payinjiar Abuyung Payinjiar Terekeka Mangalla Dongchak mayiandit Leer Town MAREANG Juba Town Gondokoro Pachienjok Bentiu PoC Thoarnhum Bentiu Town KOLANYANG Northern Bari Dhuorguol Deng Western Bieh Terekeka Southern Liech Northern Liech Jubek Jonglei Imatong Eastern Eastern Nile Lakes

Terekeka state has reported 22 cases of cholera including 8 deaths (CFR 36.4%) with 2 samples confirmed by the laboratory to be cholera. All the deaths were reported at the onset of the outbreak from Islands on River Nile where access to health services is poor. No additional deaths occurred after the rapid response team was deployed. The most of the recent cases originated from Kuda village, Lwoki payam, Nyori county on 22 September 2016. No additional cases were reported since then.

In Nimule, Imatong state, a cumulative of 29 cholera cases including four laboratory confirmed cases and one death (CFR 3.45%) were reported from 15 August 2016.The afffected locations in Imatong state included Abila, Malakia, and Motoyo. The last cholera case in Nimule was admitted in Nimule hospital on 29 Sept 2016 and discharged on 2 Oct 2016. No additional cases were reported since then.

3 Table 1.1: Cholera cases and deaths by state and county as of 20 January 2017 Week 2 Weeks 24, 2016 to 2 of 2017 Population New cases Cases per 10,000 No. Cases per 10,000 CFR State County at risk W52 population cases population [%] Western Bieh Fangak 139,509 0 - 269 19.3 1.48 Northern Liech Rubkona 126,976 35 2.76 956 75.3 0.85 Southern Liech Leer 67,167 0 - 95 14.1 4.21 Southern Liech Panyijiar 64,254 23 3.58 374 58.2 3.23 Eastern Lakes Awerial 114,837 0 - 353 30.7 1.13 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Duk 26,180 0 - 92 35.1 8.7 Jubek Juba 471,762 5 0.11 2,043 43.3 1.32 Terekeka Terekeka 177,849 0 - 22 1.2 36.36 Eastern Nile Pigi 125,496 0 - 168 13.4 2.98 Total 1,529,160 63 0.41 4,401 28.8 1.84

The cholera outbreak in Western Bieh state was confirmed on 22 September 2016 after two of four samples tested positive for Vibrio cholerae inaba. The initial cases were reported on 10 August 2016 in Old Fangak. The cumulative cases are 270 cholera cases including 13 confirmed cases and 4 deaths (4 facility and zero community) (CFR 1.48%). As of 20 January 2017, the affected areas included Old Fangak (217 cases); New Fangak (42 cases); Mareang (1 case); Paguir (1 cases); Toch (3 cases); and Kolanyang (1 case) (Figure 1.2). The last case from Old Fangak in week 49 of 2016.

Cumulatively, 4,401 cholera cases including 81 deaths (43 facilities and 38 community) (CFR 1.84%) have been reported in South Sudan involving 9 states since the initial case was reported on 18 June 2016 for Jubek state; 3rd July 2016 in Jonglei state; 14 July 2016 for Terekeka state, 15 August 2016 for Eastern Lakes and Imatong states; 10 August 2016 for Fangak in Western Bieh and state; 29 September 2016 for Rubkona in Northern Liech state; 11 October 2016 for Leer and 22 October 2016 for Panyijiar in Southern Liech state; and 10 October 2016 for Pigi in Eastern Nile state (Figure 2.1 and Table 1.1).

As seen from Figure 2.1 there was a spike in cholera transmission in weeks 42-50 of 2016 that was attributed to transmission in Bentiu PoC where most cases originate from sectors 1, 2, and 3 in blocks that are surrounding a water retention reservoir (Annex 1). Bentiu PoC now has the highest cumulative incidence for cholera.

Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 20 January 2017

350 Overall Cholera Epidemic Curve South Sudan 2016 to 2017 21.1% 300 20% 350

250 16.9% 300

15% 250 200 200 Number of cases

316 316 CFR % 150 10% 150 217 100 100 181 185 189 Nuimber of cases 168 5% 50 3.7% 50 3101.3% 97 3.2% 35 2.8% 2.4%2 .5% 2.4% 2.1%1 .9% 2.0% 1.8% 0 1 1.4%1 .6% 1.434% 1.6% 31 1.4% 0.9% 0.8% 28 18 0.8% 1.0% 23 0.6% 0.4% 22 22 12 13 0.6% 0.6% 0.7% 24 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 0 0.10%0 .0%0 .04% 0.0% 5 1 5 5 0.04% 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 2016 2017 Epidemiological week of onset 2016 2017 Date of onset Jonglei Jubek Terekeka Imatong Eastern Lakes Alive Died Western Bieh Northern Liech Southern Liech Eastern Nile CFR[%]

Cholera Epidemic Curve Eastern Lakes, South Sudan 2016 Cholera Epidemic Curve Eastern Nile, South Sudan 2016

140 70

120 60

100 50

80 40

60 30

Nuimber of cases 40 Nuimber of cases 20

20 10

0 0 13 17 11 27 118 70 46 15 8 1 2 2 6 6 5 1 1 41 42 43 44 45 46 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 50 52 2016 2016 Alive Date of onset Died Alive Date of onset Died

4 Cholera Epidemic Curve Imatong, South Sudan 2016 Cholera Epidemic Curve Jonglei, South Sudan 2016

10 30 9 25 8 7 20 6 5 15 4 10 3 Nuimber of cases Nuimber of cases 2 5 1 0 0 33 34 35 36 37 39 27 28 29 30 31 32 33 41 42 43 44 45 2016 2016

Alive Date of onset Died Alive Date of onset Died

Cholera Epidemic Curve Jubek, South Sudan 2016 Cholera Epidemic Curve, Northern Liech, South Sudan 2016

350 160

300 140 120 250 100 200 80 150 60

Nuimber of cases 100 Nuimber of cases 40 50 20 0 0 24 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 52 1 2 3 39 40 42 43 44 45 46 47 48 49 50 51 52 1 2 3 2016 2017 2016 2017

Alive Date of onset Died Alive Date of onset Died

Cholera Epidemic Curve, Southern Liech, South Sudan 2016 Cholera Epidemic Curve, Bentiu PoC, South Sudan 2016

70 160

60 140 120 50 100 40 80 30 60 Nuimber of cases Nuimber of cases 20 40 10 20 0 0 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 42 43 44 45 46 47 48 49 50 51 52 1 2 3 2016 2017 2016 2017

Alive Date of onset Died Alive Date of onset Died

Cholera Epidemic Curve, UN House PoC, South Sudan 2016 Cholera Epidemic Curve, Western Bieh, South Sudan 2016

35 70

30 60

25 50

20 40

15 30

Nuimber of cases 10 Nuimber of cases 20

5 10

0 0 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 52 1 2 3 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 2016 2017 2016

Date of onset Alive Alive Date of onset Died

5 Figure 3:1 Cholera case distribution by gender and age in Jubek State 20 January 2017

300 Cholera - age and sex distribution Jubek up to 20 Jan 2017 250 200 164 155 122 135 150 143 77 100 92 62 59

Number of Cases 117 48 50 82 106 83 107 105 39 48 59 64 35 16 22 21 10 17 104 138 57 3

5 - 15 20 25 30 35 40 45 50 55 60 65 70 10 ------3 70+ 6 Adult 11 16 21 26 31 36 41 46 51 56 61 66 Under 2 Female Male

Out of the 2043 cholera cases in Jubek State, 874 (42.8%) were female, while 1169 (57.2%) were male

Figure 3:2 Cholera case distribution by gender and age in Jonglei State 20 January 2017 18 Cholera - age and sex distribution Jonglei up to 20 Jan 2017 16 14 12 10 8 10 1 6 12

Number of Cases 2 8 4 1 2 2 7 2 5 7 3 4 2 4 7 2 1 1 3 3 1 1 0 Under 3-5 6-10 11-1516 -2021 -2526 -3031 -3536 -4041 -4546 -5051 -5556 -6061 -6566 -70 70+ Adult 2 Female Male

Out of the 92 cholera cases, in Jonglei State 40 (43.5 %) were female, while 52 (56.5%) were male

Figure 3:3 Cholera case distribution by gender and age in Eastern Lake State 20 January 2017

100Cholera - age and sex distribution Eastern Lakes up to 20 Jan 80 2017

40 39 50 16 27 9 12 Number of Cases 20 14 17 7 6 7 17 23 30 14 20 15 9 14 31 1 34 0

Female Male

Out of the 353 cholera cases, in Eastern Lake State 151 (42.7 %) were female, while 202 (57.2 %) were male.

6 Figure 3:4 Cholera case distribution by gender and age in Western Bieh State 20 January 2017

60 Cholera - age and sex distribution Western Bieh up to 20 50 Jan 2017 40 29 30 9 10 5 5 20 11 24 23 5 24 5 Number of Cases 10 22 22 14 10 8 12 0 2 4 5 1 21 6 1 21 30 1

5 - 15 20 25 30 35 40 45 50 55 60 65 70 10 ------3 70+ 6 Adult Blank 11 16 21 26 31 36 41 46 51 56 61 66 Under 2

Female Male

Out of the 268 cholera cases, in Western Bieh State 174 (65 %) were female, while 94 (35 %) were male.

Figure 3:5 Cholera case distribution by gender and age in Leer, Southern Liech State 20 January 2017

25 Cholera - age and sex distribution Leer, Southern Liech 20 up to 20 Jan 2017

15 14 10 5 2 4 2 Number of Cases 5 3 3 2 2 6 9 8 4 3 2 5 2 05 10 02 01 3 01 01 0

0 5 - 10 15 20 25 30 35 40 45 50 55 60 65 70 ------3 70+ 6 11 16 21 26 31 36 41 46 51 56 61 66 Under 2

Female Male

Out of the 91 cholera cases, in Leer, Southern Liech State 44 (48.4 %) were female, while 47 (51.6 %) were male.

Figure 3:5 Cholera cases by gender and age in Panyijiar, Southern Liech State 20 January 2017

90 Cholera - age and sex distribution Panyijiar, Southern Liech 75 up to 20 Jan 2017 60

45 34 46 5 30 25 5 4 5 Number of Cases 12 8 15 11 3 1 12 34 27 21 14 14 18 23 12 8 6 14 5 24 31 02 0

Female Male

Out of the 370 cholera cases, in Panyijiar, Southern Liech State 200 (54 %) were female, while 170 (46 %) were male.

Figure 3:6 Cholera case distribution by gender and age in Northern Liech State 20 January 2017

200 Cholera - age and sex distribution Northern Liech up to 20 Jan 2017 160

120 115 79 91 80 53 4 7

Number of Cases 18 4 40 6 6 5 86 107 90 48 43 24 34 31 31 68 11 50 17 27 62 2 0 Under 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ 2

Female Male

Out of the 959 cholera cases, in Northern Liech State 549 (57.2 %) were female, while 410 (42.8 %) were male.

Figure 3:7 Cholera case distribution by gender and age in Eastern Nile State 20 January 2017

Cholera - age and sex distribution Eastern Nile up to 20 Jan 2017 40

23 20 6 10 14 4

Number of Cases 7 3 14 13 11 16 5 6 10 13 23 25 12 21 1 0 1 0

5 - 15 20 25 30 35 40 45 50 55 60 65 70 10 ------3 70+ 6 Adult Blank 11 16 21 26 31 36 41 46 51 56 61 66 Under 2

Female Male

Out of the 168 line listed cholera cases, in Eastern Nile State 85 (50.6 %) were female, while 83 (49.4 %) were male.

Table 2: Case distribution by gender in South Sudan 20 January 2017 State Female Male Total cases Eastern Lakes 152 201 353 Imatong 13 16 29 Jonglei 40 52 92 Jubek 874 1169 2043 Terekeka 13 9 22 Western Bieh 176 94 270 Northern Liech 549 410 959 Southern Liech 246 219 465 Eastern Nile 85 83 168 Total cases 2148 2253 4401

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.

Laboratory updates

Table 3: Cholera laboratory test results for Juba by 20 January 2017 Culture results State New positives in Cumulative Cumulative Total tested week 2 Positive Negative Eastern Nile 0 0 5 5 Jonglei 0 1 4 5 Jubek 0 79 126 205 Terekeka 0 2 0 2 Eastern Lakes 02 19 42 61 Imatong 0 7 1 8 Fangak 0 13 29 42 Wau 0 0 6 6 Boma 0 0 2 2 Northern Liech 02 24 50 74 Southern Liech – Leer 0 2 0 2 Southern Liech - Panyijiar 0 1 0 1 Southern Liech – Mayendit 0 0 1 1 Eastern Nile (Pigi) 0 2 5 7 Total tested 04 150 271 421

Table 4: Cholera Alerts Date of Details of the alert Area Action notification No alerts 13-Sept- From 14-17 Nov, the MedAir Wiechdeng, Ayok MedAir responded to suspect cholera 2016 team responded to 78 suspect county, Southern cases in Wiechdeng by setting up a 10 cholera cases including 15 Bieh state bed CTU. deaths in Wiechdeng, Ayod. Recent assessments by MedAir show One case tested positive on there is no active transmission in Pagil; cholera RDT. Haat; and Wiechdeng. 8- Oct-2016 UNIDO reported 142 suspect Bhor, Thaker, UNIDO, MedAir are the healthcare cholera cases including three Tutnyang, Madol partners responding to suspect cases in deaths 1, Leah, Dablual, Mayendit. Rubchay, and Malkuer Payams, Since 7 Jan 2017, MedAir has seen at Mayendit North, least 48 cases in their CTU in Modol 1. Southern Liech state

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. Security concerns have remained a major impediment to the implementation of sustained and comprehensive cholera investigation and response activities in Leer and Mayendit.

Cholera case management is ongoing at the designated cholera treatment facilities in the nine affected states. As cases decline in the affected areas, laboratory surveillance has been strengthened to ensure that all suspect cholera cases undergo rapid diagnostic testing and stool culturing to confirm cholera. WHO has therefore supported the partners operating cholera treatment facilities with ample supplies for sample collection, onsite rapid diagnostic testing, and shipment to the National Public Health Laboratory for culturing.

9 WHO is supporting the cholera investigation and response activities in all the nine affected states and the two states with alert suspect cases. Core to WHO’s support to the current cholera response is technical support to the taskforce committees by providing updated situation reports; supporting the investigation and testing of suspect cases; support towards case management activities through trainings on cholera case management protocols; recommending tailored strategies in response to emerging trends; and support for the outbreak evaluation process that is already underway. WHO technical officers are currently deployed in Mingkaman; Bentiu, Bor, Malakal, Imatong, and Juba to support the ongoing response activities.

UNICEF continues to support the Cholera response at the community level across all relevant sectors of Health, WASH, and communication through active partnerships with following implementing partners: Health Link South Sudan (HLSS), LiveWell, ACROSS, CAPIAD, THESO, BEDN, IMC, RUWASSA, SMC, NHDF, UNIDO, World Relief, and ARUDA.

In Jubek, there has been resurgence of cases in UN House PoC since week 52 of 2016. In response to the resurgence, a multi-cluster investigation mission was undertaken during the week. Thus, response efforts have been enhanced in UN House PoC with the WASH cluster carrying out spraying of the latrines and random quality water testing and reactivation of ORPs. In addition, HHPs have been deployed to carry out hygiene promotion. There are plans to open additional ORPs in PoC 3 and to deploy mobile communication teams in the two PoCs.

Active transmission is ongoing in Southern Liech and Northern Liech states where Facility and community based response is ongoing with most cases being managed in facilities like Duong PHCC, Ganyliel PHCC, and Nyal PHCC with support from IRC, UNIDO, and Sign of Hope.

The resurgence of cholera cases in UN House PoC highlights the need to enhance cholera prevention and control activities in the PoC guided by the integrated approach for cholera response.

Recommendation and way forward for Bentiu PoC

Improving access to timely rehydration The following strategies should be considered to increase access to timely rehydration in the PoC: 1. The community health workers should be deployed to do house-to-house case search and initiate prompt treatment with ORS with immediate referral the designated cholera treatment centers. The community health workers should be able to dispense the ORS during the household visits. 2. Each block should have a designated community health worker with ORS that is known by the dwellers and who can be called on short notice to assess; initiate treatment; and refer suspect cases. 3. Open additional mobile clinics or ORPs in the most affected sectors to ensure good access to timely rehydration during day time. 4. All the existing clinics and pharmacies should be stocked with ample amounts of ORS to provide to suspect cases.

Surveillance and laboratory testing Since this is a population where oral cholera vaccination was implemented in 2014 and 2015; case based surveillance is recommended. Thus, in the current context, cases that meet the suspect cholera case definition should undergo an initial screening using the enhanced RDT testing technique (using enrichment of samples with alkaline peptone water before the test is conducted). This will improve the specificity for identifying the real cholera cases and thus accurately monitoring the evolution of the outbreak.

Secure-off the water retention pond Water retention pond: it is very clear that the possible source of infection to the community is the water retention pond. This water is contaminated with faecal matter due to rampant open defecation. The camp management should fence off this water source and forbid population from using it until the outbreak is over.

10 Targeted interventions to children as a high-risk group Nearly 80% of the cases are children: This is possibly because they swim and drink the water in the retention pond. Health education should be directed to this age-group by involving the school children in the PoC.

ORAL Cholera Vaccination (OCV) To increase immunity, there is a need for two rounds of oral cholera vaccination. The population of Bentiu PoC when the last two rounds were conducted in June 2015 was about 70,000. The current population has increased to 120,000. OCV coverage survey conducted by WHO/IOM in December 2016 showed that the OCV coverage stands at 40%. This is therefore not adequate to prevent transmission.

WASH related control activities All efforts towards improving access to safe drinking water, hygiene, and sanitation should be enhanced with regular assessments to review and update the taskforce on the following: • The amount of safe drinking water supplied per person per day by sector • Access to improved latrines per person per day by sector • Data on regular surveys to document FRC levels at the source; tap stands and household levels. • Documentation of waiting time at the tap stands to determine if there are unacceptable delays • A jerry-can cleaning and replacement drive at the tap stands in all the sectors to promote safe water chain. • Distribution of other NFIs like soap to promote and augment personal hygiene at household level. • House to house hygiene sensitization that is targeted to most affected blocks and sectors that are surrounding the water retention pond.

Social mobilization and health education for cholera control Given the current transmission levels in Bentiu PoC; ongoing social mobilization in each of the five sectors to sensitize the camp dwellers on cholera, how it is spread, the signs and symptoms, and behaviors to mitigate the risk – proper hand washing; using safe drinking water; and good sanitation. The campaign should also entail a cleaning drive in each of the sectors.

Planned Activities 1. The next weekly EPR/cholera taskforce meeting is scheduled for 25 January 2017 starting 2:00pm in the WHO Conference Hall. 2. Continue social mobilization activities, active case surveillance, and street announcements with open van, house to house awareness and distribution of WASH supplies by HHPs in affected and at risk areas in UN House PoC, Northern Liech, and Southern Liech.

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

Mr. Lexson Mabrouk Dr. Alice Igale Ag. Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955668178 Tel: +211956420189

11 Annex 1: Cholera distribution in Bentiu PoC as of 20 January 2017

Annex 1.1: Cholera case distribution by time in Bentiu PoC 20 January 2017

Epidemic Curve for cholera in Bentiu PoC as of 20 Jan 2017

30 25 20 15 10 No. cases 5 0

Date of onset

Annex 1.2: Cholera age and sex distribution in Bentiu PoC as of 20 January 2017

240 Cholera - age and sex distribution Northern Liech up to 20 Jan 2017 210 180 150 115 120 79 90 90 52

Number of Cases 3 60 7 6 17 4 6 3 30 86 107 90 48 42 24 33 31 31 68 10 50 17 27 62 2 0 63 0 Under 3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Adult Blank 2 Female Male

Annex 1.3: Cholera case distribution by sector in Bentiu PoC as of 20 January 2017

Cholera cases per 10,000 by sector, Bentiu PoC up to 15 Jan 2017

160 137 140

120

100 91 79 80 64 63 54 60 cases per 10,000 40

20 - - Sector 1 Sector 2 Sector 3 Sector 4 Sector 5 Others Grand Total

Annex 1.4: Cholera case distribution by sector and block in Bentiu PoC as of 20 January 2017