Republic of South

Cholera in Situation R eport # 89 as at 23:59 Hours, 18 -24 August 2014

Situation Update As of 24 August 2014, a total of 5,981 cholera cases including 132 deaths (CFR 2. 2%) had been reported in South Sudan as summarized in Tables 1 and 2.

Table 1. Summary of cholera cases reported in County , 23 April –24 August 2014 New New New deaths Total cases Total Total admisions discharges Total Total cases Reporting Sites 18-24 Aug currently facility community Total cases 18-24 Aug 18-24 Aug deaths discharged 2014 admitted deaths deaths 2014 2014 JTH CTC 7 5 0 2 16 0 16 1452 1470

Gurei CTC (changed to ORP) Closed 28 July 2 0 2 365 367

Tongping CTC -- 0 0 0 2 1 3 69 72

Jube 3/UN House CTC -- 0 0 0 0 0 0 87 87

Nyakuron West CTC Closed 15 July 0 0 0 18 18

Gumbo CTC Closed 5 July 0 0 0 48 48

Nyakuron ORP Closed 5 July 0 0 0 20 20

Munuki ORP Closed 5 July 0 0 0 8 8

Gumbo ORP Closed 15 July 0 3 3 67 70

Other sites 0 0 0 0 1 15 16 1 17

Total 7 5 0 2 21 19 40 2135 2177 N.B. To prevent double counting of patients, transferred cases from ORPs to CTCs are not counted in the ORPs.

Table 2: Summary of cholera cases reported outside , 23 April –24 August 2014 New New New Total cases Total Total admisions discharges deaths Total Total cases Total States Reporting Sites currently facility community 18-24 Aug 18-24 Aug 18-24 Aug deaths discharged cases admitted deaths deaths 2014 2014 2014 Kajo-Keji civil hospital 5 0 1 0 3 4 7 82 88 CES Yei Hospital -- 0 0 0 0 2 2 45 47 WES Lanyi- Mundri East -- 0 0 0 0 0 0 3 3 Jonglei Kolmanyang, Bor -- 0 0 0 0 0 0 1 1 Hospital 4 0 0 4 0 0 0 54 58 OTC PHCC, -- 0 0 0 10 0 10 141 151

Magwi PHCC 5 2 0 5 1 0 1 12 18

Pajok PHCC, Magwi -- 0 0 0 0 0 0 1 1

Nyolo CTC, Magwi 3 3 0 0 0 0 0 25 25

Idali PHCU, Lafon -- 0 0 0 5 1 6 90 96 Lwal a PHCU, Pachidi -- 0 0 0 0 1 1 1 2 payam, Lafon Longiro PHCU,Lafon -- 0 0 0 1 0 1 15 16

Lalanga PHCU, Lafon 9 0 0 0 0 2 2 63 65

EES Hospital 20 10 0 0 8 9 17 1397 1414 Bur Mutram PHCU, -- 0 0 0 0 1 1 59 60 Bur Payam, Torit Ohiri PHCC, Bur -- 0 0 0 3 0 3 53 56 Payam, Torit Ohil a PHCC, Bur -- 0 0 0 0 0 0 24 24 Payam, Torit Imurok PHCU, Imurok -- 0 0 0 2 1 3 10 13 Payam, Torit Hiyala PHCC, Torit -- 0 0 0 0 0 0 86 86 Olere PHCU, Imurok -- 0 0 0 0 0 0 4 4 Payam, Torit Osit o PHCU, Bur -- 0 0 0 0 0 0 42 42 payam, Torit Ileu PHCU, Hiyala -- 0 0 0 3 7 10 147 157 payam, Torit

1 New New New Total cases Total Total admisions discharges deaths Total Total cases Total States Reporting Sites currently facility community 18-24 Aug 18-24 Aug 18-24 Aug deaths discharged cases admitted deaths deaths 2014 2014 2014 Hile u PHCC, Himodonge Payam, -- 0 0 0 0 0 0 6 6 Torit Ofiri PHCU, Kudo -- 0 0 0 0 0 0 5 5 Payam, Torit Kudo PHCC, Kudo -- 0 0 0 1 0 1 54 55 Payam, Torit Moti PHCU, Ifwotu, -- 0 0 2 0 1 1 4 7 Torit Riwo to PHCC, -- 1 0 0 1 0 1 68 69 North SSRCORPs, Nyong 7 0 0 0 0 0 0 53 70 Payam, Torit St. Theresa, Isohe, 10 10 0 2 1 2 3 86 91 Ibahure PHCC, ibahure 5 0 0 2 1 0 1 23 25 Payam, Lopa/Lafon Other sites -- 0 0 0 0 0 0 23 24

Kaka -- 0 0 0 0 0 0 0 1

Wau Shilluk, Malakal -- 0 0 4 15 2 17 885 906 Upper Nile Malakal PoC -- 0 0 0 2 0 2 59 61

Other sites -- 0 0 0 2 0 2 55 57

Total 68 26 1 19 59 33 92 3693 3804 x: Facilities not reporting; -- no cases reported for at least two weeks

Figure 1: South Sudan Cholera Epidemic Curve, week 17-34, 2014

1200

1000

800

600

No Cases No 400

200

0 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Epidemiological week 2014 WES UNS EES CES

Figure 2: Cholera Case Distribution by Age, Sex, & State – week 34

45 40 35 30 21 Male Female 25 20 15 Number Number of cases 10 10 3 21 5 8 6 0 1 <5YRS ≥5YRS <5YRS ≥5YRS

2 Figure 3: New Cholera Cases in Juba County during week 34, 2014 4

3

2

3

Number Number of cases 1 2

1 1 0 Amarat Atlabara Hai Lokwilili Jebel Check Point

Juba Kator Northern Bari

Figure 4: New Cholera Cases in Torit County during week 34, 2014 7 6 5 4 3 6 6 2 4

Number Number of cases 1 2 1 1 1 1 1 1 1 1 1 0 Islak Kuku Inkas Mairo Lotuko Matara Ikuyala (blank) Mission Malakia Longute Naivasha Adis Ababa Adis

Nyong

Figure 5: New Cholera Cases in Isohe County during week 34, 2014 8 7 6 5 4 7 3

Number Number of cases 2 4 1 1 0 Isohe Woroworo Hafolere

Isohe

3 Figure 6: New Cholera Cases in Kajo Keji County during week 34, 2014 2

1

Number Number of cases 1 1 1 1 1

0 Limi sokare logu Umbuku Mondikilik

Figure 7: New Cholera Cases in during week 34, 2014 4

3

2

3 3 3

Number Number of cases 1 2

1 1 0 Nyolo Lobure Rei Malakia East Ray Palotaka

Iwire Magwi Nimule ObbO

Figure 8: New Cholera Cases in Magwi County during week 34, 2014 8 7 6 5 4 7 3

2 4 1 1 1 1 0 Lalanga Ibahure Ikirang IME Ibahure

Lohutok Imeh Luhutok

4 Table 3. Cholera alerts reported between 18 – 24, August 2014 Date of Details of the alert Area Action notification 18/08/2014 A suspect cholera case from Hai Hai Lokiriri, - SPLA medical corps conducted the Lokiriri died on arrival at Juba Military Juba supervised burial. hospital. He developed watery - County surveillance office is followed up diarrhea, and vomiting at around 1 am the contacts but none of them developed on 18/08/2014. cholera 18/08/2014 A cluster of 10 cases including two Kajo-Keji, CES - Following the verification conducted by the community deaths were reported in county surveillance team, the community Kajo Keji deaths were more likely to have resulted from cholera and have therefore been line listed. The close contacts received health education on cholera prevention and treatment.

Surveillance and laboratory • Only two alerts were reported during the period under review as detailed in table 3. • Partners have continued to submit cholera line lists from sites with active community transmission. During the period under review; cholera line lists were received from Juba Teaching hospital, Ministry of Health Central , Torit hospital CTC, Magwi County Health Department, Save the Children International, South Sudan Red Cross, and MSF Spain. • Weekly epidemiological characterization of the outbreak by person, time, and place is ongoing. High risk populations have been identified and prioritized for WASH and social mobilization activities. Overall, the cholera trend is on the decline in all the 13 counties where cholera cases have been confirmed. • Due to the declining cholera trend, it is recommended that stool samples are obtained from new suspected cholera cases for laboratory confirmation. This is important for determining the end of the outbreaks in each of the affected counties.

Case management • Case management activities continued in counties with active community transmission of cholera. • Due to the declining trends of cholera cases in Torit County, MSF-France handed over Torit cholera treatment centre to the State Ministry of Health and Save the Children International on 20 August 2014. • The cholera treatment centre in Juba III IDP camp has also been closed. All suspected cases in Juba III IDP camp are being referred to the CTC in UNMISS Tongping. • MSF Spain handed over the cholera treatment centre in Wau Shiluk to the State Ministry of Health on 25 August 2014. • Select ORPs are operational in state to ensure timely access to rehydration in areas with active community transmission of cholera as highlighted in table 2.

Social mobilization The Ministry of Health, along with UINCEF, WHO and other partners continues to strengthen cholera prevention and control activities.

• Eastern Equatoria State: Torit remains one of the most affected counties in the state with almost all the payams being affected. Cholera cases have continued declining although water and sanitation remain poor. Radio talk shows are held twice a week and spot messages aired on a regular basis. Efforts are being made to engage Guinea worm volunteers for community mobilization and promotion on household methods of water purification in Greater Kapoeta. • Central Equatoria State: This week, partners reached 6,451 households. An orientation of 112 church members was conducted. To date 4,775 community leaders and teachers have been sensitized on cholera prevention. In Jonglei State: Cascade meetings and training for community leaders were conducted in Bor town, Kolnyang, Pariak, Twic East and Duk in coordination with NGOs and County Health Departments. A total of 4,851 households were reached with key messages and demonstrations on hand washing, household water treatment methods and use of oral rehydration solution. Fifteen community meetings were conducted with religious leaders, local chiefs, youth and women group leaders. WASH WASH partners continue to respond to cholera in affected areas as follows:

Central Equatoria State: Juba County: • Partners conducted Jerry can cleaning campaigns, and household visits using trained hygiene promoters. • A total of 2,292 households were provided with buckets, soap, PuR, Filter cloths and cholera awareness messaging.

5 Upper Nile State: • Interventions by WASH partners in Malakal PoC and Wau Shilluk are on-going , including safe water provision, sanitation and hygiene messaging.

Eastern Equatoria State: Torit County: • Torit CTC has been handed over to the State Ministry of Health following a decline in cholera cases in Torit town. The CTC was downgraded to a CTU, and is being run by Torit hospital staff. Emergency latrines were decommissioned. • Seven hand pumps were repaired to provide safe water for communities in Torit. • The State Ministry of Physical Infrastructure was provided with; 30 boxes of purification tabs, 1000 boxes of soap and 20 drums of HTH chlorine. • A total of 338 households were reached with hygiene promotion including distribution of PUR to 254 households in Torit town.

Magwi County: • In Owinyikibul, cases are still being registered at the facilities thus a need for strengthened hygiene and sanitation promotion activities. • Nine hand pumps were repaired in and around Owinykibul in an effort to sustain access to safe water for the affected community. • Twelve hygiene promoters were trained in Owinykibul to help conduct community awareness on prevention of cholera. • Two WASH partners plan to start intervention in the county. • In Nimule: Twenty water committees with 120 members received two days’ training on water points management and water hygiene (safe water chain) conducted in Pageri and Mugali payam. • Two hand pumps were repaired in Nimule. • Twenty blocks of 40 emergency latrines (prefabs latrines) were installed in Melijo camp in an effort to improve sanitation at the camp.

Ikwotos County: • A WASH partner arrived this week to support intervention in Ikwotos.

Gaps and needs Case management, surveillance and laboratory • Submission of updated cholera line lists to the Ministry of Health needs to be strengthened • Cholera treatment centres should submit samples for new cases to the laboratory. This will inform decisions for determining the end of the outbreak in each of the affected counties.

WASH Challenges remain in Eastern Equatoria State: • Strengthen hygiene promotion in all the six affected counties. • Access to safe water supply remains a gap despite several efforts by partners to close the gap. • Open defecation remains widely practiced. • Limited access to other locations with high needs due to bad roads and insecurity especially along Torit -Kapoeta road • A WASH mobile team is assessing the area the area to begin intervention in Lopa/Lafon.

Social Mobilization • Overall, lack of knowledge and education on cholera prevention and good hygiene practices; access to clean water and sanitation, lack of soap for hand washing and solid waste disposal options remain major challenges.

Conclusions and Recommendations Cholera is on the decline countrywide. The following are the key recommendations: • Sustain current interventions (case management, surveillance and laboratory, social mobilization and WASH) in the affected counties. • Develop a protocol to evaluate the overall response of the outbreak so as to document experiences and lessons learnt to improve future responses. • Update development plans to ensure that high-risk areas are prioritised for risk communications and other evidence based interventions.

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 .

6 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: Gemtel: 9999, Vivacell: 0952000098 and Zain: 0912000098.

Contacts For more information please contact: Dr. Pinyi Nyimol Mawien Dr . Thomas Akim Ujjiga Director General - Preventive Health Services Ag. Director - IDSR MoH, Republic of South Sudan MoH, Republic of South Sudan Tel: +211955604020 Tel: +211955150406

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