Cholera Situation and Response Updates RSS 24 Nov 17

CHOLERA SITUATION AND RESPONSE UPDATES 24 NOVEMBER 2017

Epidemic trends

§ Cholera transmission reported in two counties [Juba and Budi] in the last four weeks [44- 47, 2017] with a total of 21 new cases including one death (Table 1). § There was no new laboratory confirmed case in week 47 (Table 4).

Table 1: Cholera cases by county for weeks 44, 2017 to 47, 2017 Cases reported Deaths Cumulative Cumulative New Date first (attack New during County during Facility+ reported Number rate per reporting reporting Community Facility Community of cases 10,000) period period CFR% Juba 18-Jun-16 19 2,941 50.72 0 28 10 1.33 Budi 22-Jul-17 2 852 49.82 1 62 21 9.74

In the last four weeks, cholera cases have been reported from Juba and Budi (Fig.1 and Table 1). During this period, a new focus of transmission emerged in New Bongo, Luri payam in Juba county (Fig.2 and 3). The initial cases were reported from New Bongo on 10 November 2017. At least 48 cases including 16 confirmed cases have been reported from New Bongo (Figure 3). Transmission in New Bongo has declined after the initiation of comprehensive response including reactive oral cholera vaccination (Figure 3).

Fig.1|Cholera cases by county, week 44-47, 2017 60 54 50 Budi Juba 40

30 26 20 18 Number of cases 10 17 12 2 7 0 44 45 46 470 Epidemiological week of onset

1 Fig.2|Cholera Epidemic Curve for Juba County, week 23, 2016 to week 47, 2017 350 8% 300 Alive Died CFR% 250 6% 200 4%

150 CFR% 100 2% 50 Number of cases/deaths 0 0% 21232527293133353739414345474951 1 3 5 7 9 11131517192123252729313335373941434547 2016 Epidemiological week of onset 2017

Fig.3|Cholera cases by village in Juba county, week 45-47, 2017 35 31 30 25 WK 45 WK 46 WK 47 20 13 15 10 4 3 4 43 3 5 11 11 21 12 1 2 1 21 2 1 1 1 Number of cases 0

Name of vilage in Juba county

In Budi, the cases have continued to decline with only sporadic transmission reported in Kimotong, Ngauro, and Lorema. A reactive oral cholera vaccination campaign has been completed in Budi.

Fig.4|Cholera Epidemic Curve for Budi County, week 23, 2016 to week 47, 140 2017 100% 120 Alive Died CFR% 80% 100 80 60%

60 CFR% 40% 40 20% 20 Number of cases/deaths

0 0% 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 2017 Epidemiological week of onset

2 § A cumulative of 852 cases including 83 deaths [CFR 9.74%] have been reported in Budi since week 29, 2017 (Table 1 and Figure 4). Overall, males (54.6%) are more affected than females (43.9%) in Budi county. Male children and male young adults are more affected than their female counterparts of corresponding age (Figure 5). § The outbreak in Budi started on 28 July 2017 with the initial transmission occurring among gold-miners in Ngauro. § Cordaid and the County Health Department are supporting management in Ngauro CTU, Kimotong CTU, Kimotong PHCC, Vaka ORP, Nagishot PHCC, Lorema CTU, and Kakilai PHCC in Budi county.

Figure 5|Cholera case distribution by age and sex in Budi, June 2016 - Nov 85-89yrs 2017 0.10 0 80-84yrs 0.000 75-79yrs 0.20 0 70-74yrs 0.20 0.1 65-69yrs 0.40 0 60-64yrs 0.10 0.6 55-59yrs 0.20 1.1 50-54yrs 2.40 2.7 45-49yrs 2.50 2.7 40-44yrs 2.50 3.8 35-39yrs 2.70 2.7 30-34yrs 8.10 3.9 25-29yrs 5.40 4.5 20-24yrs 6.60 4.7 15-19yrs 5.40 5.8 10-14yrs 3.40 2.6 5-9yrs 4.20 3.2 0-4yrs 10.00 5.6

12 10 8 6 4 Percentage %2 0 2 4 6 8

There are ample cholera case management kits and the cholera treatment facilities are adequately staffed for the current case-loads. In addition to case management, surveillance, and WASH interventions, and a cholera vaccine campaign is underway.

3 Fig.6|Cholera cases per 10,000 by county in South Sudan, 2016 and 2017 15 Yirol West - 143 Yirol East - 1 Tonj North - 144 Tonj East - Terekeka 1 - Rubkona 22 70 0 Renk - Panyijiar 38 40 4 Nyirol - Mayom 0 - 13 Mayendit 10 2017 2016 1 Malakal - Magwi -1 Leer - 10 87 Kapoeta South - 66 Kapoeta North - 88 Kapoeta East - Juba 15 35 Fashoda 131 - 8 Fangak 8 Duk 10 47 Canal Pigi 3 11 50 Budi - 4 Bor 5 189 Ayod - Awerial 31 74

- 20 40 60 80 100 120 140 160 180 200 cholera cases per 10,000 population

Overall cholera trends Since the start of the current outbreak on 18 June 2016, a total of 21,551 cases including 462 deaths (CFR 2.14%) have been reported from 27 counties (Table 2). The most affected counties include Ayod, Tonj East, Yirol East, Fashoda, Kapoeta East, and Kapoeta South (Figure 6).

The most affected populations in these locations include: Landing sites/ towns along River Nile; cattle camp dwellers; populations living on islands - no social services; and IDPs - recently displaced with inadequate access to WASH.

4 Fig.7|Cholera cases fatality rate (%) by county in South Sudan, 2016 and 2017 Yirol West 0.0% Yirol East 0.0% 4.5% Tonj North 0.0% Tonj East 2.5% Terekeka 33.3% Rubkona 1.1% Renk Panyijiar 2.9% 7.0% Nyirol 2.8% Mayom 44.4% Mayendit 1.5%3. 1% Malakal 2017 2016 Magwi 3.4% Leer 3.2% Kapoeta … 1.0% Kapoeta … 0.1% Kapoeta East 1.2% Juba 0.8% 1.5% Fashoda 1.6% Fangak 0.8% 0.8% Duk 6.2% 8.7% Canal Pigi 3.0% 9.6% Budi 2.1% Bor 3.0% Ayod 1.0% Awerial 1.1% 1.1%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% cholera case fatality rate - CFR [%]

Cholera case fatality rates were highest in counties with poor access to health care especially in populations living in the islands and cattle camps (Figure 7). Overall, a higher proportion of females (51.8%) are affected than males (47.6%). Children and young adults are more affected. Figure 8 shows the age and sex distribution of cases. There are no significant sex differences after adjusting for age (marginally higher number of cases in females).

Fig. 8|Cholera case distribution by age and sex, June 2016 - Nov 2017 0.000 80-84yrs 0.10 0.1 0.10 0.1 70-74yrs 0.30 0.3 0.30 0.4 60-64yrs 0.80 1.1 0.60 0.6 50-54yrs 1.40 1.5 1.50 1.8 40-44yrs 1.90 2.4 2.60 3.3 30-34yrs 3.30 4.5 3.60 5 20-24yrs 3.10 4 3.50 4.3 10-14yrs 5.70 5.4 7.50 6.5 0-4yrs 11.10 10.2

15 10 5 Percentage %0 5 10 15

Fig.9|Cholera Epidemic Curve for South Sudan, week 23, 2016 to week 47, 2017

2000 20%

Alive Died CFR% 1500 15%

1000 10% CFR%

500 5% Number of cases/deaths 0 0% 21232527293133353739414345474951 1 3 5 7 9 11131517192123252729313335373941434547 2016 Epidemiological week of onset 2017

Figure 9 shows the overall cholera epidemic curve for South Sudan. The highest transmission peaks were associated with outbreaks that affected cattle camps in the following counties – Awerial, Yirol East, Duk, Bor, Uror, Ayod, Kapoeta East, Kapoeta South, and Kapoeta North. The same locations also reported high CFR due to poor access to health care especially at the onset of the outbreak

As seen in Table 2, cholera cases have been confirmed every year since the onset of the South Sudan crisis in 2013. The 2016/17 outbreak is the longest and largest in magnitude and geographical extent. Due to the protracted crisis, displacements, insecurity, and declining investment in WASH, access to safe drinking water and sanitation facilities has declined significantly. Access to improved sanitation facilities is less than 10% while access to safe drinking water from improved water sources is estimated at 60%.

TABLE 2|CHOLERA OUTBREAKS IN SOUTH SUDAN 2014-2017

Summary measure 2014 2015 2016/17 No. cases 6,421 1,818 21,551

No. deaths 167 47 462 CFR% 2.60% 2.59% 2.14%

No. counties affected 16 3 27 Duration (weeks) 29 19 (77) Ongoing

Outbreak start date 24/04/2016 18/05/2016 18/06/2016 Date of last case 13/11/2016 24/09/2016 Ongoing

Attack rate [per 10,000] 27 17 46.36

6 Coordination of cholera response The National cholera task force is coordinating the overall cholera response. The task force meetings convene weekly on Wednesdays from 2 pm in the WHO conference hall in Juba.

Cholera response updates The overall response to cholera in South Sudan is coordinated by the national taskforce that is Chaired by MoH with support from WHO, Unicef, and partners (Health and WASH clusters).

The weekly cholera taskforce meetings are ongoing in Juba during which, the cholera situation and the ongoing cholera prevention and response activities in the affected and high-risk areas are reviewed.

During week 47, the cholera taskforce meeting was convened in Juba on 22 November 2017 to review the current cholera situation and status of outbreak response activities.

During the week, a 2-day reactive oral cholera vaccination campaign was conducted by MSF-E and MSF-CH targeting 10,560 individuals aged one year and above in New Bongo and New site from November 23-24 2017. At the end of the campaign, a total of 10,707 (101.4%) individuals were reached with first dose of oral cholera vaccine. In addition; bucket chlorination has been initiated at the well; the bore hole has been repaired; and an ORP is functional in New Bongo.

The oral cholera vaccine campaign in Budi county ended on 24 November 2017. The campaign was supported by CHD, IOM, CORDAID, UNICEF, and WHO. The campaign targeted to reach at least 150,000 individuals aged one year and above with oral cholera vaccines. Administrative coverage data has not been compiled.

Fig.10: Oral cholera vaccine administrative coverage by round and site for 2017

Fig. 10|Administrative coverage (%) for OCV by site in 2017 200 First Round Second Round 150 83 100 56 38 58 Coverage % 50 92 98.15 85 81 81 76 85 81 88 69 64 62 74 59 0

Progress of oral cholera vaccine campaigns As part of the ongoing cholera response, cholera vaccines have been deployed to complement cholera response in several high-risk populations and locations. These areas include Leer, Bor PoC, Malakal Town, Bentiu PoC, Mingkaman IDP settlement, Aburoc IDPs, Bentiu/Rubkona Town, Ayod (Pagil, Tar, Jiech, Karmun, Padek, and Kandak), Juba (Don Bosco IDPs and additional

7 high-risk locations), Tonj East and Marial Lou payam, Kapoeta North, Kapoeta South, and Kapoeta North. Out of the 1,440,358 doses secured by WHO in 2017, a total of 1 133 730 doses have been deployed (see Figure 10).

Following an oral cholera vaccine working group meeting conducted on 14 November 2017 in Juba; a total of 737,819 doses of oral cholera vaccines have been requested from the GTFCC Global stockpile (Table 3). The vaccines will be used for second round campaigns in areas listed in table 3. The first batch 400,000 doses is scheduled to arrive in Juba on 27 November 2017 while the balance will be delivered during the second week of December 2017.

Table 3| OCV doses requested from the Global Stockpile Sno. County OCV doses 1 Kapoeta South 97,000 2 Kapoeta North 141,520 3 Kapoeta East 97,000 Tonj East 164,900 4 Juba 200,000 5 Aburoc 20,797 6 Malakal Town 16,602 7 Total 737,819

Laboratory updates This week, there no new laboratory results released form the laboratory. Overall, at least 1,145 samples have been tested out of which at least 509 (44.5%) have teste positive for Vibrio Cholerae O1 Inaba by microbiological culturing (Table 4).

A total of 33 Vibrio cholerae isolates have been shipped for genetic sequencing; typing; and antimicrobial sensitivity testing by Institute Pasteur, Paris.

Table 4: Cholera laboratory culture test results June 2016 - November 2017 Week 47 Cumulative (2016-2017) County Positive Positive Negative Total tested Abyei 1 1 Akobo 2 2 Awerial 55 63 118 Ayod 2 6 8 Bor 4 4 8 Budi 2 1 3 Duk 11 6 17 Fangak 31 50 81 Fashoda 7 14 21 Juba 281 295 576 Kapoeta East 10 10 Kodok 1 2 3 Lankien 3 1 4 Leer 9 13 22 Magwi 7 1 8 Malakal 2 21 23

8 Week 47 Cumulative (2016-2017) County Positive Positive Negative Total tested Mayendit 4 6 10 Mayom 4 7 11 Panyijiar 1 1 Pibor 5 5 Pigi 2 4 6 Renk 2 2 Rubkona 0 30 95 125 Terekeka 2 2 Tonj East 8 8 16 Torit 0 0 6 6 Uror 2 2 Wau 6 6 Yirol East 10 12 23 Yirol West 4 4 Kapoeta South 12 12 24 Nyirol 3 1 4 Total tested 0 509 642 1,145

9 WASH CLUSTER RESPONSE UPDATES

Beneficiaries reached by WASH cluster partners in week 43

10 SOCIAL MOBILISATION UPDATES Social Mobilization, Communication and Hygiene Promotion Reporting Format (17-24 November, 2017) Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

Kapoeta (EEQ) SSRC, ARC, Singaita • In Chukudum, people reached through hygiene FM promotion were 2,875 (588 women, 677 men, 769 girls and 841 boys) and the activity was conducted by 20 volunteers (2 females & 13 males) covering 1,124 HHs distributing 1,272 sachets of ORS, 1,124 pieces of soap, 424 strips of aqua tabs and 6,438 sachets of PUR. • On the 17 November 2017, 60 boxes of PUR, 5 boxes of ORS, 4 boxes of aqua tabs and 10 cartons of soap were distributed to 825 beneficiaries • Street announcement by public address system was conducted on OCV campaign for six days from 18rd-24 November 2017 facilitated by South Sudan Red Cross, • 2 Radio talk show on importance of OCV campaign in Budi done on Signata 88.3 FM • 186 banners on OCV in different strategic location this include market places, schools, and churches.

1. Bo County: - Bo CDNF UNICEF supported partner CDNF continue with community Municipality, Anyidi engagement activities which include household visits with Payam, Makuac Payam, critical demonstrations, community meetings, water-point Kolnyang Payam, Baidit and market awareness, school and cattle camps Payam and Jalle payam. intervention in areas of Bor, Twic East, Duk, Pibor and 2. Twic East: - Lith Payam, Pochala counties. Kongor payam, Nyuak

11 Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

payam, Ajuong payam, and - 150 community mobilizers reached people visiting Pakeer Payam, 1,348 households (7,178 individual) with 3. Duk: - Poktap payam, messages. Dukpayuel payam, Padiet - 1,974 students were oriented on cholera payam and Ayueldit payam prevention in 10 school sessions. 4. Pibor County: Pibor, - 630 community members have attended 21 Lekuangole, Verteth, community meetings. Gumuruk and Boma - 1,869 people were oriented on cholera through24 5. Pocalla County: Pochalla, market and water point intervention sessions. Ojangbai Akoye, Akila, - Religious engagement: Social mobilizers reached Akwara, Adongo and people with effective cholera messages in 30 Burator churches during Sunday in the counties - Mass media intervention: cholera key messages and radio spots are being broadcasted on Mingkaman100 FM, and Radio Jonglei 95.9FM to reach population remote villages. - 19 public announcements have reached 14,217 people - 58 social mobilizers from CDNF received orientation on basic interpersonal communication skills in Bor and Twic east counties Jonglei (Old Fangak, Akobo and FCDI and CHDs UNICEF supported partner Fangak Community Pigi Development Initiative (FCDI) continue with community engagement activities which include household visits with critical demonstrations, community meetings, water-point and market awareness, school and cattle camps intervention in areas of Fangak, Pigi and Khorflous. - 91 community mobilizers reached 40,950 people visiting 6901 households.

12 Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

- 4550 students were oriented on cholera prevention in 13 school sessions. - 550community members have attended 22 community meetings. - 4050 people were oriented on cholera through 7 market and water point intervention. - 10 churches were reached with cholera message by trained social mobilizers in Ayod, Pigi and Fangak county Jonglei (Akobo, Nyirol, Uror) Nile Hope and Nile Hope in partnership with UNICEF C4D continue with CHDs community engagement activities which include household visits with critical demonstrations, community meetings, water-point and market awareness, school and cattle camps intervention in areas of Akobo, Nyirol and Uror. Below are some of the achievements;

- Door to Door mobilization: This week, 115 Social mobilizers conducted house to house visit and reached 5175Households (31,050 peoples) who were sensitized on behavior change on integrated emergency response including Malaria, cholera, diarrheal control and routine immunization on both Counties of Uror, Akobo and Nyirol - Cholera awareness at School: A total of 7 schools reached and 2450 pupils benefited from school- based interventions on integrated cholera awareness and routine immunization session carryout by social mobilizes at different counties of Uror, Akobo and Nyirol.

13 Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

- Community sensitization Meetings: Nile Hope social mobilizers conducted community meetings at different Payam of Akobo, Nyirol and Uror counties, Numbers of 6 meetings were held and 150 peoples including of community leaders which comprise of local chiefs, religious leaders and women and youth leaders. - Markets awareness interventions: 15 sessions were held at the market places and 7,430 reached individuals through market sessions including food vendors in Akobo, Uror and Nyirol - Intervention at water points: The social mobilizers/home health promoters from carried out 11 Sessions on cholera awareness interventions reaching 6,430 peoples on Cholera and diarrheal disease messages including demonstration on hand washing, water treatment and proper water storage.

- Public Awareness: Nile Hope Socials mobilizes had conducted 7 public awareness on cholera key messages around the town of Akobo, and Nyirol Counties using megaphones, announcing the key messages for prevention of cholera and diarrheal disease in their residential areas and reached 7,861 peoples.

14 Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

- Religious engagement: Social mobilizers reached people with effective cholera messages in over 6 churches during Sunday praying services in the counties of Uror, Nyirol and Akobo and reached 37,218 peoples including Children, women, men in different churches

Rubkona, Mayendit Guit Nile Hope and Nile Hope in partnership with UNICEF C4D continue with counties CHD community engagement activities which include household visits with critical demonstrations, community meetings, water-point and market awareness, school and cattle camps intervention in Rubkona. Below are some of the achievements; • 3060 HH and 6,853 individuals has been reached with hygiene promotion and sanitation messages. • 7080 people were oriented on cholera through 19 market and water point intervention sessions. • A total of 1,160 people from 8 cattle camps has been reached with risk of cholera and prevention strategies • Religious engagement: Social mobilizers reached 806 people with effective cholera messages in 5 churches during Sunday in the counties

1. Awerial County CHADO and UNICEF support communities in eastern (Payams: Alel, Dor, lake with continued community interaction sessions

15 Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

Puluk, Bunangok, Nile such as household visits with critical demonstrations, Magok, Abuyong) community meetings, water-point and market

2. Yirol East (Payams: awareness, school and cattle camps intervention in Adior, Malek, Lekakedu, hot spots areas in Eastern Lakes. CHADO had trained Yali, Pagarau Tin-agau and Nyang) 139 social mobilizers to reached people in different community sessions in Eastern Lakes.

§ 4400 HHs reached and 13,155 Individuals 3. Yirol West (Payams: through door to door mobilization for community Abang, Anuol, Yirol Centre (Town), Geng- on social and behavior change intervention on Geng, Geer, Aluak Luak, cholera control and diarrhea disease prevention. Mapuordit) § A total of 85 and 4,021 pupils benefited from

school-based interventions on cholera awareness session. § A total 134 water point sessions reaching a total of 1355 people including water vendors with Cholera and diarrheal disease educative messages including demonstration on water treatment and proper storage.

16 Locations with ongoing outbreak Partners present Ongoing Action with number of population reached Gaps and recommended and hot spots (Payam level) with Cholera interventions action

§ A total 120 market awareness sessions were also conducted reaching 1605 individuals including food vendors. § A total 111 community meetings and attended by 1863 people inclusive of community leaders which comprise of local chiefs, religious leaders and women and youth leaders. § A total 32 churches /parishes in the counties of Eastern reaching population with lifesaving messages on cholera control and prevention. § 39 Cattle camps with total of 1834 individual has been reached with cholera prevention and control.

Contacts Dr. Mathew Tut Dr. Joseph F. Wamala Director, Emergency Preparedness and Response Epidemiologist Ministry of Health, Ministerial ComplexJuba, Republic of South Sudan World Health Organization Email: [email protected] Ministerial Complex Juba, Republic of South Sudan Email: [email protected]