Republic of South Sudan Situation Report #109 on Cholera in South Sudan As at 23:59 Hours, 24 February 2017 Situation Update A total of 13 counties in 9 (28%) of 32 states countrywide have confirmed cholera outbreaks (Table 1; Figure 1.0). The most recent cases were confirmed in Yirol East, Eastern Lakes state on 22 February 2017. Suspect cholera cases have been reported in Malakal Town; Pajatriei Islands, Bor county; Panyagor, Twic East county; and Moldova Islands, Duk county (Table 4). During week 8 of 2017, a total of 4 samples from Yirol East and 2 samples from Mayendit tested positive for cholera (Table 3). Cumulatively, 185 (37.8 %) samples have tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 24 February 2017 (Table 3). Table 1: Summary of cholera cases reported in South Sudan as of 24 February 2017 New New Total cases Total Reporting New deaths Total facility Total cases admissions discharges currently community Total deaths Total cases Sites WK 8 deaths discharged WK 8 WK 8 admitted deaths Jubek – Juba - - - - 8 19 27 2,018 2,045 Jonglei-Duk - - - - 3 5 8 92 100 Jonglei-Bor - 15 - 7 1 3 4 51 62 Terekeka - - - - - 8 8 14 22 Eastern Lakes 12 5 - 5 2 8 10 478 493 - Awerial Eastern Lakes 1 5 - 1 5 12 17 176 194 - Yirol East Imatong - - - - - - 1 1 28 29 Pageri Western Bieh - - - - - 4 - 4 266 270 Fangak Northern Liech - - - - 3 7 2 9 1,144 1,156 Rubkona Southern - - - - 3 - 3 91 94 Liech - Leer Southern Liech - - - - - 17 4 21 435 456 Panyijiar Southern Liech - 2 2 - - - 5 5 214 219 Mayendit Central Upper 5 181 Nile - Pigi 3 2 3 5 173 Total 18 29 - 19 55 67 122 5,180 5,321 Highlights in week 8 of 2017: 1. Cholera confirmed in Yirol East after four of 10 samples tested positive for cholera Table 3. 2. New suspect cholera cases reported in Malakal Town, Central Upper Nile state Table 4. 3. A total of 18 cases reported in week 8 compared to 111 cases in week 7 of 2017 Figure 1.1. 4. Integrated response teams are supporting the response in Mingkaman, Yirol East, and Bor. 5. Transmission has declined in Yirol East, Mingkaman, Bor, Southern Liech, and Northern Liech Figure 2.1 1 A new cholera outbreak has been confirmed in Yirol East after four of 10 samples tested positive for cholera on 22 February 2017. The initial cases in Yirol East were reported on 3 February 2017 from Adior, Shambe, and Langmatot. The response in Yirol East was led by the state MoH, CHD, and health [CUAMM, WHO, UNICEF, IOM, and MSF-B] and WASH partners. Transmission has subsided and current efforts are aimed at addressing the underlying risk factors and improving skills for case management and infection prevention and control at existing cholera treatment facilities. Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 24 February 2017 World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24, 2016 to 7 of 2017 Map Date: 20 February, 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 0.78 2.92 1.48 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Leer Tonj NorthMayendit Ayod 3.19 2.39 Ethiopia Tonj East Duk Panyijiar Uror Akobo Jur River Rumbek North 8.0 4.61 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Bor South Nagero Yirol West Awerial 7.14 Pibor Wulu Tambura 2.11 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 > 60 Yambio Nzara 1.32 46 - 60 Kapoeta South 31 - 45 Torit Budi Yei Lainya 16 - 30 Magwi Ikotos 0.1 - 15 Kajo-Keji 2.84 Kenya No case reported Morobo Pageri River Democratic Republic of Congo Uganda Figure 1.1: New cholera cases admitted by location in week 7 and 8 of 2017 120 111 week 7 week 8 100 80 60 39 40 29 29 Number of Cases 18 20 12 9 1 2 2 3 3 0 Awerial Yirol East Bor South Rubkona Mayendit Pigi- canal Eastern Lakes Jonglei Northern LieCh Southern LieCh Central Upper Nile Total by week 2 The transmission in the other active transmission areas in Mingkaman, Bor, Northern and Southern Liech has declined significantly Figure 2.1. However new suspect cases are being investigated in Pajatriei Island, Bor South county and Malakal Town in Central Upper Nile state Table 4. Following the identification of the two suspect cholera cases in Malakal Town, samples were obtained for confirmatory testing and follow up visits to the community to determine the source and identify additional suspect cholera cases. The taskforce has been activated and the response plan has been updated to guide preparedness and response actions by the taskforce. Rapid response mission from 19-24 Feb 2017 visited Koyom and Moldova Islands in Duk. At least 8 suspect cases were reported in Koyom PHCU since 3 Feb 2017 Table 4. The team conducted sensitization on cholera prevention and left case management supplies with JDF. There is no access to safe water on the islands and there are only two communal latrines constructed by Africa Rise in 2016. The mission to Koyom and Moldova Islands was supported by WHO. Figure 1.2: Cumulative cholera cases by state and county of residence as at 24 February 2017 6000 5321 5000 4000 3000 Number of Cases 2045 2000 1156 1000 456 493 270 219 194 181 22 94 62 100 29 0 FANGAK Terekeka Leer Mayendit Panyijiar Rubkona Juba Bor South Duk Pageri Awerial Yirol East Pigi- canal Western Terekeka Southern Liech Northern Jubek Jonglei Imatong Eastern Lakes Central Grand Bieh Liech Upper Total Nile On 22 February 2017, a rapid response mission was organized by MSF-B to Kuei Islands in Bor South county. There is one ‘Tukul’ (Hut) used as health facility with 3 Nurses, 3 health promoters, 1 hygiene officer, 2 clinicians, and 2 laboratory technicians – all working as volunteers. There were case management supplies donated by SMC – a national NGO. The immediate needs included training of the team on cholera protocols, securing a tent for case isolation, latrine facility, and safe water. There is no borehole on the island and only one communal latrine. These needs will be addressed in follow up visits organized by state and national taskforce. Table 1.1: Cholera cases and deaths by state and county as of 24 February 2017 State County Population Week 8 Weeks 24, 2016 to 8, 2017 at risk New Cases per No. Cases per 10,000 CFR [%] cases 10,000 cases population W8 population Western Bieh Fangak 168,947 0 - 270 16.0 1.48 Northern Liech Rubkona 126,976 0 - 1156 91.0 0.78 Southern Liech Leer 95,731 0 - 94 9.8 3.19 Southern Liech Panyijiar 78,020 0 - 456 58.4 4.61 Southern Liech Mayendit 97,127 2 0.21 219 22.5 2.28 Eastern Lakes AweriaL 114,837 12 1.04 493 42.9 2.03 Eastern Lakes YiroL East 104,694 1 0.10 194 18.5 8.76 Imatong Pageri 215,130 0 - 29 1.3 3.45 Jonglei Bor South 331,611 0 - 62 1.9 6.45 JongLei Duk 96,259 0 - 100 10.4 8 Jubek Juba 579,778 0 - 2,045 35.3 1.32 3 State County Population Week 8 Weeks 24, 2016 to 8, 2017 at risk New Cases per No. Cases per 10,000 CFR [%] cases 10,000 cases population W8 population Terekeka Terekeka 209,902 0 - 22 1.0 36.36 CentraL Upper NiLe Pigi 150,800 3 0.20 181 12.0 2.76 Total 2,369,812 18 0.08 5,321 22.5 2.29 Cumulatively, 5,321 cholera cases including 122 deaths (55 facilities and 67 community) (CFR 2.29%) have been reported in South Sudan involving 13 counties in 9 states since the initial case was reported on 18 June 2016 for Jubek state; 3rd July 2016 for Duk in Jonglei state; 14 July 2016 for Terekeka state, 15 August 2016 for Mingkaman in Eastern Lakes and Pageri in Imatong states; 10 August 2016 for Fangak in Western Bieh state; 29 September 2016 for Rubkona in Northern Liech state; 11 October 2016 for Leer; 22 October 2016 for Panyijiar in Southern Liech state; 10 October 2016 for Pigi in Central Upper Nile state; 7 October 2016 for Mayendit in Southern Liech state; 30 January 2017 for Bor South in Jonglei state; and 3 February 2017 for Yirol East in Eastern Lakes state (Figure 2.1 and Table 1.1). Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 24 February 2017 350 25 300 21.05 20 250 16.92 15 200 150 CFR [%] Number of cases 10 100 6.67 6.91 5.11 4.48 5 50 3.33 3.33 3.49 2.75 2.42 2.05 1.85 2.26 2.00 2.24 2.30 1.42 1.55 1.35 1.76 1.27 0.62 0.86 0.42 0.76 0.75 0.82 0.63 0.57 0.79 0.60 0 - - - - - 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 4 5 6 7 8 EpidemioLogicaL week of onset 2016 2017 JongLei Jubek Terekeka Imatong Eastern Lakes Western Bieh Northern Liech Southern Liech CentraL Upper NiLe CFR[%] Figure 3:1 Cholera case distribution by gender and county 24 February 2017 Cholera case gender distributionby IDP site wk 27 of 2016 to week 8 of 2107 100% 90% 35 37 80% 44 42 41 50 48 50 54 56 57 57 55 54 70% 60% 50% e itiuin % Sex distribution 40% 65 63 30% 56 58 59 50 52 50 46 44 43 43 45 46 20% 10% 0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Yirol East Overall Female Male Overall, males and females have been affected evenly Figure 3.1.