Republic of South Sudan Cholera in South Sudan Situation Report # 13 as at 23:59 Hours, 28 May 2014 Background On 29 April 2014, a suspected case of cholera was reported from the MSF clinic at UN House/Juba III Protection of Civilian (PoC) camp. The previous day he had visited relatives in Gudele where he developed severe diarrhoea. One of the contacts in the household had developed acute watery diarrhea on the 24 April 2014. Following field investigations and laboratory confirmation, on 15 May 2014, the Ministry of Health declared an outbreak of cholera in Juba. Since then, several suspected cases have been recorded and laboratory confirmed from different suburbs in Juba. A retrospective record review at the emergency medical ward of Juba Teaching Hospital (JTH) revealed seven suspected cholera cases including one death, with the first case admitted at JTH on 23 April 2014. Situation Update The table below summarizes the number of suspected and confirmed cases reported in Juba. Table 1 Summary of cholera cases, 23 April - 28 May 2014 No. Summary of cases JTH Gurei Tongping UN House Other Total CTC CTC CTC (Juba III) sites A Total new admisions today 67 25 0 0 0 92 B Total new discharges today 69 16 0 0 0 85 C Total new deaths today 0 0 0 0 0 0 D Total number of cases currently admitted 103 26 0 2 0 131 E Leave Against Medical Advice (LAMA) 15 0 0 0 0 15 F Total facility deaths since the onset of 15 0 0 0 1 16 the outbreak G Community deaths since the onset of the 0 0 0 0 11 11 outbreak H Cumulative deaths since the onset of the 15 0 0 0 12 27 outbreaks J Cumulative cases discharged 604 75 3 7 1 690 K Cumulative cases 763 101 3 9 16 892 L Number of cases with laboratory 29 0 0 1 4 34 confirmation by culture *Includes cases detected in private health facilities and at community level § On 28 May 2014, 92 new cases were admitted at the cholera treatment centres (CTC) in Juba and 85 cases discharged leaving 131 patients on admission in the cholera treatment centres (table 1). A total of 15 cases in JTH CTC left the isolation ward without proper discharge. This highlights the need to enhance security checks at the CTC gate. § Cases have been reported from nine Payams in Juba county with the most affected being Munuki 279 (31%). See table 2. 1 Table 2 Cholera cases by area of origin in Juba, 23 April - 28 May 2014 Payam Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Cases by Payam (%) Munuki 0 0 0 72 125 82 279 (31) Rejaf 1 0 0 24 73 94 192 (22) Northern Bari 1 2 0 63 70 20 156 (17) Juba 0 0 0 26 95 22 143 (16) Kator 1 0 0 14 43 25 83 (9) Missing 0 1 0 4 23 0 28 (3) Gondokoro 0 0 0 3 2 0 5 (1) Lirya 0 0 0 1 0 0 1 (0.1) Lokiriri 0 0 0 2 1 1 4 (0.4) Mangala 0 0 0 0 0 1 1 (0.1) Total by epi-week 3 3 0 209 432 245 892 (100) § The most affected villages include Gumbo in Rejaf, Gudele I in Munuki, Tongping in Juba, and Gudele II in Northern Bari (figure 1). Figure 1: Cholera cases from the five most affected villages per Payam, 23 April - 28 May 2014 § Since the beginning of the outbreak on 23 April 2014, 892 cumulative cholera cases including 27 deaths (16 institutional and 11 community deaths) with CFR= 3% have been reported. The majority of the deaths reported in hospital died on arrival. Hence the need to strengthen community case detection and prompt initiation of ORS treatment while immediate referral to the nearest CTC is being organized. § Figure 2 shows the outbreak trend since it started on 23 April 2013.Two peaks of transmission were registered on 19/05/2014 and 26/05/2014. 2 Figure 2: Juba cholera epidemic curve, 23 April 2014 - 28 May 2014 § Of the 892 cholera cases reported, majority (497, 62%) are male, and aged 20-34 years (356, 41%). Figure 3: Distribution of cholera cases by age, Juba, 23 April - 28 May 2014 3 Figure 4: Number of daily admissions at the Juba CTCs, 23 April - 28 May 2014 Assessment of risk factors and possible exposure is ongoing at all locations. The main risk factors for cholera in Juba are suspected to include the following: § Drinking of untreated river water which in Juba is primarily supplied by water tankers, § Poor latrine use, lack of latrines and open defecation, § Eating foods sold on the roadside and at makeshift markets. § Poor personal hygiene practices (for example hand washing) and community hygiene. § In addition, consumption of water from unsafe sources such as surface water-river and ponds, poor community handling of dead bodies and unsupervised burials are other factors that increase the risk of the Juba community to contracting cholera. Cholera Alerts Table 3 Summary of cholera alerts No Date Details of the alert Area Needs/Actions taken received 1. 29/05/2014 • Five suspect Yei, Central • Taskforce has been re-activated cholera cases Equatoria • Isolation ward has been designated in including one death Yei Civil hospital • The four suspect • PSI contacted to provide water guard cases are admitted • Dissemination of cholera brochures and in Yei Civil Hospital radio messages is underway • Index case died • Rapid diagnostic test positive for cholera after he developed • Three collected samples will be sent to profuse watery Juba diarrhoea on arrival • Suspected cases have been isolated in from Juba Yei civil hospital • 4 No Date Details of the alert Area Needs/Actions taken received 2. 29/05/2014 Two bodies of Yei, Central • The Yei and Juba county surveillance suspected cholera Equatoria officers are currently investigating the community deaths have report to identify further cases and list been transferred from contacts. Juba to Yei Response actions today Case Management § In order to decongest the JTH CTC, the case management, surveillance and laboratory working group has agreed that ambulances will now transfer some of the cholera cases to the Gurei CTC. § The Ministry of Health working with WHO, UNICEF, and NPA are planning to set up a cholera treatment centre in Gumbo. § MSF Spain is currently training health workers in Melut hospital on cholera case management and has already prepositioned cholera case management kits. A follow-up mission by MSF to Kaka revealed that no additional deaths have occurred. All drinking water is being treated and all the AWD cases in Kaka PHCC were discharged. Surveillance and Laboratory § Five suspected cholera cases including one death were reported in Yei County, Central Equatoria State. The index case travelled from Juba to Yei on 26/05/2014 and developed symptom on 28/05/2014. He was brought to Yei Civil Hospital on the morning of 29/05/2014 but died shortly after admission. The other four cases have been isolated in Yei Civil Hospital following positive cholera RDT results. The stool samples have been sent to the national reference laboratory for culture and sensitivity. § The national public health laboratory isolated vibrio cholerae inaba from two samples collected from JTH and Kajo Keji in Central Equatoria state. The Kajo Keji county health has been alerted to conduct further case verification and contact identification. However, antimicrobial sensitivity testing cannot be done since there are no antimicrobial discs in the laboratory. § On 29/05/2014, the AMREF Laboratory in Kenya released additional cholera test results. Out of the 45 additional samples tested, 24 (53%) were positive for Vibrio cholera inaba. The isolates were sensitive to Tetracycline by resistant to Ampicillin, chloramphenicol, Nalidixic acid, and Cotrimoxazole. § The surveillance team continues to receive and investigate all cholera alerts from the peripheral facilities and community levels. § Epidemiological analysis of the outbreak data is ongoing to inform the current response. Social Mobilization § House to house cholera prevention and control campaigns continued today in Juba, Kator and Rejaf reaching a total of 2,530 households with key messages on cholera prevention through hand washing and chlorination demonstrations. These include 630 HHs from Rejaf, 700 HHs from Juba and 1200 Hs from Kator. § Cholera prevention and control campaigns covered 1000 households in Gudele and 400 HHs in Lologo; a total of 8,104 households reached to date in those areas. 5 § To date, 28,944 males and 22,934 females have been reached in Munuki A, B, C and Gudele I and II with cholera prevention messages. A total of 29,222 PUR sachets for water treatment and 11,845 ORS have been distributed in the area. § Other community mobilization activities include: o Awareness activities in Gumbo IDPs camp. OVCI during their awareness campaign got three (3) cases of suspected cholera of them children. They immediately called the ambulance and the 3 children were transferred to Juba CTC. Tents were these sick children were disinfected by the Ambulance officers. o Street announcements and distribution of about 150 pcs of IEC materials in Gumbo and Gudele. o Mobilization using music, dance and drama in Gudele I and II markets. Four (4) drama sessions were performed on cholera prevention with average attendance of 200 persons in each session. o Music shops in strategic market points shall begin broadcasting hourly messages on cholera prevention and treatment 4 stations are in the pipeline for this activity. This will focus on the main markets of Munuki, Gudele, Juba taxi park market and Konyo konyo.