Republic of South Sudan Situation Report #101 on Cholera in South Sudan As at 23:59 Hours, 29 December 2016 Situation Update Cholera outbreaks were 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, Panyijiar, and Ayod (Table 4). Cumulatively 139 (34.6 %) of the samples tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 29 December 2016 (Table 3). Jubek state has recorded 2,006 cholera cases including 27 deaths (CFR 1.35 %). No new cholera case was reported in Jubek State during week 51 of 2016 (Table 1 and Figure 1.1). Table 1: Summary of cholera cases reported in South Sudan as of 29 December 2016 New New New Total cases Total Reporting Total facility Total cases Total admissions discharges deaths currently community Total deaths Sites deaths discharged cases WK 51 WK 51 WK 51 admitted deaths Jubek – - - - - 8 19 27 1,979 2,006 Juba Jonglei-Duk - - - - 5 3 8 84 92 Terekeka - - - - - 8 8 14 22 Eastern Lakes - - - - - 1 3 4 349 353 Awerial Imatong - - - - - - 1 1 28 29 Pageri Western Bieh - - - - - 4 - 4 266 270 Fangak Northern Liech - 101 98 - 30 6 2 8 759 797 Rubkona Southern - - - - 3 - 3 86 89 Liech - Leer Eastern Nile 5 168 - Pigi 5 163 Total 101 98 - 30 32 36 68 3,728 3,826 Active transmission is ongoing in Bentiu PoC where: 1. Cases have been on the increase since week 41 with 101 new cases reported in week 51. 2. Nearly 80% of the cases are children under 14 years of age (Annex 1). 3. New cases in recent arrivals from Guit, Leer, and Koch. 4. More women are affected than males possibly due to their traditional domestic chores (Annex 1). 5. The sectors neighboring the waste water pond also have the highest attack rate of cholera (Annex 1). 6. The 12 blocks which closely border this pond registered 25% of cholera cases (Annex 1). 7. The epidemic curve denotes continuous source outbreak that is consistent with exposure to water from the pond (Annex 1). 8. Tailored recommendations considering the current trends in Bentiu PoC 1 In Southern Liech (Leer and Mayendit), the response is led by UNIDO although implementation of sustained and comprehensive investigation and response activities continues to be constrained by security concerns. In Pigi, Eastern Nile state, transmission has been contained with the last four cases discharged from Kurwai PHCC on 15 November 2016. Cholera was confirmed in Pigi after two cases tested positive by culture on 2 November 2016. A least 163 cases including 6 deaths (5 health facility and one community) (CFR 2.98%) were reported since 10 October 2016. Health and WASH activities in Pigi are led by NHDF supported by WHO, UNICEF, and MSF-F. Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 29 December 2016 World Health Organization Cholera Fatality Density Map for cases per population and CFR Weeks 24-49 2016 Map Date: 16 December, 2016 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 1.10 2.98 1.48 Luakpiny/NasirMaiwut Aweil South Raga Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Tonj North Leer Ayod Mayendit 2.38 Ethiopia Tonj East Duk Uror Akobo Jur River Rumbek NorthPanyijiar 8.7 Wau Twic East Pochalla Central African Republic Tonj SouthCueibetRumbek Centre Yirol East Rumbek East Nagero Bor South Yirol West Awerial Pibor Wulu Tambura 1.14 Mvolo Legend Terekeka xx Case fatality rate (CFR) 36.4 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 1.35 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 Figure 1.1: New cholera cases admitted by location in week 51 of 2016 120 101 90 60 30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of Cases 0 Puluk Abuyung Dongchak Kator Juba Rejaf Munuki Northern Nimule Terekeka New Fangak Old Fangak Toch Thonyor Yang Rubchar Dhoryiel Bentiu PoC Bentiu Town Piliny Bari Eastern Lakes Jonglei Jubek Imatong Terekeka Western Bieh Southern Liech Northern 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 17 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. 2 Figure 1.2: Cumulative cholera cases by payam of residence as at 29 December 2016 900 788 800 700 606 600 500 470 400 351 358 320 Number of Cases 300 210 219 200 167 90 100 22 37 42 27 40 2 7 1 1 3 2 4 2 1 15 1 1 5 1 1 7 1 1 2 13 1 1 3 1 1 1 0 Yang Toch Buko Rejaf Piliny Kator Yamg Puluk Adok Lwoki Leer Padiat Paguir Lokiliri fangak kurwai Pageet Nimule Khaigai Munuki Uganda Rubchar Nyarjwa Thonyor Dhorbor Dhoryiel Abuyung Mareang Terekeka Mangalla Dongchak Kolanyang Leer Town Juba Town Gondokoro Bentiu PoC Old Fangak Bentiu Town New Fangak Northern Bari Dhuorguol Deng Eastern Imatong Jonglei Jubek Terekeka Western Bieh Northern Liech Southern Liech Eastern Lakes Nile 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. Table 1.1: Cholera cases and deaths by state and county as of 29 December 2016 Week 51 Weeks 24-51 New Cases per Cases per Population cases 10,000 10,000 State County at risk W51 population No. cases population CFR [%] Western Bieh Fangak 139,509 0 - 270 19.4 1.48 Northern Liech Rubkona 126,976 101 7.95 797 62.8 1.00 Southern Liech Leer 67,167 0 - 89 13.3 3.37 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 0 - 2,006 42.5 1.35 Terekeka Terekeka 177,849 0 - 22 1.2 36.4 Eastern Nile Pigi 125,496 0 - 168 13.4 2.98 Total 1,464,906 101 0.69 3,826 26.1 1.78 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 29 December 2016, 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). Three cases were reported from Old Fangak in week 48 of 2016. In Northern Liech state, 797 cholera cases including 22 confirmed cases and eight deaths (CFR 1.00%) 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. The new cases in Bentiu are largely reported among children under two years and in individuals that arrived from Leer, Mayendit, Koch, Panyijiar, and Guit after the 2015 oral cholera vaccine campaign in Bentiu PoC. Over 90% of cholera cases in Bentiu PoC did not receive oral cholera vaccine (Annex 1).