Republic of South Sudan CHOLERA SITUATION AND RESPONSE UPDATES 17 NOVEMBER 2017 Epidemic trends § Cholera transmission reported in two counties [Juba and Budi] in the last four weeks [43- 46, 2017]. § Out of the 26 samples tested in the week, 16 (62%) were positive by culture. All positive samples were from New Bongo (a new focus of transmission in Juba) (Table 4). Table 1: Cholera cases by county for weeks 43, 2017 to 46, 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-16 113 2,922 50.40 2 28 10 1.33 Budi 22-Jul-17 42 850 49.70 1 62 20 9.95 § 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 40 cases including 16 confirmed cases have been reported from New Bongo (Figure 3). Fig.1|Cholera cases by county, week 43-46, 2017 60 54 50 Budi Juba 40 30 27 20 18 Number of cases 14 10 17 13 12 0 43 44 45 460 Epidemiological week of onset 1 § Two assessment missions to New Bongo were undertaken during the week. The affected population is using two shallow wells as drinking water source after the sole borehole in the area broke down. There are no improved sanitation facilities in the area and the population has no access to a primary health care facility. New Bongo and the surrounding areas have an estimated population of 11,000. Following the assessment missions, an oral rehydration point has been set up by HLSS; bucket chlorination has been initiated; plans are underway to repair the borehole; a roadshow is planned in the area; and a reactive vaccination campaign using oral cholera vaccines will be implemented on 23 and 24 November 2017. Fig.2|Cholera Epidemic Curve for Juba County, week 23, 2016 to week 46, 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 111315171921232527293133353739414345 2016 Epidemiological week of onset 2017 Fig.3|Cholera cases by village in Juba county, week 45-46, 2017 45 40 40 35 30 25 20 15 10 5 3 3 3 4 Number of cases 5 1 1 1 1 2 2 2 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 is already underway in the county. § A cumulative of 850 cases including 82 deaths [CFR 9.65%] 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 2 gold-miners in Ngauro. Fig.4|Cholera Epidemic Curve for Budi County, week 23, 2016 to week 46, 140 2017 120% 120 100% Alive Died CFR% 100 80% 80 60% 60 CFR% 40 40% 20% Number of cases/deaths 20 0 0% 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 2017 Epidemiological week of onset 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 21,530 cases including 461 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 5 Fig.9|Cholera Epidemic Curve for South Sudan, week 23, 2016 to week 46, 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 111315171921232527293133353739414345 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 21,530 No. deaths 167 47 461 CFR% 2.60% 2.59% 2.14% No. counties affected 16 3 27 Duration (weeks) 29 19 (76) 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 46.31 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.