Situation Report #26 on Cholera in South Sudan As at 23:59 Hours, 17 July 2015

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1 Republic of South Sudan Situation Report #6 on Cholera in South Sudan As at :9 Hours, 7 July Situation Update As of 7 July, a total of,6 cholera cases including 8 (CFR.%) have been reported in Juba and Bor Counties in Central Equatoria and Jonglei States respectively. In Juba County, cases including 7 (CFR.7%) have been reported from seven Payams and 96 villages (Table ). In Bor, 96 cases including one death (CFR.%) have been reported from Malou in Makuach Payam and other areas within the County. The initial cases in Juba were traced back to 8 May in UN House PoC where the first cholera case was confirmed on June. Most of the cholera cases in Juba have been reported from Gumbo followed by site, Gudele, Juba PoC, and Munuki (Figure ). In Bor, the initial cases were reported from Malou in Makuach Payam. Later, cases were reported from Arek, Block 8, Hai Salam, Achengdii, Langbar and several other areas around the city. Table. Summary of cholera cases reported in Juba and Bor Counties, 8 May 7 July Reporting Sites admisions discharges currently admitted LAMA* facility community discharged CES Juba County IMC UN House PoC clinic 8 6 Juba Teaching Hospital MedAir Gumbo CTU 6 6 MedAir Gudele ORP 8 8 HLSS Nyakuron ORP 8 8 HLSS Kator ORP HLSS Gurei ORP HLSS Munuki ORP HLSS Al Sabah ORP HLSS Lologo ORP MSF Munuki CTC 8 Other sites in Juba 8 Jonglei State Bor Bor State Hospital *LAMA: LEAVE AGAINST MEDICAL ADVICE; CES- Central Equatoria State A total of new cholera cases including one health facility death were reported in Juba on 7 July (Table and Figure ). o new cases including one health facility death were reported from Juba County, with the majority of the cases originating from Gudele, Rock City and Suk Jebel. Figure : cholera cases by residence on 7 July Hai Soura Giada Lologo Lologo Jebel Kujur Munuki Nyakuron Jebel Suk Rock City Gudele Gudele Amadi Gurei Plot Gudele plot 9 Kor William Kodoro Juba Kator Munuki Northern Bari Rejaf

2 Cumulatively,6 cholera cases including 8 ( facility and 6 community) have been reported in Juba and Bor Counties since the initial case was reported on 6 May in Juba (Tables and ). Of the 8, seven (8.%) have occurred in children under five years. Table : cholera cases by facility and week in Juba and Bor Counties, 8 May 7 July cases by epidemiological week of Reporting Facility Grand CES Juba County JTH Juba IMC clinic HLSS Nyakuron ORP 8 HLSS Kator ORP MedAir Gudele ORP 8 8 MedAir Gumbo CTU HLSS Gurei ORP HLSS Munuki ORP HLSS Al Shabah ORP HLSS Lologo ORP MSF Munuki CTC Other sites in Juba 6 Jonglei State Bor County 6 96 Bor State Hospital 6 96 Grand As seen from Figure, the initial and isolated cases were reported from UN House PoC in Juba starting on 6 May. However, following epidemiological investigations on 7 May, cases could be traced back to 8 May. Cholera was eventually confirmed on June in Juba after Vibrio cholerae inaba was isolated from the one of five samples tested in the National Public Health Laboratory. Since 6 June, sustained and consistently increasing community transmission was established in Juba with increasingly more suspect cases reported outside UN House PoC. There are three discernible transmission peaks with the initial peak of cases occurring on June while the subsequent and higher peaks occurred on June, and 6 June before reaching the highest peak on 8 June. Since then, successively shorter transmission peaks have been registered, a trend that is consistent with declining community transmission. In Bor, the initial case occurred on 6 June with increasing cases from week 6 to week 7 when the highest transmission peak was registered. In the subsequent weeks, successively shorter transmission peaks have been registered, a trend that is consistent with declining community transmission. Figure : Epidemic curve for suspect cholera cases in Juba, 8 May 7 July 7 6 // /8/ // // /7/ // 6// 6// 6/8/ 9. 6// 6//.9 6/7/ 6// 6//.7 6/6/ 6/9/.8 7// 7//. 7/8/ 7// 7//.9 7/7/ Case Fatality Rate [%] JS: Jonglei State; CES: Central Equatoria State; CFR: Case Fatality Rate JS CES CFR The probable risk factors fueling transmission include: residing in a crowded IDP camp with poor sanitation and hygiene; using untreated water from the Water tankers; lack of household chlorination of drinking water;

3 eating food from unregulated roadside food vendors or makeshift markets; and open defecation/poor latrine use. Figure : Spot map for suspect cholera cases by residence in Juba, 8 May 7 July As of 7 July, the sites reporting the majority of cases in Juba include Gumbo, site, Gudele, Juba PoC, and Munuki with satellite cases distributed in seven Payams and 96 villages in Juba County (Figure ). In Bor County, the majority 9 (%) of the cases originated from Malou in Makuach Payam and later from areas like Arek, Block 8, Hai Salam, Achengdii and Langbar. Out of the 99 suspect cholera cases with known age from Juba, (%) were children less than five years of age, while 87 (86%) were individuals aged five years and above. In Bor, 6 (8%) of the cases have occurred in children under five years of age, while (%) occurred in individuals aged five years and above (Table ). Table : Suspect case distribution by age in Juba and Bor Counties, 8 May 7 July Case distribution by age Cases (%) CES Juba 99 <yrs () +yrs 87 (86) Jonglei State Bor County 96 <yrs 6 (8) +yrs () Grand 88 Out of the 99 cholera cases with known gender in Juba, 9 (%) were female, while 7 (8%) were male while in Bor, (7%) of the cases were females, while (%) were males (Table ).

4 Table : Case distribution by gender and age in Juba and Bor Counties, 8 May 7 July Case distribution by gender N (%) CES - Juba 99 Female 9 () Male 7 (8) Jonglei state Bor County 96 Female (7) Male () Grand 88 Laboratory updates Table : Cholera laboratory test results for Juba and Bor, 8 May 7 July Health Facility Number of RDT tests Number of cholera RDT positives Number of stool cultures Number of cholera Culture positives CES Juba Al Sabah hospital Juba Teaching Hospital Juba PoC clinic 7 Juba Military Hospital Morobo clinic 6 Gorom PHCC MedAir Gumbo CTU Jonglei state Bor Bor State Hospital As seen from Table, 8 (88 %) of the samples have been RDT positive while 9 (%) have been confirmed by culture after the National Public Health Laboratory isolated Vibrio cholerae inaba. Most of the culture confirmed cases have been reported from Juba PoC and site (Figure ). In Bor, four culture positive cases have been confirmed. Of the samples submitted from Kajo Keji, 9 tested negative for cholera following microbiological culturing, while the test results for two samples are pending. Figure : Number of culture positives by residence in Juba, 8 May 7 July 8 6 Atlabara Bilpam Giada Gudele Gumbo Jebel Kujur Juba Nabari Kator Juba Kor William Mangatain IDP Munuki site Nyakuron West Digala Kodoro Juba PoC Achendii Bor Table 6: Cholera Alerts to 7 July Date of Details of the alert Area Action notification -July- One suspect cholera case involving a year old male from Makambale police training center in Rumbek -July- One suspect case was reported in Kuajok, Warrap state hospital on July. The case involves an elderly man initially seen in a private facility with profuse diarrhoea and vomiting and severe dehydration Makamb ale police training center, Rumbek Kuajok State Hospital - Epidemiological investigations conducted by the state rapid response team - Case isolated in Rumbek State Hospital - Treatment initiated - Sample collected and shipped to Juba for testing. - Case being managed in Kuajok State Hospital. - No travel history to cholera affected area - Stool sample positive on RDT - The stool sample tested negative for cholera following microbiological culturing at the National Public Health Laboratory

5 Date of notification 6-Jun- -Jun- Details of the alert Area Action Nineteen suspect cholera cases were initially reported in Kajo Keji Civil hospital. The cases have now risen to a cumulative total of 6. Two suspect cholera cases reported from Torit State Hospital Kajo Keji, CES Torit, EES - A total of 6 acute watery diarrhoea cases have been line listed with two cases on admission at the hospital - samples submitted for microbiological culturing - 9 samples tested negative for cholera following microbiological culturing at the National Public Health Laboratory while two are pending - Three stool samples collected and received in Juba on 7 June. All three samples were negative for cholera after microbiological culturing - Refresher training on cholera conducted for the state hospital healthcare workers - Temporary isolation for at least patients set up in Torit State Hospital - Since June, at least nine alerts of suspect cholera cases have been reported outside Juba. The national and respective state cholera taskforce committees have initiated the recommended follow up actions as described in Table 6. Planned and On-going Activities. The next national cholera taskforce meeting is scheduled for Tuesday July at : am in the Ministry of Health Ministerial Boardroom.. The next cholera coordination meeting in UN House PoC is scheduled for July at : am in the RRP Boardroom. Many thanks to the staff at CTCs, MoH at national level and state levels, especially the Department of IDSR, who have helped to gather the information presented here. Situation Reports are posted on the WHO website: as well as on the Humanitarian Info webpage: The MoH/WHO surveillance team welcomes feedback and data provided by individual agencies. Given the fast evolving nature of this epidemic, errors and omissions are inevitable: we will be grateful for any information that helps to rectify these. Send any comments and feedback to: outbreak_ss_7@yahoo.com, The Toll free numbers for alerts are: Zain: 998. Contacts For more information please contact: Dr. John Rumunu Director General - Preventive Health Services MoH, Republic of South Sudan Tel: Dr. Thomas Akim Ujjiga Director - IDSR MoH, Republic of South Sudan Tel: +96