Malakal 8% Torit. Fashoda. Ikotos. Kapoeta North. Yirol West. Raga. Aweil North. Ezo. Aweil South. Mundri East. Nzara. Gogrial East.

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1 Weekly Epidemiological Bulletin Integrated Disease Surveillance and Response (IDSR) Republic of South Sudan W nd -8 th Jan 7 Highlights Completeness for weekly reporting was 33% for the nonconflict states and 76% for the IDP sites. Malaria is a leading cause of morbidity in nonconflict areas and IDPs. Transmission in most counties that had experienced upsurge in cases has reduced to expected ranges. Active cholera transmission is ongoing but declining in Northern Liech and Southern Liech; and UN House PoC. Measles transmission is ongoing in Wau PoC where at least 53 cases were reported in week of 7. Three suspect meningitis cases reported from Bentiu PoC. Acute watery diarrhoea was the leading cause of death in IDPs during the week. Public Health Priorities Figure a IDSR Proportional morbidity WK, 7 Special focus on malaria Malaria accounted for 39% and 7% of consultations in nonconflict-affected and IDP areas (Figs. a and b). Analysis of malaria trends at state level showed that malaria cases were within expected levels in all the states (Fig. 8af). In the 6 (33%) affected counties; malaria cases have continued to decline to expected transmission levels (Fig. 9a). Early Warning, Alert and Response Active responses Cholera Malaria Measles Kala azar Hepatitis E virus Guinea worm Active alerts: Meningitis 4% % % AWD ABD Malaria Event based surveillance W of 7 Two states - Imatong and Wau submitted event log data with no events reported during the reporting period. System performance Completeness for weekly reporting was 33% for the nonconflict states and 75% for the IDP sites (Table ). Only two counties attained % completeness in reporting. Overall, 4 counties attained completeness of at least 8% (Figures c). Timeliness for weekly reporting remains very low (9-69%) for both the non-conflict affected states and IDP sites (Table ). Table Surveillance performance in South Sudan as of W 7 System 47% Total Facilities Figure b Proportional morbidity in IDPs W 7 % 7% % 4% %.7% 39% Measles Malaria Timelines Completeness Timeliness Completeness in week of 7 Cumulative for 7 IDSR 39 44(9%) 459 (33%) 44(9%) 459 (33%) EWARN 48 33(69%) 36(75%) 33(69%) 36(75%) ARI AWD ABD Other Measles Others Figure c IDSR Completeness by county in W 7 Malakal 8% Torit 8% Rubkona % Lofan % Pariang % Wau 3% Budi 9% National 33% Bor South 34% Twic Mayardit 4% Manyo 4% Fashoda 4% Ikotos 4% Kapoeta North 4% Tonj North 43% Maiwut 5% Yirol West 5% Kapoeta East 5% Raga 53% Yambio 59% Kajo-keji 66% Ibba 67% Ulang 7% Jur River 7% Tambura 73% Abiemnhom 75% Aweil North 75% Ezo 79% Abyei 8% Aweil South 8% Mundri East 8% Longochuk 85% Nzara 85% Gogrial East 86% Nagero 88% Maban 88% Aweil West 89% Mundri West 89% Mvolo 9% Maridi 96% Tonj South % Mayendit % % % 4% 6% 8% % % Completeness

2 IDSR and EWARN Reporting Performance by Partner and County in 7 Table Reporting Performance [Timeliness and Completeness] by Partner and County as of W 7 Partner Number of health facilities Completeness W 7 In Week of 7, only 7 hospitals (33%), 4 PHCCs (3%), and 34 PHCUs (34%) in 4 counties of the nonconflict-affected states submitted their IDSR reports (Table ). A total of 39 counties did not submit any IDSR report in the reporting week (Table ).However eight of these counties submit their data through EWARS (Table ). partner-supported health facilities in the conflict-affected states did not submit their reports in the reporting week (Table ). Trends for top causes of Morbidity Table 4 Top causes of morbidity in 6 and 7 Malaria remains the top cause of morbidity in the nonconflict states followed by Acute watery diarrhea while for the IDP sites ARI is the leading cause of morbidity followed by malaria.(figures a, b, 6a, 6b, Table 4). Timeliness # # % # % GOAL % % HLSS 3 3 % 3 % IMA 5 % % IMC 6 6 % 6 % IOM 3 3 % 3 % IRC % % Medair 3 67% 67% MSF-E % % MSF-H % % SMC 4 5% % UNIDO 4 4 % 4 % UNKEA % % World Relief % % System IDSR EWARN Total % 33 69% Disease New cases W 6 7 Malaria,88 4,758 AWD 4,94 4,54 Meningitis ABD,3 69 Measles 4 AJS Malaria 8,3 3,858 AWD,6,539 ARI 4,4 5,65 ABD 8 45 Measles 3 5 AJS 7 8 Meningitis - 3 No. IDSR Silent Counties W 7 Silent Counties W 7 Juba* Lainya Morobo Terekeka Yei Kapoeta South Magwi Akobo * Ayod Canal/Pigi Duk Fangak Nyirol Pibor Pochalla Twic East uror Awerial* Cueibet Rumbek Centre Rumbek East Rumbek North Wulu Yirol East Aweil Centre Aweil East Guit Koch Leer* Mayom Payinjiar* Akoka Baliet Luakpiny/Nasir* Melut Panyikang Renk Gogrial West Tonj East *Counties with EWARS reporting sites The health facilities in the IDPs that did not submit their reports in week are supported by IMA, MSF-E, MSF-H, MedAir, UNKEA, World Relief, and SMC (Table ). The best performing partner-supported facilities during the week were GOAL, HLSS, IMC, IOM,, IRC, and UNIDO. Consultations Table 3 Consultations in South Sudan as of W 7 Surveillance System Table 3 shows the total consultations in 7. IDSR Consultations in week of 7 Cumulative consultations for 7 <5 years 5 years Total <5 years 5 years Total IDSR 5,53 3,864 39,78 5,53 3,864 39,78 EWARN 3,33 3,33 Total 63,5 63,5 Overall morbidity trends for 4-7 Figure 6a IDSR priority disease morbidity trends W 6 to W5 6 Figure 6b EWARN Priority Disease Proportionate Morbidity W5 3 to W 7 cases per, population IDSR Priority Disease Morbidity trends from week 6 to week of reporting in Completeness (%) Percentage of all consultations 8% 7% 6% 5% 4% 3% % % % %_Malaria %_ARI %_Measles %_AJS %_AWD %_ABD 6--3 Completeness ABD Malaria Measles AWD

3 Malaria Across the country Malaria was the top cause of morbidity accounting for 39% and 7% of the consultations in the nonconflict-affected states and IDP sites respectively (Fig. a, b). However, the incidence in week 7 is low compared to the previous two years(5-6) As seen from Figs. 8a-f, analysis of malaria trends at state level showed that malaria cases were within expected levels in all the states*. In the 6 (33%) affected counties; the malaria trends have continued to decline. (Fig 9a). The malaria incidence in the IDP sites are within expected levels (Figs. a-d). In the week, five(5) malaria deaths were reported from Aweil North (); Mayendit(), Bentiu POC() and Juba UN House Poc () (Tables 5, 6). Cases per, Population Status: Urgent Figure 7 IDSR malaria trends by week, of reporting Figure 8a Malaria Incidence for Wau state, week to 5, 6 and week 7 Figure 8b IDSR trends for malaria Gogrial, Tonj, Twic, Wk to Wk 5, 6 and Wk 7 5 cases per, 5 cases per, Third quartile -4 7 Epidemiological Week 6 Third quartile -4 7 Malaria cases per, 5 5 Figure 8c IDSR trends for Malaria Aweil, Aweil East, Lol from week to 5,6 and Wk Third quartile -4 7 cases per, Figure 8d IDSR trends for malaria in Western Lakes, Eastern Lakes, and Gok states, Wk to Wk 5, 6 and Wk Third quartile Malaria 8 Figure 8e IDSR Malaria trends for Imatong and Lomurnyang, week - 5, 5 and Wk 7 8 Figure 8f IDSR trends for Malaria in Gbudwe, Maridi, and Amadi states from week to 5, 6 and Wk 7 cases per, 6 4 cases per, Third quartile Third quartile -4 7 *Actual disease trends may be masked by low reporting rates

4 Status: Urgent Malaria trends by county () 3 Figure 9a IDSR trends for Malaria in KajoKeji county from week to 5, 6 and WK 7 5 Figure 9a IDSR trends for Malaria in Bor county from week to 5, 6 and Wk 7 Week Week 4 Week 7 Week Week 6 Week Week 8 Week 34 Week 4 Week 46 Week Third quartile Week Week 3 Week 5 Week 7 Week Third quartile Figure 9a IDSR trends for Malaria in Budi county from week to 5, 6 and Wk 7 Week Week 3 Week 5 Week 7 Week Figure 9a IDSR trends for Malaria in Ikotos county from week to 5, 6 and Wk 6 Week Week 3 Week 5 Week 7 Week Third quartile Third quartile 3-5 Figure 9a IDSR trends for Malaria in Yirol West county from week to 5, 6 and Wk 7 Figure 9a IDSR trends for Malaria in Awiel North county from week to 5, 6 and Wk Week Week 3 Week 5 Week 7 Week Third quartile 3-5 Week Week 3 Week 5 Week 7 Week Third quartile 3-5 Figure 9a IDSR trends for Malaria in Mayendit county from week to 5, 6 and Wk 7 Figure 9a IDSR trends for Malaria in Payinjiar county from week to 5, 6 and Wk Week Week 3 Week 5 Week 7 Week Week Week 3 Week 5 Week 7 Week Third quartile Third quartile 3-5

5 Malaria trends by county () Status: Urgent Figure 9a IDSR trends for Malaria in KajoKeji county from week to 5, 6 and WK 7 Week Week 3 Week 5 Week 7 Week Third quartile Figure 9a IDSR trends for Malaria in Bor county from week to 5, 6 and Wk 7 Week Week 3 Week 5 Week 7 Week Third quartile Figure 9a IDSR trends for Malaria in Budi county from week to 5, 6 and Wk 7 Week Week 3 Week 5 Week 7 Week Figure 9a IDSR trends for Malaria in Ikotos county from week to 5, 6 and Wk 6 Week Week 3 Week 5 Week 7 Week Third quartile Third quartile 3-5 Figure 9a IDSR trends for Malaria in Yirol West county from week to 5, 6 and Wk 7 Figure 9a IDSR trends for Malaria in Awiel North county from week to 5, 6 and Wk Week Week 3 Week 5 Week 7 Week 9 Week Week 3 Week 5 Week 7 Week Third quartile Third quartile Figure 9a IDSR trends for Malaria in Mayendit county from week to 5, 6 and Wk 7 Figure 9a IDSR trends for Malaria in Payinjiar county from week to 5, 6 and Wk Week Week 3 Week 5 Week 7 Week 9 Week Week 3 Week 5 Week 7 Week Third quartile Third quartile 3-5

6 Malaria in IDPs, Figure a Malaria trend for IDPs in Bentiu PoC 4 to 7, Figure b Malaria trend for IDPs in Malakal PoC 4 to 6 8 cases per, Week of reporting incidence 7 Third quartile incidence 4 incidence 5 incidence 6 cases per, Week of reporting incidence 4 incidence 5 incidence 7 Third quartile incidence 6 6 Figure c EWARN trends for Malaria in UN House PoC 4 to 7 3 Figure d EWARN trends for Malaria in Mingkaman, 4 to 7 cases per, 4 Cases per, Week of reporting incidence 4 incidence 7 incidence 5 Third quartile incidence incidence 4 incidence 5 incidence 6 incidence 7 Third quartile Acute Respiratory Infection (ARI) Percent of total consultations 35% 3% 5% % 5% % 5% % Figure ARI trends in IDPs W5 3 to W of reporting Percent of all consultations 8% 7% 6% 5% 4% 3% % % % Figure b ARI Incidence by IDP Site in W 7 IOM Payer Clinic IOM Gerger Clinic Medair Abayok Clinic Medair Wonthow Clinic IOM Ramela Clinic UNIDO Gandor PHCU MSF-H Bentiu Town Clinic MSF-H Bentiu PoC Hospital IRC Sector 4 Clinic IOM Halaka Clinic IOM Bentiu Sector PHCC UNIDO Bow PHCU IMC Akobo Hospital IMC Malakal PoC Clinic IOM Wonthow Mobile Clinic IOM Abayok Clinic IMC UN House Clinic IOM Sector 5 Clinic IOM Malakal PoC Clinic IMC Malakal PoC Clinic IOM Wau PoC PHCU IOM Bentiu Sector 3 PHCC UNIDO Majak PHCU GOAL Koradar IDP clinic GOAL Dethoma Camp UNIDO Meer Mobile Clinic HLSS Mingkaman Hospital IOM Nazareth Mobile Clinic IMC ER PoC In the IDPs, ARI registered the second highest proportionate morbidity of 4.8% as compared to 7.8% in week 5 of 5 and.6% in week 5 of 6 (Fig. ). Figure b shows ARI morbidity by IDP site in week 5 of 6. Meningitis (suspected) In week of 7 three suspect meningitis cases were reported from Bentiu PoC, while 4 suspected cases were reported in week 5 of 6. Case-based laboratory backed investigations are ongoing. In 6 a total of 7 samples were tested in the National Public Health Laboratory in 6 - none of these has been confirmed to be due to epidemic meningitis. Since the onset of the dry season in week 47a total of 4 suspect meningitis cases have been reported with the most recent being suspect cases reported from Bentiu PoC in week 5. A total of 5 suspect meningitis cases have been reported in Bentiu PoC. The initial suspect in Bentiu PoC was reported on 6 Nov 6. Seven out of 4 suspect cases have been tested using rapid pastorex with 4 testing positive for Streptococcus pneumoniae; two samples involving two-month-old children tested positive for Neisseria meningitidis Y/W35; one case was positive for Hemophilus influenza type b; one case tested negative; and the one from Wau Teaching Hospital was not tested. A meningitis alert has been issued and surveillance has been enhanced countrywide.

7 Acute watery diarrhoea (AWD) AWD is among the top five causes of morbidity and currently accounts for % of all consultations in the nonconflict-affected states and IDP sites respectively (Fig. a, b). The overall AWD incidence [cases per,] in the reporting week was 36.8 in the nonconflict-affected areas with Gbudwe, Amadi, and Maridi and Namurnyang and Imatong states states being the most affected (Fig. ). Cases per, Population Figure IDSR AWD trends by weeks -5 of 4-6 and WK 7 In the IDP sites, AWD morbidity is higher when compared to the same period of 5 and 6 (Fig. 3) Figure 4 shows AWD morbidity by IDP site in week of 7 of reporting Acute watery diarrhoea (AWD) Percent of all consultations 5% % 5% % 5% % Figure 3 AWD trends in IDPs W5 3 to W Percent of all consultations 6% 5% 4% 3% % % % Figure b AWD Incidence by IDP Site in W 7 HLSS Mingkaman Hospital IOM Ramela Clinic UNIDO Gandor PHCU UNIDO Bow PHCU MSF-H Bentiu PoC Hospital MSF-H Bentiu Town Clinic IMC UNMISS PoC Clinic IRC Sector 4 Clinic GOAL Dethoma Camp SMC Dorok Mobile Clinic IOM Gerger Clinic UNIDO Meer Mobile Clinic IMC ER PoC UNIDO Majak PHCU IMC Akobo Hospital Medair Wonthow Clinic Medair Abayok Clinic IOM Sector 5 Clinic IMC Malakal PoC Clinic GOAL Koradar IDP clinic IOM Bentiu Sector 3 PHCC IOM Bentiu Sector PHCC IMC UN House Clinic IOM Wau PoC PHCU IOM Nazareth Mobile Clinic IOM Wonthow Mobile Clinic IMC Malakal PoC Clinic HLSS Bor Clinic IOM Cathedral Church IDP Acute bloody diarrhoea (ABD) ABD burden has remained stable from last week at % and % of consultations in the non-conflict affected states and IDP sites respectively (Fig. a, b). The overall ABD incidence [cases per,] in the reporting week was 5. in the non-conflict affected areas with Gbudwe, Amadi, and Maridi states and Lol, Wau and Raja states being the most affected (Fig. 5). Among the IDPs, the current ABD burden is lower when compared to 5 and 4 but similar to same period in 6 (Fig. 6 and 7). Cases per, Population Figure 5 IDSR ABD trend by weeks -5 of 3 6 and WK of reporting Figure 7 shows the number of ABD cases by IDP clinic in week of 7. Acute bloody diarrhoea (ABD) 6% Figure 6 ABD trends in IDPs W5 3 to W 7 5% Percent of all consultations 4% 3% % % % Percent of all consultations % 8% 6% 4% % % 8% 6% 4% % % UNIDO Bow PHCU IOM Halaka Clinic GOAL Dethoma Camp MSF-H Bentiu Town Clinic Figure 7 ABD burden by IDP Site in W 7 Medair Wonthow Clinic SMC Dorok Mobile Clinic IOM Abayok Clinic IOM Wonthow Mobile SMC Padiet Mobile Clinic IOM Bentiu Sector 3 PHCC IOM Malakal PoC Clinic IOM Cathedral Church IOM Bentiu Sector PHCC IOM Sector 5 Clinic HLSS Mingkaman IDP Site IMC UNMISS PoC Clinic IMC Malakal PoC Clinic HLSS Bor Clinic

8 Measles At least 53 new measles cases reported from Wau PoC in the week (Table 4.). One suspect case reported from Malakal PoC. Cumulatively in 6, a total of,94 suspected measles cases including at least 8 deaths (CFR.%) were reported countrywide (Table 4.). Investigations and response to cases in Wau and Malakal are underway. In Week of 7 only there is only one County(wau) with Confirmed Measles outbreaks (Table 4.) Table 4. Measles cases by location and status as at W of 7 County Suspect cases in 7 Confirmed Cases in 7 Samples tested in 7 Wau 53 Outbreak status in 7 Confirmed Malakal Alert 5 Figure 8. Epicurve showing Measles cases in Wau, W5 5 to WK 7 Number of cases Week of rash onset 6 7 Aive Deaths Measles cases in Wau have continued to decrease for the second consecutive week, Having peaked at 9 cases in 6, 7 cases were reported in week 5 and65 cases in week of 7 of show the trend of measles (Fig 8.) % 8% Cases[No] 6% 4% % % Table 4.4 Trend of measles cases by age-group and week in Rubkona, W-W5, of rash onset in 6 <yrs -4yrs 5-9yrs -4yrs 5yrs Cases[No] % 8% 6% 4% % % Table 4.3 Trend of measles cases by age-group and week in Wau, W-5 of 6 and Week of rash onset in 6 and 7 <yrs -4yrs 5-9yrs -4yrs 5+yrs Fig 4. to 4. compares the trend of measles cases by age-group in Wau and Rubkona. Unlike the outbreak in Rubkona were most of the cases were below 5 years, the Measles outbreak in Wau is showing a significant proportion of cases in above 5 years age group especiall in weeks 5-5 of 6 and week of 7

9 Visceral Leishmaniasis Kala-azar In 6, a total of 4, cases [3,755 (93.8%) new; 74 (4.3 %) relapses; and 73 (.8%) PKDL] including 9 deaths (CFR.3%) and 7 (.8%) defaulter were reported from treatment centers. During the corresponding period in 5, a total of 3,67 cases including 8 deaths (CFR 3.5%) and 47 (4.8%) defaulters were reported from treatment centers. Of the 4, cases reported in 6, the majority were from Lankien (8), Old Fangak (943), Kurwai (66), Ulang (46), Walgak (45), Chuil (7), Kodok (5), and Melut (47). The most affected groups included male [,99 cases (54.9%)], those aged 5-4 years [536 cases (38.4%]) and those aged 5years [78 (3.8%). Children under five years were less affected [8 cases (8.%)]. Since week 7, 6, the number of weekly cases were higher than the those reported during the corresponding period of 5. Hepatitis E Virus (HEV) In Week of 7 5 cases were reported from Bentiu PoC. (Fig. 9). The transmission of HEV is also reported in Bentiu town and all have been linked to suboptimal access to safe water and sanitation Earlier in 6 two clusters of AJS reported in Mayom [49 cases including deaths since 9/5/6] and Abyei [involving 8 cases including 4 deaths [since 5 Oct 6]. Seven of samples tested positive for HEV by PCR. Co-infection with malaria was common in the children that died. Since the beginning of the crisis, 3,4 HEV cases including 5 deaths (CFR.77%) reported in Bentiu; 58 cases including seven deaths (CFR 4.4%) in Mingkaman; 38 cases including one death (CFR.6%) in Lankien; 3 confirmed HEV cases in Melut; 3 HEV confirmed cases in Guit; and HEV confirmed case in Leer. No, cases in other sites Figure 9 HEV trends in Mingkaman, Bentiu & Lankien W 4 to W Awerial Lankien Bentiu No. cases in Bentiu Other diseases of public health importance Table. Non Polio AFP rate by county as of week of 7 Acute Flaccid Paralysis Suspected Polio Four(4) new suspected AFP cases were reported in week from across the country and investigations are ongoing. During 6, a cumulative of 35 AFP cases were reported countrywide. the annualized non-polio AFP (NPAFP) rate (cases per, population children -4 years) is 3.9 per, population of children -4 years (target per, children -4 years). In 6 Only two state hubs(unity and Central Equatoria) did not attain the targeted NPAFP rate of per, children -4 years (Fig. 9.). The non-polio Enterovirus (NPEV) isolation rate (a measure of the quality of the specimen cold chain) was % in 6 (target %). Stool adequacy was 9% in 6, a rate that is higher than the target of 8%. Guinea Worm Dracunculiasis In week, there was no report of any suspected Guinea worm from across the Country. However, In December 6 South Sudan reported ithe sixth CDC-confirmed Guinea worm case. The case is an 8-year-old female detected on th November 6 in Khor William village, Roc-roc-dong Payam, Jur river County, Wau state. Cumulatively in 6 Six (6) confirmed Guinea worm cases were reported compared o Four (4) cases in 5. The cash reward for reporting a Guinea worm case is now 5, SSP. Animal bites Suspected rabies There were no new suspect rabies cases in the week. Viral Haemorrhagic Fever No new suspect hemorrhagic fever cases reported from across the Country in Week. In 6 a cluster of suspected VHF was investigated in Aweil North with 55 suspect VHF cases including deaths (CFR 8.%) reportd since 4 December 5. Children were most afffected and accounted for most cases and deaths. There are no new deaths reported since 8 February 6. Most common symptoms included: unexplained bleeding (epistaxis), fever, fatigue, vomiting, jaundice. There is no evidence of person-to-person transmission. Mixed vectorborne VHF suspected. A total of 38 blood samples were initially obtained from suspect cases and shipped for testing. Test results (PCR, PRNT, ELISA) from WHO CC laboratories in Uganda (UVRI), South Africa (NICD) and Senegal (IPD) were negative for Ebola, Marburg, CCHF, Rift Valley Fever, Yellow Fever, Zika, West Nile, and Arenaviruses; 5 samples tested positive for Onyong-nyong virus by PRNT; 3 samples were IgM positive for Chikungunya; and IgM positive for Dengue at NICD. An additional 66 samples were collected during the follow up investigations (-3 June 6) have been shipped to NICD, South Africa and Netherlands for testing.

10 Cholera Cholera outbreaks have been confirmed in nine states [Jubek, Terekeka, Jonglei, Imatong, Eastern Lakes, Western Bieh, Northern Liech, Southern Liech; and Eastern Nile] (Figs 9. & 9.3). Active cholera transmission is ongoing but declining in Northern Liech and Southern Liech; and UN House PoC. As of 5 Jan 7, a cumulative of 4, cholera cases including 75 deaths (37 facilities and 38 community) (CFR.8%) had been reported in South Sudan (Table 4.). National and state level cholera taskforce committees are coordinating preparedness and response activities. Current trends highlight the need to enhance the cholera response in Northern and Southern Liech states. Table 4. Cholera cases and deaths by county as of 5 Jan 7 Number of cases Figure 9. Cholera Epidemic curve in South Sudan as of 5 Jan 7.% 6.9% % 35.8% 3.3% 3.7% %.4%.7%.9% %.9%.4%.6%.4%.4%.6%.4%.8%.%.%.%.%.% 3.8%.6%.6%.%.4% 5.% 5.%.% 5 % of onset 6 7 Jonglei Jubek Terekeka Imatong Eastern Lakes Western Bieh Northern Liech CFR[%] Southern Liech Eastern Nile Readers are referred to the cholera situation report for details on the ongoing cholera response in South Sudan % 5% % CFR % Reporting sites Total cases Total Facility deaths Total community deaths Total deaths Juba County, Duk County Terekeka County 8 8 Awerial County Pageri 9 Fangak Rubkona Leer Panyijiar Pigi Total 4, Figure 9.3 Cholera incidence (cases per,) and case fatality rate (%) as of 5 Jan 7 Cholera Fatality Density Map for cases per population and CFR Figure.: Weeks 4, 6 to incidence of 7 (cases per,) and case Map Date: 8, January 7 Manyo fatality rate (%) as of 3 October 6 Central African Republic Legend xx Case fatality rate (CFR) Counties with Cholera alert Cases per, population No case reported River Raga Tambura Nagero Ezo Yambio Nzara Sudan Fashoda Maban Abyei Pariang Malakal Abiemnhom Baliet Aweil North Aweil East Rubkona Panyikang Fangak Twic Guit Longochuk Mayom Pigi Aweil West Luakpiny/NasirMaiwut Aweil South Gogrial East Koch Nyirol Ulang Aweil Centre Gogrial West Tonj North Leer Ayod Mayendit 4.6 Tonj East Duk 8.7 Uror Akobo Jur River Panyijiar Rumbek North 6.5 Wau Tonj SouthCueibet Twic East Pochalla Rumbek Centre Wulu Ibba Yirol East Rumbek East Mvolo Democratic Republic of Congo Yirol West Mundri WestMundri East Maridi Juba Yei Lainya Bor South Awerial.34.3 Terekeka Kajo-Keji Morobo Melut Lafon Torit Magwi 3.45 Pageri Uganda Renk Ikotos Budi Pibor Kapoeta North Kapoeta South Ethiopia World Health Organization The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. 5 Kilometers Kapoeta East Kenya

11 Mortality Table 5 Mortality from IDSR reports countrywide W 7 COUNTY ABD <5yrs AWD 5yrs Malaria <5yrs Mayendit Aweil West Mundri East Aweil North Total deaths Total deaths <5yrs A total of six deaths were reported from the stable areas with three attributed to malaria and one to suspect cholera (Table 5). Total deaths 5yrs 3 5 Among the IDPs, Akobo, Juba 3, Wau PoC and Bentiu PoC submitted mortality data (Table 6). This week (); 7 deaths were reported including 3 (48%) in Bentiu PoC and 8 (3%) in children <5 years (Table 6). This week, complications related to Gun Shot wounds were the leading cause of mortality in IDPs. (Table 6). The U5MR in all the IDP sites that submitted mortality data in week of 7 were below the emergency threshold of deaths per, per day (Fig. ). Table 6 Proportional mortality by cause of death in IDPs W 7 Akobo Bentiu Juba 3 Wau PoC Proporti onate Cause of Death Grand mortalit by IDP site <5yrs 5yrs 5yrs <5yrs 5yrs <5yrs Total y [%] acute watery 9 diarrhoea 3 5 cardiac arrest 4 Chronic 4 diarrhoea Chronic Disease 4 malaria 7 pneumonia 7 Sepsis 4 Stroke 4 TB/HIV/AIDS 4 Unknown 3 3 Drowned 4 cholera 4 severe wasting 7 Cardiac arrest 4 Tetanus + STI 4 choronic illeness 4 Aneamia 4 Septicemia 4 Grand Total The Crude Mortality Rates [CMR] in all the IDP sites that submitted mortality data in week of 7 were below the emergency threshold of death per, per day (Fig. ). The other causes of mortality in the week are shown in Tables 5 and 6. Note: Mortality rates are calculated for PoC sites only and are based on the latest available population data from OCHA. They are reported from line lists and should include community and facility-based deaths. However, due to rapid in/out migration from the PoC sites, and possible under-reporting of community-level deaths, they should be interpreted carefully. Crude and under five mortality rates in IDPs deaths per, per day Figure EWARN U5MR by Site - W 6 to W of Bentiu Juba 3 Malakal Mingkaman Melut Akobo Wau Shiluk Threshold deaths per, per day Figure EWARN Crude Mortality Rate for W 6 to W of Bentiu Juba 3 Malakal Mingkaman Melut Akobo Wau Shiluk Threshold Wau PoC Overall mortality in 7 Table 7 Mortality by IDP site and cause of death W 7 IDP site acute watery diarrhoea malaria pneumonia Stroke TB/HIV/AIDS Bentiu 8 3 Juba 3 8 Akobo 3 Wau PoC 3 3 Grand Total 5 7 Proportionate mortality [%] cholera Cardiac arrest Tetanus + STI choronic illeness Aneamia Septicemia Others Grand Total A total of 7 deaths were reported in the IDP sites in Week, Most of deaths occurred in Bentiu PoC and Juba 3 PoC (Table 7). Among the priority AWD accounted for the highest proportionate mortality(8.5%) followed by Pneumonia. During Week, 3% of the deaths occurred in Children aged fiver years and below, the commonest causes of death were acute watery diarrhea and Pneumonia(Table 6 and 7)

12 Data sources This bulletin presents disease trends from the Integrated Disease Surveillance and Response (IDSR) System and the Early Warning Alert and Disease Network (EWARN). The respective data is submitted by public health facilities serving host communities (non-conflict affected states or non IDP sites) and partner-supported facilities serving internally displaced persons (IDP) in the Republic of South Sudan. Editorial Editorial: Dr. Alice L. Igale, Dr. Abraham Adut, Korsuk L. Scopus, Robert M. Lasu, Rose A. Dagama, Jane Pita, Dr. Patrick, R. Otim, Gabriel Waat, Dr. Allan M. Mpairwe, Dr. Joseph F. Wamala, Dr. John P. Rumunu Acknowledgements MoH and WHO gratefully acknowledge the support of all MoH staff in the states, WHO Field Officers, and implementing-health cluster partners in collecting and reporting the data used in this bulletin. Contact For more information, please contact: Department of Epidemics, Preparedness and Response MoH Republic of South Sudan Outbreak toll-free line using vivacell:44 This bulletin is produced by the Ministry of Health with technical support from the WHO Supported by the Global EWARS project