Cholera in Juba, Central Equatoria State,

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1 Republic of South Sudan Cholera in Juba, Central Equatoria State, Republic of South Sudan Situation Report # as at 3:59 Hours, July 5 Situation Update As of July 5, a total of 53 cholera cases including 3 (CFR 5.%) have been reported from 5 villages in eight payams of Juba County (Table ). The initial cases were traced back to 8 May 5 in UN House PoC where the first cholera case was confirmed on June 5. Most of the cholera cases in Juba have been reported from New site followed by Gudele, Juba 3 PoC, Gumbo, and Gudele (Figure ). Table. Summary of cholera cases reported in Juba County, 8 May July 5 Reporting Sites New admisions New discharges New Total cases currently admitted LAMA* Total facility Total community Total Total cases discharged Total cases IMC UN House PoC clinic 3 39 Hai Referendum IDP clinic Juba Teaching Hospital Al Sabah Hospital Morobo clinic 3 Nyakuron PHCC Juba Military Hospital 5 5 Luri Military St. Kizito clinic Mauna Medical clinic Juba Prison MedAir Gumbo ORP 8 8 Gorom PHCC 3 Total *LAMA: LEAVE AGAINST MEDICAL ADVICE A total of new cholera cases were reported in Juba on July 5. o Juba Teaching Hospital reported 3 new cases while MedAir Gumbo ORP reported eight cases. o Most new cases reported on July 5 originated from Gumbo, Lologo and Gudele (Figure ). o Two new villages, Lupepe and Suk Juba, reported cholera cases for the first time. Figure : New cholera cases by residence on July Hai Amarat Kator Lologo Gudele Gudele Jebel Kujur Munuki Rock City Munuki Bk B Gudele Gurei New site gorom refugee camp Digala Gumbo Kor William Gezira Kondokoro Juba Kator Munuki Northern Bari Rejaf Gondokoro

2 Cumulatively, 53 cholera cases including 3 ( facility and 3 community) have been reported since the initial case was reported in Juba on May 5 ( Tables and ). Of the 3, ( %) have occurred in children under five years. The age-specific CFR among children under five years of age is 9.5%, which is higher when compared to the age-specific CFR of 5.5% among cases aged five years and above. Table : New cholera cases by facility and week in Juba, 8 May July 5 New cases by epidemiological week of 5 Reporting Facility 3 5 Grand Total Al Sabah hospital Hai referendum IDP clinic JTH IMC UN House PoC clinic 9 3 Juba Military hospital 5 5 Morobo clinic 3 Nyakuron PHCC Luri Military St. Kizito clinic Mauna Medical Clinic Juba Prison MedAir Gumbo ORP 9 Gorom PHCC 3 3 Grand Total As seen from Figure, the initial and isolated cases were reported from UN House PoC starting on May 5. However, following epidemiological investigations on May 5, cases could be traced back to 8 May 5. Cholera was eventually confirmed on June 5 after Vibrio cholerae inaba was isolated from the one of five samples tested in the National Public Health Laboratory. Since June 5, sustained and consistently increasing community transmission has been established with increasingly more suspect cases reported outside UN House PoC. There are three discernible transmission peaks with the initial peak of 5 cases occurring on 3 June 5 while the subsequent and higher peaks occurred on June, June, and 8 June with, 9, and 5 cases respectively (Figure ). Figure : Epidemic curve for suspect cholera cases in Juba, 8 May July Investigation and confirmation of initial case in UN house PoC Confirmation of initial case in UN house Poc Alive Date of onset Died 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; eating food from unregulated roadside food vendors or makeshift markets; and open defecation/poor latrine use.

3 Figure 3: Spot map for suspect cholera cases by residence in Juba, 8 May July 5 As of July 5, the sites reporting the majority of cases in Juba include New site, Gudele, Juba 3 IDP, Gumbo, and Gudele. Nonetheless, there are satellite cases distributed in eight payams and 5 villages in Juba County (Figure 3 and ). Figure : Cholera cases by residence in Juba, 8 May July Juba Nabari Juba Korobou Hai Jalaba Hai Zendia Makas Sabab Juba Prison Hai Soura Hai Commercial Suk Juba Hai Kosti 3 Lologo Giada Suk Sita Atlabara A Bongoroke 3 Munuki Mauna Luri Nyakuron Dar es Salam Hai Kuwait Juba Kator Munuki Northern Bari Rejaf Lokiliri Gondokoro Mia Sava Hai Seminary New site Walawalak Gurei Gorom Hai Referendum Jebel Lado Gumbo Mijiki Checkpoint Kor Romula Jebel Yesua Nesitu Kondokoro Out of the 5 suspect cholera cases with known age, 8 (3%) were children less than five years of age, while (8%) were individuals five years and above (Figure 5). 3

4 Figure 5: Suspect case distribution by age in Juba, 8 May July 5 3% <5Yrs 5+Yrs 8% Out of the 5 cholera cases with known gender, (%) were female, while 3 (%) were male (Table 3). Table 3: Case distribution by gender and age in Juba, 8 May July 5 Gender and age N (%) Female 9 (39) <5yrs 8 5+yrs 9 Male 3 () <5yrs 5+yrs 9 Grand Total 559 () Laboratory updates Table : Cholera laboratory test results for Juba, 8 May July 5 Health Facility Number of RDT tests Number of cholera RDT positives Number of stool cultures Number of cholera Culture positives Al Sabah hospital Juba Teaching Hospital 33 3 Juba 3 PoC clinic 9 Juba Military Hospital Morobo clinic Gorom PHCC Total As seen from Table, 5 (%) of the samples have been RDT positive while 33 (%) have been confirmed by culture after Vibrio cholerae inaba was isolated by the National Public Health Laboratory. Most of the culture confirmed cases have been reported from Juba 3 PoC and New site (Figure ). Of the five samples sent for culturing from Bor State Hospital three have returned Vibrio cholerae positive results. The serotype is not indicated.

5 Figure : Number of culture positives by residence in Juba, 8 May July Table 5: Cholera Alerts 3 to July 5 Date of Details of the alert Area Action notification -July-5 Four acute watery diarrhoea cases including one death Bele village, Bungu - Four acute watery diarrhoea cases including one death reported from Bele village. reported from Bele village in Bungu Payam, Juba. Payam, Juba - Initial cases in this cluster developed severe diarrhoea at a funeral in Bele village and were rushed to Juba for treatment. - One death occurred in the night of July 5 and was buried on July 5. 3-Jun-5 -Jun-5 -Jun-5 -Jun-5 5-Jun-5 Kabigiri PHCC in Wonduruba Payam in Juba County admitted four acute watery diarrhoea cases on 3 June 5. Community death following acute watery diarrhoea was reported in Juba Prison. Nineteen suspect cholera cases reported in Kajo Keji Civil Hospital Bor State Hospital reported suspect cholera cases including one death from Malou area. Two suspect cholera cases reported from Torit State Hospital Kabigiri PHCC, Wonduruba PHCC - Cluster verified by the county rapid response team. - The four cases are admitted in Kabigiri PHCC. - Initial case travelled from Juba on 8 June 5. - Four samples collected and shipped to Juba. - Case management ongoing. Juba Prison - Case verification and supervised burial conducted by the state rapid response team. Kajo Keji, CES Bor, Jonglei State - A total of 9 acute watery diarrhoea cases have been line listed with eight cases on admission at the hospital. - Ten samples shipped to Juba for culture and sensitivity. - suspect cholera cases including one new death have been reported in Bor. - Out of the suspect cholera cases, have been discharged and are still hospitalized in the cholera treatment centre setup by MSF in Bor State Hospital. - New cases reported from High Machor, km from to the index village of Malou. - Five stool samples shipped to Juba for microbiological culturing. - Supplies including Carry Blair, RDTs, and case management kits dispatched to Bor. - Epidemiological investigation undertaken by the state rapid response team. - Preparations are underway to deploy the national rapid response team to support the ongoing response led by the state Ministry of Health. Torit, EES - Three stool samples collected and received in Juba on June 5. - Refresher training on cholera conducted for the state hospital healthcare workers. - Temporary isolation for at least patients set up in Torit State Hospital. - 5

6 Since 5 June 5, at least six 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 5. Planned activities. The next national cholera taskforce meeting is scheduled for Monday July 5 at : am in the Ministry of Health Ministerial Boardroom.. The next cholera coordination meeting in UN House PoC is scheduled for 9 July 5 at :3 am in the RRP Boardroom. 3. A training of trainers training has been organized by the communications-working group and will run from to July 5 in Juba. Trainees will be expected to sensitize home hygiene promoters in all the high risk states on cholera prevention, active case finding and reporting, and prompt initiation of cholera treatment. Interested partners should contact: amachuol@unicef.org.. The national rapid response team (RRT) will be deployed to Bor week of to July 5 to support the ongoing response led by the State Ministry of Health. 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_@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: +9555