Cholera outbreak in Juba, Central Equatoria State. Situation Report (Sitrep No. 5) as at 18:00 Hours; 20 May 2014

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1 Cholera outbreak in Juba, Central Equatoria State Situation Report (Sitrep No. ) as at 18:00 Hours; 0 May 01 Summary statistics The Ministry of Health declared an outbreak of cholera on 9 May 01. Since then, several suspected cases have been recorded from different suburbs in at Juba Teaching Hospital. The table below summarizes the number of suspected and confirmed cases reported in Juba. No Summary of cases 18/0/01 19/0/01 0/0/01 1 New admissions today New deaths today 0 0 Cumulative cases Deaths since the onset of the outbreak Health Facilities Community Total number of cases currently admitted 81 9 Cumulative cases discharged Specimens collected today Total Samples shipped to AMREF, Nairobi Cumulative specimens collected Number of cases with lab. Confirmation: By culture Rapid pastorex Situation update Seventy-eight (78) new cases were admitted at cholera treatment centre (CTC) in Juba Teaching Hospital (JTH) on 0 May 01. A total of 8 cases were discharged on 0 May 01 leaving 9 patients on admission in the cholera treatment centre. Overall, a cumulative of cholera cases including six () health facility deaths and seven (7) community deaths (CFR.9%) have been reported since the onset of the outbreak on April 01. The majority of the reported cases 179 (7%) have been treated at the Juba Teaching Hospital (JTH) Cholera Treatment Centre (CTC). Cholera cases have been reported from six Payams in Juba county with the most affected being Northern Bari 10 (9%), Muniki (1%), Rejaf (9%), Juba 0 (11%), and Kator 1 (%). Payam Number of cholera cases by week Cases by Payam n (%) Week 17 Week 18 Week 0 Week 1 Northern Bari (9%) Muniki (1%) Rejaf (9%) Juba (11%) Kator (%) Gondokoro 0 0 (1%) Missing (%) Total by epiweek (100%) 1 7

2 The map below shows the geographical distribution of cholera cases in Juba since April 01.

3 Figure 1 shows the outbreak trends since the start of the outbreak on April 01. These trends show a common outbreak with increasing transmission in the affected communities. Assessment of risk factors is underway but preliminary results indicate that most people are drinking unboiled or untreated water from the River Nile. Number of cases 70 Cholera cases in Juba county, week 17 1 of Alive 19 0 Date and epidemiologic week of onset Community death 0/0/01 19/0/01 18/0/01 17/0/01 1/0/01 1/0/01 1/0/01 1/0/01 1/0/01 11/0/01 0/0/01 9/0/01 8/0/01 /0/01 /0/01 /0/01 0 1/0/ Health Facility death The histogram shows cholera cases by the date of the onset of illness. Therefore the number of new cases for any one date on the chart is less than the corresponding number of new cases admitted in the CTC since patients are delaying by - days to seek care. The majority of the reported cholera cases are males 11 (7%) in the 1- year age group 117 (%). Cholera cases by age, Juba week 18 1, Male Female <1 yr rs 10 rs 1 1 rs 1 0 rs rs 0 rs rs 0 rs rs 0 rs rs rs 0 +y rs Number of cases

4 The main risk factors for cholera in Juba are suspected to include the following: drinking of untreated river water which in Juba is primarily supplied by water tankers, poor latrine use, eating foods sold on the roadside and at makeshift markets. Poor personal hygiene practices (for example hand washing) and community hygiene, In addition, open defecation, consumption of water from unsafe sources such as surface water-river and ponds, poor community handling of dead bodies and unsupervised burials are other risk factors that increase the risk of the Juba community to contracting cholera. Cholera Alert reports: At least six () alerts of acute watery diarrhoea (AWD) (suspect cholera) outside Juba County have been reported to the Ministry of Health through the national taskforce. One alert came from Kaka military barracks in Manyo county, Upper Nile State, where at least 0 AWD cases including 9 deaths were reported on 19/0/01. The State Ministry of Health supported by IMA & UNICEF will travel to the barracks on 1/0/01 to investigate and support the immediate response. A preliminary MSF Spain assessment indicated the Kaka military facility lacked IV fluids, chlorine for disinfection and antibiotics. It is thought that as the water treatment plant in the area is non functional, the soldiers have been drinking untreated water straight from the Nile. A military barracks outside Panyagor in Bor reported at least 7 AWD cases including three () deaths over the weekend. A joint State MoH, WHO and UNICEF led by IMA travelled to the barracks on 0/0/01 to investigate the reports and support the initial response. A request for support has come from the Division commander Owiny Kibul in response to the increasing AWD cases in the barracks. In addition, two requests for support following reports of AWD have also come in from Esidu on Juba-Nimule road and Luri. These are being followed by Ministry of Health with support from the national taskforce in Juba. Response Actions Today Coordination The case management and surveillance working met to review the cholera response activities in Juba as well as the preparedness level in the other states reporting suspected cases of cholera. Discussions on how best the MoH can be supported by WHO and other partners in order to efficiently respond and control the outbreak took place. The outcomes of the meeting include; streamlining of staff supervision at the CTC in JTH, conduct refresher training for staff on case management, identify and conduct training for sprayers. Other outcomes are; follow up with on the release of ambulances for patient referrals, assign a team with an ambulance to handle dead bodies, follow up on suspected cases reported from Owinyi Kibul and Luri, provide

5 supplies to Kaka and conduct outbreak investigation, conduct investigation in Twic East and respond accordingly and provide estimated caseload and project for partners use. The Health promotion and education working group meeting was held with the participation of UNICEF, WHO, SSRC, chaired by the MOH. The outcome of the meeting is; three teams were formed to work the trained volunteers to ensure proper health education at community levels. The teams are composed of UNICEF, WHO, MOH and South Sudan Red cross. More partners are still required to join the teams. The State ministry of Health, Central Equatoria conducted a partners meeting involving NPA, OVCI, SSRC-CES, ART, UNICEF, Juba County, Medair and Magna to develop county level micro plans. Case management: (MOH, WHO and Medair) Medair and WHO continue to support the Ministry of Health with case management at the CTC in JTH. WHO continued to support with infection control at JTH CTC due to staff challenges and increasing case load. Medair is the lead agency on case management at the CTC. Social mobilization: (WHO, UNICEF, MEDAIR, SSRC, CES and ART): South Sudan Red Cross volunteers have initiated house-to-house sensitizations that covered 87 households. Soap and ORS demonstrations were conducted and distribution at household level done. UNICEF supported PSI, IMA, OXFAM and ACTED with posters to community use and display both at the Central and State levels. Radio campaigns are running in seven stations in languages (English, Arabic, Dinka, Nuer and Bari) covering Juba county. WASH: (UNICEF, Medair, OXFAM, PIN and NPA) Water quality monitoring and chlorination of water and provision of drinking water continued in Juba Teaching Hospital. 9 water quality monitors from Juba Urban Water Corporation were trained on water quality monitoring. UNICEF provided chlorine for the city council to support chlorination of water at the designated collection sites for water trucks. Solidarites conducted hygiene promotion and disinfection of latrines at UN House. ACTED set up additional hand washing stations in Tongping, conducted sensitization through video and recruited new Hygiene Promoters to immediately increase hygiene promotion efforts immediately. South Sudan Red Cross assessed the Mangalla barracks and will share the assessment report. UNICEF dispatched chlorine, megaphones, pool tester kit, buckets, water purification tablets, Jerry cans, soap and protective items to support the cholera response in Kaka, Upper Nile state. UNICEF and partners conducted a camp cleaning campaign in Tongping POC as part of cholera prevention activities.

6 UNICEF WASH joined an assessment team to Twic East County, Jongeli on a mission to assess investigate suspected cholera cases in the area. Surveillance and Laboratory: (WHO & MOH) WHO continued to support the Ministry of Health with the collection and analysis of patient descriptive and exposure data to inform the response. WHO team joined the team to Panyangor to investigate suspected cases of cholera reported in the area and, Continued to support partners with Carry Blair for sample collection from all areas that reported suspected cases. Current gaps: Arrangements should be made to provide food for patients admitted in the JTH CTC. Insecticide treated mosquito nets and blankets should be provided for the admitted cases. Community engagement is still limited. There is still no supervision of burials at the community level. In addition, the disinfection of dead bodies at the community level and patients households has not yet started. Planned activities The WASH Cluster is in the process of shipping cholera response supplies to various locations where suspected cases have been reported. WHO will provide technical support and training health workers in all areas where suspected cases have been reported. WHO will support the transportation of all collected samples to AMREF Nairobi for culture. Conclusion: All EPR working groups have started implementing their work plans. Additional partners continue to join the response. There is a risk of the outbreak spreading to other surrounding counties and villages if community interventions are not rigorously conducted. Plans and budgets for community level interventions have been developed, however their implementation is challenging due to financial constraints. From all indications, if community level interventions are implemented, the spread of cholera will be interrupted. For more information please contact: Dr. Pinyi Nyimol Mawien Director General Preventive Health Services Ministry of Health - Republic of South Sudan Tel: Dr Othwonh Thabo Ag. Director - Integrated Disease Surveillance and Response Ministry of Health - Republic of South Sudan Tel: