Situation Report #117 on Cholera in South Sudan As at 23:59 Hours, 21 April 2017

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1 Republic of South Sudan Situation Report #117 on Cholera in South Sudan As at 23:59 Hours, 21 April 2017 Situation Update Cholera has been confirmed in Mayom and Kodok after one of two samples in each of the locations tested positive for Vibrio cholerae on 20 April A total of 18 counties in 10 (31%) of 32 states countrywide have confirmed cholera outbreaks (Table 1; Figure 1.0). During week 16 of 2017, eight samples from Duk (6), Mayom (1), and Kodok (1) tested positive for Vibrio cholerae (Table 3). Cumulatively, 218 (38%) samples have tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 21 April 2017 (Table 3). Table 1: Summary of cholera cases reported in South Sudan as of 21 April 2017 New admissions WK 16 New discharges WK 16 New deaths WK 16 Total cases currently admitted County Juba ,018 2,045 Duk Bor Terekeka Awerial ,026 Yirol East Yirol West Pageri Ayod Fangak Rubkona ,167 1,176 Mayom Leer Panyijiar Mayendit Pigi Kodok Malakal Total ,490 6,774 Highlights in week 16 of 2017: 1. Cholera confirmed in Mayom and Kodok after one of two samples in each of the locations tested positive for Vibrio cholerae Table In week 16, cholera cases were reported from Awerial, Yirol East, Yirol West, Ayod, and Kodok Table The counties with active cholera transmission are Yirol East, Yirol West, Awerial, and Ayod Figure A new cluster of suspect cholera cases reported in Tar cattle camp near Pagil in Ayod Table The transmission in Awerial (Dor), Yirol East (Tharnuar), and Ayod (Buol and Tar) is largely attributed to disease spread in affected cattle camps. 6. Oral rehydration points and/or mobile teams have been deployed to respond to cholera cases in affected cattle camps. The communication strategy has been updated accordingly. Total facility deaths Total community deaths Total deaths Total cases discharged Total cases 1

2 Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 15 April 2017 As seen from Figure 1, while cholera outbreaks have been confirmed in 18 counties, active transmission is currently ongoing in Yirol East, Yirol West, Awerial, and Ayod. Suspect cholera cases are being investigated in Tar cattle camp, Ayod. Figure 1.1: New cholera cases admitted by location in week 15 and 16 of 2017 Number of Cases week 15 week Awerial Yirol East Yirol West FANGAK Ayod Kodok Eastern Lakes Fangak Fashoda Total by week 2

3 Figure 1.2: Cumulative cholera cases by state and county of residence as at 21 April , Number of Cases , , Terekeka Leer Mayendit Panyijiar Rubkona Mayom Juba Bor South Duk Pageri Kodok FANGAK Ayod Awerial Yirol East Yirol West Pigi- canal Malakal Terekeka Southern Liech Northern Liech Jubek Jonglei Imatong Fashoda Fangak Eastern Lakes Central Upper Nile Grand Total , Table 1.1: Cholera cases and deaths by state and county as of 21 April 2017 State County Population at risk Week 16 Weeks 24, 2016 to 16 of 2017 New cases W16 Cases per 10,000 population No. cases Cases per 10,000 population Fangak Fangak 168, Fangak Ayod 204, Northern Liech Rubkona 126, Northern Liech Mayom 191, Southern Liech Leer 95, Southern Liech Panyijiar 78, Southern Liech Mayendit 97, Eastern Lakes Awerial 114, Eastern Lakes Yirol East 104, Eastern Lakes Yirol West 155, Imatong Pageri 215, Jonglei Bor South 331, Jonglei Duk 96, Jubek Juba 579, , Terekeka Terekeka 209, Central Upper Nile Pigi 1, Fashoda Kodok 59, Central Upper Nile Malakal 214, Total 3,195, , Cumulatively, 6,774 cholera cases including 221 deaths (70 facilities and 151 community) (CFR 3.25%) have been reported in South Sudan involving 18 counties in 10 states since the initial case was reported on 18 June 2016 for Jubek state; 3 rd July 2016 for Duk in Jonglei state; 14 July 2016 for Terekeka state, 15 August 2016 for Mingkaman in Eastern Lakes and Pageri in Imatong states; 10 August 2016 for Fangak in Western Bieh state; 29 CFR [%] 3

4 September 2016 for Rubkona in Northern Liech state; 11 October 2016 for Leer; 22 October 2016 for Panyijiar in Southern Liech state; 10 October 2016 for Pigi in Central Upper Nile state; 7 October 2016 for Mayendit in Southern Liech state; 30 January 2017 for Bor South in Jonglei state; 3 February 2017 for Yirol East in Eastern Lakes state; 22 February 2017 for Malakal, in Central Upper Nile state; and 8 April 2017 for Ayod (Figure 2.1 and Table 1.1). Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 21 April Number of cases CFR [%] Epidemiological week of onset Jonglei Jubek Terekeka Imatong Eastern Lakes Fangak Northern Liech Southern Liech Central Upper Nile CFR[%] The case spike in week 13 is attributable to cholera outbreak in Mamour cattle camp in Duk which at the time was camped in a swampy area where the herdsmen sought water and pasture for their cattle Figure 2.1. Figure 3:1 Cholera case distribution by gender and county 21 April % Cholera case gender distributionby IDP site wk 27 of 2016 to week 16 of % Sex distribution % 80% 70% 60% % 40% % 20% 10% % Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Yirol East Malakal Overall Female Male 4

5 Overall, males and females are almost evenly Figure 3.1. The gender distribution of cholera cases by county is shown in Figure 3.1. Figure 3:2 Cholera case distribution age in South Sudan 21 April Cholera case age distribution by wk 27 of 2016 to week 16 of Age in Years5 <5yrs 5-9 yrs 10-14yrs 15-19yrs 20-24yrs Age distribution % 25-29yrs 30-34yrs 35-39yrs 40-44yrs 45-49yrs -54yrs 55-59yrs 60-64yrs 65-69yrs Children under 19 years constitute 72% of the total cholera cases Figure 3.2. The age distribution of cholera cases by county is shown in Figure 3.3. Figure 3:3 Cholera case distribution by age and county in South Sudan 21 April % Cholera case age distributionby IDP site wk 27 of 2016 to week 16 of % 80% 70% Age distribution % 60% % 40% 30% 20% 10% 0% Awerial Bor South Duk FANGAK Juba Leer Mayendit Pageri Panyijiar Pigi- canal Rubkona Terekeka Yirol East Malakal <5yrs 5-9 yrs 10-14yrs 15-19yrs 20-24yrs 25-29yrs 30-34yrs 35-39yrs 40-44yrs 45-49yrs -54yrs 55-59yrs 60-64yrs 65-69yrs 70+yrs Probable risk factors The probable risk factors fueling transmission include: using untreated water from the River Nile and water tankers; lack of household chlorination of drinking water; eating food from unregulated roadside food vendors or makeshift markets; open defecation/poor latrine use especially following the conflict. Other factors 1. Due to the protracted nature of the crisis since 2013, there has been destruction of infrastructure and limited investments to improve social services to the general population as such, living conditions have deteriorated with declining access to safe water and sanitation amenities. 2. Due to the worsening, economic situation, the cost of accessing safe water from the water trucks has increased substantially thus forcing households to resort to unsafe water sources. 3. In Southern Liech, humanitarian access remained limited due to persistent hostilities that kept away partners and thus impeding the initiation of comprehensive and sustained cholera interventions to interrupt transmission and prevent widespread and protracted outbreak. Consequently, transmission has continued in 5

6 Southern Liech since late September 2016 with continued case spillovers to Bentiu, Panyijiar, Awerial, and Bor South. 4. While WASH partners have endeavoured to improve access to safe water and sanitation in Bentiu PoC; the continued arrival of people into the PoC has remained a challenge. In addition, current transmission in Bentiu PoC is linked to an oxidation water pond that is being used for bathing, washing, swimming and sometimes to collect water for household use since its water is soft and considered more palatable by the local population. The pond therefore needs to be secured-off to stem the ongoing transmission and to prevent future outbreaks. Table 3: Cholera laboratory test results for Juba by 21 April 2017 State Culture results New positives in week 16 Cumulative Cumulative Negative Total tested Positive Central Upper Nile Jonglei-Duk Jonglei-Bor South Jubek Terekeka Eastern Lakes - Mingkaman Eastern Lakes Yirol East Imatong Fangak Fangak Fangak Ayod Wau Boma Northern Liech Rubkona Northern Liech Mayom Southern Liech Leer Southern Liech - Panyijiar Southern Liech Mayendit Fashoda Kodok Central Upper Nile (Pigi) Central Upper Nile (Malakal) Total tested Table 4: Cholera Alerts Notification Details of the alert date No alerts Area Action 19-Apr-2017 MedAir team based in Pagil reported over 700 suspect cholera cases reported from Tar cattle camp - 9 hours walk from Pagil Tar cattle camp, Ayod - MedAir rapid response team deployed to set up CTC and manage cholera cases in Tar cattle camp - Over 700 already treated by mobile team from Apr Cholera Response Activities Overall coordination of the cholera response at the national level is coordinated by the National cholera taskforce to review outbreak trends and progress of implementation activities. Sub-national cholera taskforce committees are coordinating the cholera response in Northern and Southern Liech, Yirol East, Mingkaman, Bor, Duk, Ayod, and Malakal Town. Since mid-february 2017, there have been increasing reports of suspect cholera cases in cattle camps. As pastures reduce and seasonal water streams dry up during the dry season; the cattle camps gravitate and 6

7 converge on the remaining water sources usually in the swampy areas along River Nile and other rivers where they use and share the same water with the animals and use the same water for defecation. In the circumstances, when a cattle camp stumbles on water contaminated with the cholera bacteria; the transmission rates as seen from the cases and death rates can be high. The affected cattle camps include Guthom in Yirol East, Jalle in Bor; cattle camps in Awerial near Mingkaman, Mamour in Duk-Padiet; Buol cattle camps in Ayod, Torch cattle camps along River Kier in Ayod, Tar cattle camp in Ayod, and other cattle camps near Pagil in Ayod. The transmission in Awerial (Dor), Yirol East (Tharnuar), and Ayod (Buol and Tar) is largely attributed to disease spread in affected cattle camps. Oral rehydration points and/or mobile teams have been deployed to respond to cholera cases in affected cattle camps. The communication strategy has been updated accordingly. Complementary oral cholera vaccination At least 43,197 individuals one year and above received OCV in Leer, Malakal Town, and Bor PoC in Reactive oral cholera vaccination is slated for the week of 24 April 2017 in Mingkaman IDP settlement and the week of 15 th May 2017 for Bentiu PoC. Social mobilization activity updates As part of mass media, UNICEF, WHO, MoH and partners continue with radio messaging through 13 FM stations in Malakal, Awerial, Yirol and Bentiu PoC site, where active transmission of cholera is still ongoing. During the week (12-19 April 2017), 978 radio jingles, 3 talk-shows have been aired. This brings to cumulative a total of 21,414 radio jingles, 16 talk-shows and 3 interviews being aired and reaching an estimated of 1.4 million people nationwide. The 13 radio stations engaged include; Spirit FM (YEI), Bakhita FM, City FM, Radio One, Classic FM, Dream FM, Liberty FM, Jonglei FM, Mingkaman FM, Freedom Voice Torit, Eye Radio and Radio Miraya. Ministry of Health in collaboration with telecom companies Zain and Vivacell continue to broadcast cholera key messages through bulk-sms with their subscribers. Additionally, the Cholera hotline (1144) has been activated and is currently responding to all calls as well as educating callers on cholera signs and symptoms. Social mobilization Cholera Response in Jonglei State, Eastern Lakes and Bentiu In Jonglei, UNICEF in partnership with Community Development Organization Network CNDF, through 70 trained social mobilizers have reached 2,597 households (15,582 individuals) this week. This brings to a cumulative total of 9,981 households (51,452 individuals) reached with cholera prevention and control key messages in Bor town, Jalle, Twic East and Duk counties. The trained social mobilizers have also undertaken other community engagement activities reaching a total of 54 schools with 12,977 pupils, 48 water point sessions with 3,401 people including water vendors and 2,128 people community leaders inclusive of local chiefs, religious and women and youth leaders sensitized on knowledge of cholera signs and symptoms for early reporting and referrals. In Northern part of Jonglei, UNICEF supported C4D partner Fangak Community Development Initiative (FCDI) have kicked off social mobilization activities in cholera hotspots areas in Fangak and Ayod. This week, 30 trained FCDI social mobilizers have reached 345 households (2,070 individuals), 6 schools with a total of 671 children, 4 people through market and water point sessions. In Eastern Lakes State, UNICEF supported C4D partner CHADO, in collaboration with County Health Department (CHD) this week have reached 663 households (3,978 Individuals) through 32 trained community volunteers. This brings the cumulative to a total of 16,606 households educated on cholera and diarrheal disease prevention and control. Furthermore, 61 schools and 11,872 pupils benefitted from school based interventions and 130 market sessions reached 4,026 people including food vendors. Additionally, 127 water point sessions reached 4,640 people including water vendors and 5,171 individuals benefitted from 85 community meeting in Awerial County including Mingkaman IDPs and Gut-thom. In Bentiu POC, UNICEF C4D in partnership with UNIDO reached 122 households and 8 schools (4613 children) with cholera/awd prevention and control key messages. The volunteers also conducted health education sessions in market and water points reaching 12,572 people. 7

8 Wash cluster response highlights Additional WASH supplies sent to DUK, WASH cholera response is carried by CRS and UNICEF. CMD continue to lead the response in Ayod- WASH supplies will be flown on 22nd April to the key locations in Ayod County World Vision, Solidarite International, IOM and Cordaid are in Kodok to facilitate the implementation of the WASH response to the cholera cases. Fangak, response hampered due to poor security. ACF, Nile Hope, ADA, ZOA present. PAH distributed WASH supplies as part of the EP and R Response in some of the location in Fangak in the last few months but we are exploring the locations which are left out. Lakes, Awerial County- Cholera cases coming from cattle camps and host communities, are being addressed by RUWASSA, HELP but more support is needed. Yirol East and West; The WASH response has HELP as partner and requires more support of WASH partners. IOM staff were shot in that region and therefore WASH partners are finding it tough to mobilize. Wash Jonglei updates IAS is supporting the implementation of WASH activities in Bor PoC while AAID is implementing hygiene awareness, sanitation and water chlorination, on each island of the 17 islands hygiene promoters have been deployed. UNICEF WASH section and Partners did disinfection exercise in both CTC and ORP of which both patients, co-patients and visitors plus health workers are disinfected using 0.2% active chlorine for feet and 0.05% active chlorine solution for washing hands. Oxfam distributed cholera kits to 1,329 HH in 7 islands of Twic East and Bor County. 6,645 individuals reached with Hygiene messages. Oxfam trained 9 schools (90 participants) in Bor County with WASH components. Oxfam did cleaning campaign in Bor Market and distributed wheelbarrows, gumboots, gloves, spades and mask for the upkeep of sanitation and level of hygiene in the market. Bor Municipality and SMC doing disinfection of travelers at the Bor docking site and giving of health education messages on cholera at the river side. UNICEF completed drilling of 5 boreholes in Duk, trained disinfection team of 4 in Padiet and 2 in Amiel. Reached 3 people in Mareng with cholera response messages. At least 300 individuals were reached with mass disinfection (feet and hand washing) in Poktap and discharged patients were given health education. Planned Activities/recommendations 1. The next weekly EPR/cholera taskforce meeting is scheduled for 26 April 2017 starting 2:00pm in the WHO Conference Hall. 2. Roll out a comprehensive integrated response including oral cholera vaccination in response to the cholera outbreak in Malakal Town, Bentiu PoC, Mingkaman IDPs, and Bor PoC. 3. Continue with the ongoing response to the outbreaks in Mingkaman, Yirol East, Bor, Southern Liech, Northern Liech, and Pigi/Malakal Town in Central Upper Nile states. 4. Develop tailored strategies for cholera prevention and response in affected and at-risk cattle camps. 5. Implement reactive oral cholera vaccination during the week of 24 April 2017 in Mingkaman IDP settlement and the week of 15 th May 2017 for Bentiu PoC. 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: 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_2007@yahoo.com, The Toll-free number for Vivacell calls is: Contacts For more information, please contact Dr. Pinyi Nyimol Mawien Director General - Preventive Health Services MoH, Republic of South Sudan Tel: Dr. Alice Igale Ag. Director - IDSR MoH, Republic of South Sudan Tel: