Creation date: 5 October 2017 Sources: Ministries of Health and WHO

Bulletin: Cholera/ AWD Outbreaks in Eastern and Southern AfricaRegional Update - as at 5 October 2017HighlightsMore than 102,814 cholera / AWD cases and 1551 deaths (Case Fatality Rate: 1.5%) have been reported in 11 of 21 countries of Eastern and Southern Africa Region (ESAR) since the beginning of 2017. These countries include; Angola, Burundi, Kenya, Malawi, Mozambique, Rwanda, Somalia, South Sudan, Tanzania, Zambia and Zimbabwe. Somalia accounts for 76.6% of the total cases reported in 2017, followed by South Sudan at 15.9%.

In the past 4 weeks (Week 36-39), 6 out of the 21 countries in ESAR have reported active transmis-sion of cholera / AWD (Burundi, Malawi, Somalia, South Sudan, Kenya and Tanzania), with Tanzania reporting the highest number of new cases (125) in week 38. Cumulatively, South Sudan has recorded the highest CFR (1.9%) followed by Kenya (1.8%) and Tanzania (1.7%) in 2017. CFR for Somalia was above 2% at the beginning of 2017 but has since dropped to 1.4%.

Somalia: There has been a slight increase in the epidemic trend. During week 38 (week ending 24 September 2017), 92 new cases were reported in the country; compared to 61 cases reported in week 37 (Week ending 17 September 2017). All the 92 new cases reported in week 38 emerged from Somali land. Most affected regions areTogdheer, Awdal and Mjeex.

Kenya: 5 out of the 47 Counties (Nairobi, Garissa, Vihiga, Nakuru and Machakos) have an active cholera outbreak. During week 38, 37 new cases including 1 death (CFR 2.7%) were reported compared to 49 cases reported in week 37.

South Sudan: A declining trend in cholera cases has been noted over the past 3 weeks. 3 Counties have active transmission (Juba, Budi and Kapoeta South). During week 36 (Week ending 10 September 2017), 18 new cases were reported; compared to 21 cases reported in week 35 (week ending 3 September 2017).

Tanzania: A decrease in epidemic trend was noted in week 38, 125 new cases including 1 death (CFR 0.8%) have been reported; compared to 236 cases including 1 deaths (CFR 0.4%) in week 37. New cases emerged from Tanga, Mbeya, Iringa, Kigoma and Songwe regions.

Malawi: Current outbreak started within the catchment area of the Chikwawa Hospital. 7 new cases have been reported in Week 39 (week ending 1 October 2017); compared to 12 cases in week 38.

Burundi: During week 38, 3 new cases were reported; compared to 4 cases in week 37. These cases emerged from the city center of Nyanza Lac (Makamba) and Bubanza province.

77,774

6

125

16, 372

19

2122

389

103 128

4

3223

92

2,99637

7

18

2,697

1

1 / 55 0 / 1118

0 / 305

3

4

1 / 45

191

South Sudan EthiopiaSomalia

KenyaUganda

Rwanda

Burundi

Tanzania

AngolaZambia

Malawi

Mozambique

Zimbabwe

BotswanaNamibia

South Africa

Lesotho

Swaziland

Madagascar

Eritrea

New cholera cases (last 1 week)2017 Cumulative cases

Cholera DeathsNumber of new cholera deaths (Week 38) / 2017 Cumulative deaths

Distribution of new cases: Week 36 to Week 39No data

No. of new cases reported in Week 36 - 39 1 to 500 cases > 500 cases

Legend

No outbreak reported in 2017

Table: Summary of Cholera / AWD Outbreaks by CountryCountry Start Date Cumulative no. of cases Cumulative no. of deaths StatusSomalia March 2016 93,474 1,666 OngoingTanzania August 2015 26, 697 417 OngoingSouth Sudan June 2016 20,547 386 OngoingKenya October 2016 3,096 59 OngoingMozambique January 2017 2122 4 ControlledZambia February 2016 1482 33 ControlledAngola December 2016 490 26 ControlledBurundi December 2016 223 0 OngoingMalawi March 2017 128 1 OngoingZimbabwe November 2016 16 4 ControlledRwanda January 2017 4 0 Controlled

11Countries

102,814 Cases

1551 deaths

1.5% CFR

Country Priorities and Response Interventions

-Strengthen coordination of cholera preparedness and response-Preposition cholera buffer stocks and other medical supplies -Enhance surveillance and case investigation at all levels -Improve adherance to case management and infection control protocols at treatment sites-Complementary use of safe and effective oral cholera vaccines in identified hotspot areas-Community Mobilization and hygiene promotion-Provision of WASH supplies

Country Priorities Response Interventions

South Sudan

-Increase access to adequate amounts of safe water and appropriate sanitation-Conduct cholera vaccinations in hotspot areas-Engage community based integrated emergency response team in early detection-Adopt standardized case management and infection prevention and control protocols -Provide integrated training in WASH and health at treatment sites-Provide infection control materials at treatment sites -Targeted regular water quality testing-Behaviour change that integrates WASH and Health messages-Orientation of food handlers to adhere to public health standards

Somalia

-Enhance multi-sector co-ordination through existing structures and resources-Strengthen district capacity for prompt case detection, confirmation and management-Ensure the availability of safe water and safe human waste disposal -Strengthen cholera prevention and health promotion in high risk areas

Kenya

1,800,000

817,221

72,000

49,000

17,600

2500

1073

70

70

No. of people reached with cholera prevention messages throughmass media, supported by UNICEF

No. of children 1-5yrs immunized with OCV btwn Feb and Aug 2017

No. of households reached with cholera prevention messages

No. of school children and teachers reached with cholera preventionmessages

No. of community leaders, food and water vendors reached withcholera prevention messages

No. of pastoralist reached with cholera prevention messages

No. of social mobilizers and hygiene promoters trained since end ofJune 2017

No. of cholera treatment centres operational

Proportion of cholera treatment centres supported by UNICEF

221,660

17,252

10,460

3,300

153

29

19

16

No. of people reached with safe drinking water byUNICEF

No. of households received WASH NFIs

No of households received water treatmentproducts

No. of people provided with access to safesanitation

No. of rehabilitated boreholes

No of participants from WASH partner organizationstrained by UNICEF on cholera prevention

No. of boreholes constructed

No. of latrine stances constructed

• UNICEF supported the Government with an Interagency Emergency kit that contains medicines and medical devices for 10,000 people

• 1,340 cholera cases have been treated in Nairobi County

• 4 CTCs are currently operational in Nairobi County

800,000

42,275

40,000

52

No. of people reached with cholera prevention andcontrol messages through IEC materials

No of AWD/Cholera patients benefitting frommedical kits and supplies provided by UNICEF

No of people expected to benefit fromprepositioned cholera medical kits and supplies

No of cholera facilities supported by UNICEF

• A planned epidemiological study on cholera hotspots and epidemiological basins in the East and Southern Africa Region (ESAR). The objective of the study is to gain a thorough understanding of the epidemiological information on cholera epidemics in the East and South Africa Region, with an initial focus on Horn of Africa basin (South Sudan, Kenya and Somalia) and the Zambezi Basin (Mozambique, Angola, Malawi, Zambia and Zimbabwe) • UNICEF, WHO and Government of Zanzibar are planning to develop a Multi-Sectoral Cholera Elimination Plan 2018-2027. The effort will be led by WHO and MoH with UNICEF supporting the community component

Upcoming Activities

Country Priorities and Response Interventions

-Prepositioning of cholera supplies-Training, supervision and mentoring of health workers in CTUs-Monitoring and maintaining adequate stock levels of cholera supplies in Chikwawa district-Orientation of health workers and district Teams (DHMTs) on data management-Ensure quality case management in CTUs -Conduct mass hygiene promotion and cholera prevention campaign in Chikwawa district-Conduct Oral Cholera Vaccine (OCV) Immunization in hot spot areas-Provide WASH supplies in CTCs, health centers, communities and schools-Construct appropriately located diarrhea /vomit disposal pits-Promote construction and use of community latrines through CLTS

Response interventions in Nyanza Lac include:

• Water tank of 10,000 liters with 4 taps provided in the CTC • Water trucking • Water supply system repaired • Social mobilization in the affected areas

Country Priorities Response Interventions

Malawi

Tanzania

-Improve case management -Improve water supply

Burundi

-Develop a cholera elimination plan for Zanzibar-Advocacy and partnerships for resource mobilization -Capacity building of medical personnel on cholera case management-Provision of critical supplies like chlorine products, ORS and IEC materials in most at risk regions-Social Mobilisation to prevent and control cholera- Follow up on construction of toilets

3000

2700

500

400

360

300

300

200

5

No. of ORS sachets provided

No of kg of chlorine (HTH) provided byWorld Vision and other partners

No of 100g bars of soap provided

No. of boxes of ringers lactate provided

No of 1kg bars of soap provided

No. of 20L buckets with tap provided

No. of 20L buckets without tap provided

No. of 60L buckets provided forhandwashing

No. of tarpaulins provided by UNICEF

• UNICEF has supported five regions with 2,112,000 water guard tablets, 1 Wagtech (Potatest+) field test kit and 40 boxes Jumbo agua tabs for bulky chlorination

• Medical supplies given include giving set, ringer’s lactate, gumboots and aprons

• UNHCR has contributed ORS to support Kigoma municipal council

The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

Creation date: 5 October 2017 Sources: Ministries of Health and WHO

Annex 1: Distribution of Cholera/AWD outbreaks in the Horn of Africa - 5 October 2017

117

Tana

1

1

GarissaKerichoNakuru

161794

Mombasa

1

5

4

29

Wajir

NarokRiver

Turkana

Sool

Banadir

Bari

Bay

Galgaduud

Gedo

Hiraan

Lower Juba

Lower Shabelle

Mudug

Nugaal

Sanaag

Togdheer

Awdal

Middle Shabelle

Central Equatoria

Eastern Equatoria

Jonglei

Unity

Lakes

WarrapUpper Nile

CFR: 16.7% Murang’aKiambuNairobi

2722

3084

5599

24852399

735

64239

790

12934

SomaliOromia

Amhara

South Sudan

EthiopiaSomalia

Kenya

Legend

Status of outbreakOutbreak containedOutbreak active

No outbreak reported

Cholera / AWD Cases

XXNew cases

Cumulative cases 2017

No data

Afar

Tigray

Beneshangul Gumuz

Gambela

SNNPR

7050

2587

656

Uganda

Addis AbabaHareri

Dire Dawa

491739

1684

4106

2491

5622

Bakool3880

14913

Western Equatoria

Western Bahr el Ghazal

Northern Bahr el Ghazal1

185

Kajiado

19

56

37

Siaya

Machakos

382

364338

12,052

131

52

13

22Kilifi

Vihiga

CFR: XX%: Calculated based on new deaths reported

4687

335

60 5474

Homa Bay

Kisumu

Siaya

- Sub-optimal coordination in responding to outbreaks- Limited resources such as water treatment chemicals- Limited capacity in response as majority of the Rapid Response Teams especially at county level are not trained on outbreak response- Limited resources for health promotion and community engagement- Insecurity in various parts of the country reporting cholera outbreak

Kenya: Challenges

- Insecurity in Bay, Bakol, Gedo and Lower Shabelle- Despite decreasing epidemic trend, drivers of the current epidemic include limited access to safe water and poor sanitation in IDP settlements in all the affected regions

Somalia: Challenges

- Inadequate funding for most of the WASH cluster partners to conduct outbreak response activities in Juba- Ongoing fuel crisis is likely to result to malfunctioning of water treatment plants- A significant section of the cholera affected populations are nomadic pastoralist and communities living in remote, hard to reach villages and cattle camps- Poor road networks and lack of phone connectivity in some affected areas- Unpredictable movement of cattle keepers- Prolonged conflict and insecurity- Population displacements into crowded IDP camps and islands with limited humanitarian access to optimize interventions

South Sudan: Challenges

The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

Creation date: 5 October 2017 Sources: Ministries of Health and WHO

Annex 2: Distribution of Cholera/AWD outbreaks in Southern Africa - 5 October 2017

303300

83Pwani

188

35816

215

Dodoma

CFR: 2.9%

108

7

52

Singida

Mbeya46

344140 Dar es Salam

MorogoroIringa

Kigoma

Dodoma

Mara

Tabora

Singida

Tanga

Rukwa

Unguja

1

Nsanje

Chikwawa

Mwanza

7108

19

Masvingo1

Manicaland4

Harare1

Nampula

597

Maputo 510

Tete1015

Cabinda 232

Zaire236

5Luanda

- Cross border movements between Mozambique and Malawi influence the evolution of outbreaks- Poor access to safe water- Low sanitation coverage- Poor hygiene practices especially hand washing with soap at critical times- Boreholes in Kasisi and Katunga locations are saline

Challenges: Malawi

- Some communities do not use the aqua tabs distributed to them because they dont like the taste and smell as well as misconception that the tabs might impair fertility- Inadequate access to safe water in most of the affected areas- Delays in outbreak surveillance and reporting leading to increased spread- Treatment of water by boiling or using aqua tabs is not a common practice to over 80% of households - Huge issues on water quality. Water from deep wells and pipelines has tested positive for vibrio cholerae - Low coverage on improved sanitation facilities and practicing open defecation in most of the affected areas- Rampant street food vending in Zanzibar

Challenges: Tanzania

- Continuous threat of transmission of cholera infections along the lower Congo River Basin that is shared by both Angola and the Democratic Republic of Congo - Limited stocks of RDT in Lunda Norte, where there is presence of refugees from DRC- Gaps in infection control in Soyo and Cabinda

Challenges: Angola

- Cross border movements between Burundi and DRC- Low Sanitation coverage- Insuffcient access to safe water in the city centre

Challenge: Burundi

Legend

Status of outbreak

Outbreak containedOutbreak active

No outbreak reported

Cholera / AWD Cases

XXNew cases

Cumulative cases 2017

CFR: xx% - Calculated based on new cases and deaths reported

Angola

South Africa

Tanzania

Burundi

Mozambique

Namibia Botswana

Zimbabwe

ZambiaMalawi Malawi

Rwanda

Rwanda

82Luapula21

Northern Province

2246

Katavi

Njombe10

Cibitoke 172

Bubanza

Bujumbura rural 2

8Makamba Province 1

27

2144

93

WesternProvince

4

Creation date: 5 October 2017 Sources: WHO / UNICEF Joint Monitoring Programme, Ministries of Health and WHO

Annex 3: An overlay of Sanitation Facilities and Number of Cholera/ AWD Cases and Deaths Reported between January and September 2017

6

19

2122

389

103

4

3223

77,774

92

2,99637

1287

16, 372

18

1252,697

1

1 / 55 0 / 1118

0 / 305

3

4

1 / 45

191

South Sudan EthiopiaSomalia

KenyaUganda

Rwanda

Burundi

Tanzania

AngolaZambia

Malawi

MozambiqueZimbabwe

BotswanaNamibia

South Africa

Lesotho

Swaziland

Madagascar

Eritrea

New cholera cases (last 1 week)2017 Cumulative cases

Cholera DeathsNumber of new cholera deaths (Week 36) / 2017 Cumulative deaths

Legend

0 to 25% 25 to 50% > 50%Percentage of population using unimproved sanitation facilities

South Sudan

Ethiopia

Somalia

KenyaUganda

Rwanda

Burundi Tanzania

Angola

Zambia

Malawi

MozambiqueZimbabwe

BotswanaNamibia

South Africa Lesotho

Swaziland

Madagascar

Eritrea

39%

15%13%

33%

50%36%11% 50%

11%

36%3%

60%8%

15%

17%

11%5%8%

76%

7%7%

59%

27%

30%

21%37%

12%

44%

17%9%

30%

10%14%

32%

44%

23%5%

36%

36%

44%

23%

27%6%

34%

11%5%

50%

62%14%

22%2%

14% 2%11%

34%

39%

73%17%

8%2%

10%9%20%61%

58%24%7%11%

24%

13%52%

11%

19%

15%60%

6%

31%

12%42%

15%

39%

24%11%

26%

Legend

Sanitation LadderBasic serviceSafely Managed Limited serviceNo service

Unimproved service

0 to 25% 25 to 50% > 50%Percentage of population using unimproved sanitation facilities

Sanitation ladder• Safely managedUse of improved facilities which are not shared with other households and where excreta are safely disposed in situ or transported and treated off-site• BasicUse of improved facilities which are not shared with other households• LimitedUse of improved facilities shared between two or more households• UnimprovedUse of pit latrines without a slab or platform, hanging latrines or bucket latrines• Open defecation / No serviceDisposal of human faeces in fields, forests,bushes, open bodies of water, beaches and other open spaces or with solid waste

3 of the 21 countries in Eastern and Southern Africa have over 50% of their population using unimproved sanitation facilities and they include; Tanzania, Ethiopia and Uganda. Cumulatively, Tanzania has reported 2697 cases since the beginning of 2017. Countries which have 25 to 50% of their population using unimproved sanitation facilities include: Somalia, Kenya, Burundi, Malawi, Mozambique, Zambia and Madagascar. Cumulatively, these countries have reported 83, 346 cases in 2017, and majority of these cases emerging from Somalia. 10 countries have less than 25% of their population using unimproved sanitation facilities, and mostly located in the Southern Africa region

Coverage of Sanitation Facilities Coverage of Sanitation Facilities and Cholera / AWD

Creation date: 5 October 2017 Sources: WHO / UNICEF Joint Monitoring Programme, Ministries of Health and WHO

Annex 4: An Overlay of Drinking Water Supply Systems and Number of Cholera / AWD Cases and Deaths Reported Between Jan and Sept 2017

6

19

2122

389

103

4

3223

77,774

92

2,99637

7128

16, 372

18

1252,697

1

1 / 55 0 / 1118

0 / 305

3

4

1 / 45

191

South Sudan EthiopiaSomalia

KenyaUganda

Rwanda

Burundi

Tanzania

AngolaZambia

Malawi

MozambiqueZimbabwe

BotswanaNamibia

South Africa

Lesotho

Swaziland

Madagascar

Eritrea

New cholera cases (week 36 to 39)2017 Cumulative cases

Cholera DeathsNumber of new cholera deaths (Week 38) / 2017 Cumulative deaths

Legend

Percentage of population using an unimproved water source1% to 10% > 20%11% to 20%

South Sudan

EthiopiaSomalia

KenyaUganda

Rwanda

Burundi Tanzania

Angola

Zambia

Malawi

MozambiqueZimbabwe

BotswanaNamibia

South AfricaLesotho

Swaziland

Madagascar

Eritrea

41%

16%19%

24%

56%20%

17%7%

79%

18%1%2%

19%

43%16%

22%

10%

29%

25%

25%

11%

58%9%

10%

23%

71%12%

16%1%

50%

3%

31%

16%

47%

14%

25%

14%

67%20%

10%3%

79%

6%5%10%

57%21%14%

8%

40%

19%

29%

12%

85%

10%2%

3%

50%30%

13%7%

68%7%10%

15%

50%

13%

24%

13%

61%6%

21%

12%

67%10%16%

7%

LegendPercentage of population using an unimproved water source

1% to 10% > 20%11% to 20%

Safely ManagedDrinking Water Ladder

Basic Service

Limited ServiceUnimproved

No service

Drinking Water Ladder• Safely managedDrinking water from an improved water source which is located on premises, available when needed and free from faecal and priority chemical contamination• BasicDrinking water from an improved source, provided collection time is not >30 minutes queuing• LimitedDrinking water from an improved sourcefor which collection time exceeds 30 minutes for a roundtrip including queuing• UnimprovedDrinking water from an unprotected dug well or unprotected spring• Surface waterDrinking water directly from a river, dam, lake, pond, stream, or irrigation canal

6%

33%

38%

15%8%

6 of the 21 countries in Eastern and Southern Africa have over 20% of their population using an unimproved water source and they include; Ethiopia, Somalia, Tanzania, Zambia, Mozambique and Madagascar. Of these countries, Somalia has recorded the highest number of cholera cases and deaths. Countries which have 11 to 20% of their population using unimproved water sources include; South Sudan, Uganda, Rwanda, Burundi, Eritrea, Angola, Zimbabwe and Lesotho. 5 of these countries (South Sudan, Rwanda, Burundi, Angola and Zimbabwe) have reported outbreaks in 2017.

Drinking Water Supply Systems Drinking Water Supply Systems and Cholera / AWD

Country Wk 1 to Wk 34

Week 35 Week 36 Week 37 Week 38 Week 39 2017 Cumulative Cumulative since the beginning of the outbreak

Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths CFR Cases Deaths CFR

Somalia 59,610 834 137 2 22 0 61 0 92 0 77,774 1118 1.4% 93,474 1,666 1.8%

Kenya 1,096 12 183 0 46 3 49 1 37 1 2996 55 1.8% 3096 59 1.9%

South Sudan 6,263 187 21 0 18 0 16,372 305 1.9% 20, 547 386 1.9%

Tanzania 2,347 33 116 3 148 1 236 1 125 1 2,697 45 1.7% 26,697 417 1.6%

Burundi 42 0 0 0 5 0 4 0 3 0 223 0 0 223 0 0

Malawi 103 1 2 0 2 0 2 0 12 0 7 0 128 1 0.8% 128 1 0.8%

Zimbabwe 6 3 0 0 0 0 0 0 0 0 0 0 6 3 50% 16 4 25%

Mozambique 0 0 0 0 0 0 0 0 0 0 0 0 2,122 4 0.2% 2,122 4 0.2%

Angola 374 16 0 0 0 0 0 0 0 0 0 0 389 19 4.9% 490 26 5.3%

Zambia 101 0 0 0 0 0 0 0 0 0 0 0 103 1 1% 1482 33 2.2%

Rwanda 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0% 4 0 0.0%

Uganda 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0% 0 0 0%

Madagascar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Comoros 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Swaziland 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0% 0 0 0%

Botswana

Eritrea

Lesotho

Namibia

South Africa

TOTAL 102, 814 1551 1.5 127,732 2596 2.0%

For further information Contact:

Georges Tabbal Ida Marie Ameda Maureen Khambira

Regional WASH Emergencies Specialist Health Emergencies Specialist Information Management Specialist Email: gtabbal@unicef.org Email: iameda@unicef.org Email: mkhambira@unicef.org

Annex 5: Weekly Reported Cholera / AWD Cases and Deaths for Countries in Eastern and Southern

Africa