1

Republic of South Sudan

Situation Report #104 on Cholera in South Sudan As at 23:59 Hours, 20 January 2017

Situation Update Cholera outbreaks have been confirmed in 9 (32%) of 28 states countrywide. The affected states include Imatong, Eastern Lakes, Jubek, Terekeka, Jonglei, Western Bieh, Northern Liech, Southern Liech; and Eastern Nile (Table 1 and Figure 1.0). Suspect cholera cases were reported in Mayendit and Ayod but are not confirmed (Table 4). One sample collected by MedAir from Madol 1CTU in Mayendit tested negative for cholera by culture in week 2, 2017. Cumulatively 150 (35.7 %) of the samples tested positive for Vibrio Cholerae inaba in the National Public Health Laboratory as of 20 January 2017 (Table 3).

Table 1: Summary of cholera cases reported in South Sudan as of 20 January 2017

Highlights in week 2 of 2017: 1. A total of 35 cases reported from Bentiu PoC in week 2 of 2017; compared to 86 cases in week 1 of 2017

Table 1, Figure 1.1. 2. Five cases reported in UN House PoC in week 2 of 2017 compared to 23 cases in week 1 of 2017 Table 1. 3. A total of 23 cases reported from Panyijiar in week 2 of 2017 compared to 40 in week 1 of 2017 Table 1,

Reporting Sites

New

admission

s WK 2

New

discharges

WK 2

New

deaths

WK 2

Total

cases

currentl

y

admitte

d

Total

facility

deaths

Total

communi

ty deaths

Total

deaths

Total

cases

discharge

d

Total

cases

Jubek – Juba 5 40 - 1 8 19 27 2,015 2,043

Jonglei-Duk - - - - 5 3 8 84 92

Terekeka - - - - - 8 8 14 22

Eastern Lakes -

Awerial - 1 - - 1 3 4 349 353

Imatong - Pageri - - - - - 1 1 28 29

Western Bieh -

Fangak - - - - 4 - 4 266 270

Northern Liech -

Rubkona 35 36 - 30 7 2 9 920 959

Southern Liech -

Leer - - - - 3 - 3 88 91

Southern Liech -

Panyijiar 23 - - - 10 2 12 362 374

Eastern Nile -

Pigi 5 5

163 168

Total63 77 - 31 43 38 81 4,289 4,401

2

Figure 1.1. 4. There were two culture positive cases from Awerial and two positive cases from Bentiu PoC during the

week. One sample from Madol in Mayendit tested negative for cholera by culture Table 3. 5. At least 48 suspect cholera cases reported in MedAir CTU in Madol 1, Mayendit, Southern Liech since 7

Jan 2017 Table 4. 6. Overall; active transmission is ongoing but declining in Northern Liech (Bentiu PoC) and Southern Liech

(Leer and Panyijiar); and Jubek (UN House PoC) Figure 2.1.

In Jubek, there has been resurgence of cases in UN House PoC where at least 41 cases including 10 confirmed cases have been reported since week 52 of 2016. The majority, 39 (95%) of the cases from the recent wave of cases in UN House PoC originated from PoC 3. In response to the resurgence, a multi-cluster investigation mission was undertaken during the week. Thus, response efforts have been enhanced in UN House PoC with the WASH cluster carrying out spraying of the latrines and random quality water testing and reactivation of ORPs. In addition, HHPs have been deployed to carry out hygiene promotion. There are plans to open additional ORPs in PoC 3 and to deploy mobile communication teams in the two PoCs. In Northern Liech state, 959 cholera cases including 24 confirmed cases and nine deaths (CFR 0.85%) were reported in Bentiu Town/PoC since 29 September 2016. The cholera taskforce, chaired by MoH and constituted by Health and WASH cluster partners is coordinating the response. Ongoing transmission is suspected to be associated with exposure to an unsecured water reservoir whose water is used for washing, bathing, swimming, and occasionally for domestic use. Bentiu PoC now has the highest cumulative incidence for cholera Table 1.1. In Southern Liech, two cholera cases originating from Leer Town tested positive for Vibrio cholerae Inaba on 11 October 2016. One additional case from Ganyliel in Panyijiar tested positive for cholera on 3 January 2017. Cumulatively, 91 cholera cases have been line listed from Leer and at least 374 cases including 12 deaths from Panyijiar in Southern Liech state. The initial case in Panyijiar was seen on 22 October 2016 involving a trader from Duk. Facility and community based response is ongoing with most cases being managed in facilities like Duong PHCC, Ganyliel PHCC, and Nyal PHCC with support from IRC, and UNIDO. Since 7 October 2016, at least 142 suspect cholera cases including three deaths were reported by UNIDO and MedAir response teams in Mayendit. The MedAir CTU in Madol 1 has seen at least 48 cases since 7 January 2017. Figure 1.0: Cholera incidence (cases per 10,000) and case fatality rate (%) as of 20 January 2017

Sudan

Ethiopia

Kenya

Uganda

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.

0 100 20050

Kilometers

Cholera Fatality Density Map for cases per population and CFRWeeks 24, 2016 to 2 of 2017

Central African Republic

8.7

36.36

Map Date: 18, January 2017

6.52

River

Legendxx Case fatality rate (CFR)

Counties with Cholera alert

Cases per 10,000 population

40.1 - 5020.1 - 4010.1 - 20

5.1 - 10

0.1 - 5

No case reported

Democratic Republic of Congo

Raga

Pibor

Wau

Juba

Lafon

Uror

Ayod

Wulu

Ibba Kapoeta East

Yei

Ezo

Baliet

Renk

Abyei

Maban

Duk

Tambura

Akobo

Bor South

Torit

Melut

Nagero

Maridi

Budi

Nyirol

Terekeka

Yambio

Pariang

Nzara

Tonj North

Fangak

Pochalla

Mvolo

Twic

Aweil CentreKoch

Guit

Magwi

Cueibet Twic East

LongochukAweil East

Awerial

Mayom

Yirol East

Ikotos

Aweil North

Maiwut

Yirol West

Jur River

Manyo

Ulang

Tonj South

Panyijiar

Lainya

Panyikang

Tonj East

Mundri West

Aweil West

Mundri East

Fashoda

Rubkona

Kapoeta North

Leer

Gogrial EastLuakpiny/Nasir

Gogrial West

Mayendit

Rumbek North

Kajo-Keji

Rumbek East

Rumbek Centre

Abiemnhom

Morobo

Aweil South

Malakal

Kapoeta South

Pageri

1.48

1.31

3.45

1.34

Pigi2.980.85

4.26

3

Figure 1.1: New cholera cases admitted by location in week 2 of 2017

In Eastern Lakes state, cholera cases were reported in Mingkaman IDP settlement. The initial cases were confirmed on 24 August 2016, after two of four samples tested postive for Vibrio cholerae Inaba. The cumulative cases are 353 cholera cases including 19 confirmed cases and 4 deaths (one facility and three community) (CFR 1.13 %). This outbreak has been controlled with only sporadic cases being reported – the most recent being admitted on 16 December 2016. In Jonglei state, 92 suspected cholera cases including 8 deaths (CFR 8.7 %) were reported from Duk County involving mainly the three Islands of Kawer, Long, and Moldova. The index case was reported on 3rd July 2016 from Moldova Island. Of the five samples from Duk Islands that underwent culturing, one sample from Moldova Island, also the most affected, was confirmed as cholera on 29 July 2016. The most recent cases reported in Duk originated from Koyom Island on 10 Nov 2016. No additional cases were reported since then. Figure 1.2: Cumulative cholera cases by payam of residence as at 20 January 2017

Terekeka state has reported 22 cases of cholera including 8 deaths (CFR 36.4%) with 2 samples confirmed by the laboratory to be cholera. All the deaths were reported at the onset of the outbreak from Islands on River Nile where access to health services is poor. No additional deaths occurred after the rapid response team was deployed. The most of the recent cases originated from Kuda village, Lwoki payam, Nyori county on 22 September 2016. No additional cases were reported since then. In Nimule, Imatong state, a cumulative of 29 cholera cases including four laboratory confirmed cases and one death (CFR 3.45%) were reported from 15 August 2016.The afffected locations in Imatong state included Abila, Malakia, and Motoyo. The last cholera case in Nimule was admitted in Nimule hospital on 29 Sept 2016 and discharged on 2 Oct 2016. No additional cases were reported since then.

5

35

23

0

30

60

Juba Rubkona Panyijiar

Jubek Northern Liech Southern Liech

Num

bero

fCases

5 1

219

421 1 1 15 2 1 4

411

32 27 321 2 3 1 1 1 2

6115 2 1 3 20 1

119

2 4

76

3 1 13 1 1 7

950

643

358

470

237

320

210

3 1

90

1 2 5 22

167

1

352

10

100

200

300

400

500

600

700

800

900

1000

TOCH

PAGU

IR

OFG

NFG

MAR

EANG Leer

KOLANY

ANG

Terekeka

Nyarjwa

Lwoki

Buko

Yang Yai

Tiap

Thonyor

Thoarnhum

Rubchar

Payinjiar

Payinjiar

Payam

Parie

l

Pachienjok

Pachak

Nyal

mayom

mayiandit

Maluak

LeerTow

n

Kol

Khaigai

katith

Jiech

Gap

Ganyliel

DhuorguolD

eng

Dhoryiel

Adok

Piliny

Dhorbor

BentiuTow

n

BentiuPoC

Rejaf

NorthernBari

Munuki

Mangalla

Lokiliri

Kator

JubaTow

n

Gondokoro

Padiat

Dongchak

Uganda

Uganda

Nimule

kurw

ai

fangak

Puluk

Abuyung

WesternBieh Terekeka SouthernLiech NorthernLiech Jubek Jonglei Imatong EasternNile

EasternLakes

Num

bero

fCases

4

Table 1.1: Cholera cases and deaths by state and county as of 20 January 2017

State CountyPopulation

atrisk

Week2 Weeks24,2016to2of2017 NewcasesW52

Casesper10,000population

No.cases

Casesper10,000population

CFR[%]

WesternBieh Fangak 139,509 0 - 269 19.3 1.48NorthernLiech Rubkona 126,976 35 2.76 956 75.3 0.85SouthernLiech Leer 67,167 0 - 95 14.1 4.21SouthernLiech Panyijiar 64,254 23 3.58 374 58.2 3.23EasternLakes Awerial 114,837 0 - 353 30.7 1.13Imatong Pageri 215,130 0 - 29 1.3 3.45Jonglei Duk 26,180 0 - 92 35.1 8.7Jubek Juba 471,762 5 0.11 2,043 43.3 1.32Terekeka Terekeka 177,849 0 - 22 1.2 36.36EasternNile Pigi 125,496 0 - 168 13.4 2.98 Total 1,529,160 63 0.41 4,401 28.8 1.84

The cholera outbreak in Western Bieh state was confirmed on 22 September 2016 after two of four samples tested positive for Vibrio cholerae inaba. The initial cases were reported on 10 August 2016 in Old Fangak. The cumulative cases are 270 cholera cases including 13 confirmed cases and 4 deaths (4 facility and zero community) (CFR 1.48%). As of 20 January 2017, the affected areas included Old Fangak (217 cases); New Fangak (42 cases); Mareang (1 case); Paguir (1 cases); Toch (3 cases); and Kolanyang (1 case) (Figure 1.2). The last case from Old Fangak in week 49 of 2016. Cumulatively, 4,401 cholera cases including 81 deaths (43 facilities and 38 community) (CFR 1.84%) have been reported in South Sudan involving 9 states since the initial case was reported on 18 June 2016 for Jubek state; 3rd July 2016 in Jonglei state; 14 July 2016 for Terekeka state, 15 August 2016 for Eastern Lakes and Imatong states; 10 August 2016 for Fangak in Western Bieh and state; 29 September 2016 for Rubkona in Northern Liech state; 11 October 2016 for Leer and 22 October 2016 for Panyijiar in Southern Liech state; and 10 October 2016 for Pigi in Eastern Nile state (Figure 2.1 and Table 1.1). As seen from Figure 2.1 there was a spike in cholera transmission in weeks 42-50 of 2016 that was attributed to transmission in Bentiu PoC where most cases originate from sectors 1, 2, and 3 in blocks that are surrounding a water retention reservoir (Annex 1). Bentiu PoC now has the highest cumulative incidence for cholera.

Figure 2:1 Epidemic curve for cholera cases in South Sudan, from 18 June - 20 January 2017

1 41

35

181

316 316

217

185168

189

101 97

4322 22 31 12 28 18 13 5 1 5

235 40.0% 0.0% 0.0%

21.1%

16.9%

2.1% 1.9% 0.6% 0.9% 1.4% 1.6%

2.8% 3.3%

0.4% 1.4% 0.8%

1.6%

3.7%

0.0%

2.4% 2.5%

0.8% 2.0%

0.6% 1.8% 1.4%

0.6%

2.4% 1.0% 0.7%

3.2%

0.0% 0%

5%

10%

15%

20%

0

50

100

150

200

250

300

350

22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3

2016 2017

CFR%

Numberofca

ses

Epidemiologicalweekofonset

Jonglei Jubek Terekeka Imatong EasternLakes

WesternBieh NorthernLiech SouthernLiech EasternNile CFR[%]

0

50

100

150

200

250

300

350

24 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3

2016 2017

Nuimberofcases

Dateofonset

OverallCholeraEpidemicCurve SouthSudan2016to2017

Alive Died

0

20

40

60

80

100

120

140

13 17 11 27 118 70 46 15 8 1 2 2 6 6 5 1 1

33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 50 52

2016

Nuimberofcases

Dateofonset

CholeraEpidemicCurveEasternLakes,SouthSudan2016

Alive Died

0

10

20

30

40

50

60

70

41 42 43 44 45 46

2016

Nuimberofcases

Dateofonset

CholeraEpidemicCurveEasternNile,SouthSudan 2016

Alive Died

5

012345678910

33 34 35 36 37 39

2016

Nuimberofcases

Dateofonset

CholeraEpidemicCurveImatong,South Sudan2016

Alive Died

0

5

10

15

20

25

30

27 28 29 30 31 32 33 41 42 43 44 45

2016

Nuimberofcases

Dateofonset

CholeraEpidemicCurveJonglei, South Sudan2016

Alive Died

0

50

100

150

200

250

300

350

24 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 52 1 2 3

2016 2017

Nuimberofcases

Dateofonset

CholeraEpidemicCurveJubek, SouthSudan2016

Alive Died

0

20

40

60

80

100

120

140

160

39 40 42 43 44 45 46 47 48 49 50 51 52 1 2 3

2016 2017

Nuimberofcases

Dateofonset

CholeraEpidemicCurve,NorthernLiech,South Sudan2016

Alive Died

0

10

20

30

40

50

60

70

39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3

2016 2017

Nuimberofcases

Dateofonset

CholeraEpidemicCurve, SouthernLiech,South Sudan2016

Alive Died

0

20

40

60

80

100

120

140

160

42 43 44 45 46 47 48 49 50 51 52 1 2 3

2016 2017

Nuimberofcases

Dateofonset

CholeraEpidemicCurve, BentiuPoC,South Sudan2016

Alive Died

0

5

10

15

20

25

30

35

29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 52 1 2 3

2016 2017

Nuimberofcases

Dateofonset

CholeraEpidemicCurve,UNHousePoC,South Sudan2016

Alive

0

10

20

30

40

50

60

70

32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49

2016

Nuimberofcases

Dateofonset

CholeraEpidemicCurve,WesternBieh,SouthSudan2016

Alive Died

6

Figure 3:1 Cholera case distribution by gender and age in Jubek State 20 January 2017

Out of the 2043 cholera cases in Jubek State, 874 (42.8%) were female, while 1169 (57.2%) were male Figure 3:2 Cholera case distribution by gender and age in Jonglei State 20 January 2017

Out of the 92 cholera cases, in Jonglei State 40 (43.5 %) were female, while 52 (56.5%) were male Figure 3:3 Cholera case distribution by gender and age in Eastern Lake State 20 January 2017

Out of the 353 cholera cases, in Eastern Lake State 151 (42.7 %) were female, while 202 (57.2 %) were male.

82 117 10648 83 107 105

59 64 35 21 10 17 4 8 5 3

143164

122

6277

155 135

92 5948 39

16 22 10 13 7 3050

100150200250300

Under2 3-5

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erofCa

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Cholera - ageandsexdistribution Jubekup to20Jan2017

Female Male

5 7 3 4 2 4 7 2 1 1

1210

81

2

1

22

1 3 3 17

02468

1012141618

Under2

3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Adult

Numb

erof

Cases

Cholera - ageandsexdistribution Jongleiup to20Jan2017

Female Male

6 7 17 23 30 14 20 15 9 1 3 1 314 1727 50

39

9 16 12 74 1 4

0

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40

60

80

100

Numb

erof

Cases

Cholera - ageandsexdistribution EasternLakesupto20Jan2017

Female Male

7

Figure 3:4 Cholera case distribution by gender and age in Western Bieh State 20 January 2017

Out of the 268 cholera cases, in Western Bieh State 174 (65 %) were female, while 94 (35 %) were male. Figure 3:5 Cholera case distribution by gender and age in Leer, Southern Liech State 20 January 2017

Out of the 91 cholera cases, in Leer, Southern Liech State 44 (48.4 %) were female, while 47 (51.6 %) were male. Figure 3:5 Cholera cases by gender and age in Panyijiar, Southern Liech State 20 January 2017

Out of the 370 cholera cases, in Panyijiar, Southern Liech State 200 (54 %) were female, while 170 (46 %) were male.

14 22 24 22 2310

244 12 5 1 2 6 1 2 3 1

119

29

10 5

5

5

85

0 1 12

1 1 0 10102030405060

Under2 3-5

6-1

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65 66-

70 70+

Adult

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Cases

Cholera - ageandsexdistribution WesternBiehup to20Jan2017

Female Male

6 9 8 4 3 2 5 2 0 1 0 0 3 0 0 0

214 5

4 3 32

25 0 2 1

21 1 0

0

5

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2 3-5

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Cholera - ageandsexdistribution Leer,Southern Liechup to20Jan2017

Female Male

12 34 27 21 14 14 18 23 12 8 6 1 5 2 3 012

3446

254 5 5 5

8 11 3 4 1 4 1 20

15

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Cholera - ageandsexdistribution Panyijiar,Southern Liechup to20Jan2017

Female Male

8

Figure 3:6 Cholera case distribution by gender and age in Northern Liech State 20 January 2017

Out of the 959 cholera cases, in Northern Liech State 549 (57.2 %) were female, while 410 (42.8 %) were male. Figure 3:7 Cholera case distribution by gender and age in Eastern Nile State 20 January 2017

Out of the 168 line listed cholera cases, in Eastern Nile State 85 (50.6 %) were female, while 83 (49.4 %) were male. Table 2: Case distribution by gender in South Sudan 20 January 2017 State Female Male TotalcasesEasternLakes 152 201 353Imatong 13 16 29Jonglei 40 52 92Jubek 874 1169 2043Terekeka 13 9 22WesternBieh 176 94 270NorthernLiech 549 410 959SouthernLiech 246 219 465EasternNile 85 83 168

Totalcases 2148 2253 4401

86 107 90 48 43 24 34 31 31 6 11 5 17 2 6 2

79115

91

53 46 7 18 4

8 6 05

7 2 20

40

80

120

160

200

Under2

3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+

Numb

erofCa

ses

Cholera - ageandsexdistribution Northern Liechupto20Jan2017

Female Male

14 13 11 16 5 6 10 1 2 2 1 2 1 0 1 0

6 10 1423

7 34

3 3 5 2 1 1 0 1 00

20

40

Under2 3-5

6-1

0 11-

15 16-

20 21-

25 26-

30 31-

35 36-

40 41-

45 46-

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55 56-

60 61-

65 66-

70 70+

Adult

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erof

Cases

Cholera - ageandsexdistribution EasternNileup to20Jan2017

Female Male

9

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. Laboratory updates

Table 3: Cholera laboratory test results for Juba by 20 January 2017

State Culture results

New positives in week 2

Cumulative Positive

Cumulative Negative Total tested

Eastern Nile 0 0 5 5 Jonglei 0 1 4 5 Jubek 0 79 126 205 Terekeka 0 2 0 2 Eastern Lakes 02 19 42 61 Imatong 0 7 1 8 Fangak 0 13 29 42 Wau 0 0 6 6 Boma 0 0 2 2 Northern Liech 02 24 50 74 Southern Liech – Leer 0 2 0 2 Southern Liech - Panyijiar 0 1 0 1 Southern Liech – Mayendit 0 0 1 1 Eastern Nile (Pigi) 0 2 5 7 Total tested 04 150 271 421

Table 4: Cholera Alerts Date of notification

Details of the alert No alerts

Area Action

13-Sept-2016

From 14-17 Nov, the MedAir team responded to 78 suspect cholera cases including 15 deaths in Wiechdeng, Ayod. One case tested positive on cholera RDT.

Wiechdeng, Ayok county, Southern

Bieh state

MedAir responded to suspect cholera cases in Wiechdeng by setting up a 10 bed CTU. Recent assessments by MedAir show there is no active transmission in Pagil; Haat; and Wiechdeng.

8- Oct-2016 UNIDO reported 142 suspect cholera cases including three deaths

Bhor, Thaker, Tutnyang, Madol 1, Leah, Dablual,

Rubchay, and Malkuer Payams, Mayendit North, Southern Liech

state

UNIDO, MedAir are the healthcare partners responding to suspect cases in Mayendit. Since 7 Jan 2017, MedAir has seen at least 48 cases in their CTU in Modol 1.

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. Security concerns have remained a major impediment to the implementation of sustained and comprehensive cholera investigation and response activities in Leer and Mayendit. Cholera case management is ongoing at the designated cholera treatment facilities in the nine affected states. As cases decline in the affected areas, laboratory surveillance has been strengthened to ensure that all suspect cholera cases undergo rapid diagnostic testing and stool culturing to confirm cholera. WHO has therefore supported the partners operating cholera treatment facilities with ample supplies for sample collection, onsite rapid diagnostic testing, and shipment to the National Public Health Laboratory for culturing.

10

WHO is supporting the cholera investigation and response activities in all the nine affected states and the two states with alert suspect cases. Core to WHO’s support to the current cholera response is technical support to the taskforce committees by providing updated situation reports; supporting the investigation and testing of suspect cases; support towards case management activities through trainings on cholera case management protocols; recommending tailored strategies in response to emerging trends; and support for the outbreak evaluation process that is already underway. WHO technical officers are currently deployed in Mingkaman; Bentiu, Bor, Malakal, Imatong, and Juba to support the ongoing response activities. UNICEF continues to support the Cholera response at the community level across all relevant sectors of Health, WASH, and communication through active partnerships with following implementing partners: Health Link South Sudan (HLSS), LiveWell, ACROSS, CAPIAD, THESO, BEDN, IMC, RUWASSA, SMC, NHDF, UNIDO, World Relief, and ARUDA. In Jubek, there has been resurgence of cases in UN House PoC since week 52 of 2016. In response to the resurgence, a multi-cluster investigation mission was undertaken during the week. Thus, response efforts have been enhanced in UN House PoC with the WASH cluster carrying out spraying of the latrines and random quality water testing and reactivation of ORPs. In addition, HHPs have been deployed to carry out hygiene promotion. There are plans to open additional ORPs in PoC 3 and to deploy mobile communication teams in the two PoCs. Active transmission is ongoing in Southern Liech and Northern Liech states where Facility and community based response is ongoing with most cases being managed in facilities like Duong PHCC, Ganyliel PHCC, and Nyal PHCC with support from IRC, UNIDO, and Sign of Hope. Since 7 October 2016, at least 142 suspect cholera cases including three deaths were reported by UNIDO and MedAir response teams in Mayendit. The MedAir CTU in Madol 1 has seen at least 48 cases since 7 January 2017. The resurgence of cholera cases in UN House PoC highlights the need to enhance cholera prevention and control activities in the PoC guided by the integrated approach for cholera response.

RecommendationandwayforwardforBentiuPoC

Improving access to timely rehydration The following strategies should be considered to increase access to timely rehydration in the PoC:

1. The community health workers should be deployed to do house-to-house case search and initiate prompt treatment with ORS with immediate referral the designated cholera treatment centers. The community health workers should be able to dispense the ORS during the household visits.

2. Each block should have a designated community health worker with ORS that is known by the dwellers and who can be called on short notice to assess; initiate treatment; and refer suspect cases.

3. Open additional mobile clinics or ORPs in the most affected sectors to ensure good access to timely rehydration during day time.

4. All the existing clinics and pharmacies should be stocked with ample amounts of ORS to provide to suspect cases.

Surveillance and laboratory testing Since this is a population where oral cholera vaccination was implemented in 2014 and 2015; case based surveillance is recommended. Thus, in the current context, cases that meet the suspect cholera case definition should undergo an initial screening using the enhanced RDT testing technique (using enrichment of samples with alkaline peptone water before the test is conducted). This will improve the specificity for identifying the real cholera cases and thus accurately monitoring the evolution of the outbreak. Secure-off the water retention pond Water retention pond: it is very clear that the possible source of infection to the community is the water retention pond. This water is contaminated with faecal matter due to rampant open defecation. The camp management should fence off this water source and forbid population from using it until the outbreak is over.

11

Targeted interventions to children as a high-risk group Nearly 80% of the cases are children: This is possibly because they swim and drink the water in the retention pond. Health education should be directed to this age-group by involving the school children in the PoC. ORAL Cholera Vaccination (OCV) To increase immunity, there is a need for two rounds of oral cholera vaccination. The population of Bentiu PoC when the last two rounds were conducted in June 2015 was about 70,000. The current population has increased to 120,000. OCV coverage survey conducted by WHO/IOM in December 2016 showed that the OCV coverage stands at 40%. This is therefore not adequate to prevent transmission. WASH related control activities All efforts towards improving access to safe drinking water, hygiene, and sanitation should be enhanced with regular assessments to review and update the taskforce on the following:

• The amount of safe drinking water supplied per person per day by sector • Access to improved latrines per person per day by sector • Data on regular surveys to document FRC levels at the source; tap stands and household levels. • Documentation of waiting time at the tap stands to determine if there are unacceptable delays • A jerry-can cleaning and replacement drive at the tap stands in all the sectors to promote safe water

chain. • Distribution of other NFIs like soap to promote and augment personal hygiene at household level. • House to house hygiene sensitization that is targeted to most affected blocks and sectors that are

surrounding the water retention pond.

Social mobilization and health education for cholera control Given the current transmission levels in Bentiu PoC; ongoing social mobilization in each of the five sectors to sensitize the camp dwellers on cholera, how it is spread, the signs and symptoms, and behaviors to mitigate the risk – proper hand washing; using safe drinking water; and good sanitation. The campaign should also entail a cleaning drive in each of the sectors. Planned Activities 1. The next weekly EPR/cholera taskforce meeting is scheduled for 25 January 2017 starting 2:00pm in the

WHO Conference Hall. 2. Continue social mobilization activities, active case surveillance, and street announcements with open van,

house to house awareness and distribution of WASH supplies by HHPs in affected and at risk areas in UN House PoC, Northern Liech, and Southern Liech.

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: http://www.who.int/hac/crises/ssd/en/ as well as on the Humanitarian Info webpage: http://southsudan.humanitarianresponse.info/clusters/health. 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: E-mail: outbreak_ss_2007@yahoo.com, The Toll-free number for Vivacell calls is: 1144. Contacts For more information, please contact

Mr. Lexson Mabrouk Ag. Director General - Preventive Health Services MoH, Republic of South Sudan Tel: +211955668178

Dr. Alice Igale Ag. Director - IDSR MoH, Republic of South Sudan Tel: +211956420189

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Annex1:CholeradistributioninBentiuPoCasof20January2017

Annex 1.1: Cholera case distribution by time in Bentiu PoC 20 January 2017

Annex 1.2: Cholera age and sex distribution in Bentiu PoC as of 20 January 2017

Annex 1.3: Cholera case distribution by sector in Bentiu PoC as of 20 January 2017

051015202530

No.cases

Dateofonset

EpidemicCurveforcholerainBentiuPoCasof20Jan2017

86 107 90 48 42 24 33 31 31 6 10 5 17 2 6 2 0 6

79115

90

52 36 7 17 4

8 6 03

7 2 2 0 3

0

30

60

90

120

150

180

210

240

Under2

3-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Adult Blank

Num

bero

fCases

Cholera- ageandsexdistributionNorthernLiechupto20Jan2017

Female Male

137

91

64 6354

-

79

- 20

40

60

80

100

120

140

160

Sector1 Sector2 Sector3 Sector4 Sector5 Others GrandTotal

casesp

er10,000

Choleracasesper10,000bysector,BentiuPoCupto15Jan2017

13

Annex 1.4: Cholera case distribution by sector and block in Bentiu PoC as of 20 January 2017