Republic of South Sudan

Cholera in Juba, Central Equatoria State,

Republic of South Sudan
Situation Report # 6 as at 23:59 Hours, 27 June 2015
Situation Update
As of 27 June 2015, a total of 347 cholera cases including 26 deaths (CFR 8.3%) have been reported from 63
villages in eight payams of Juba County (Table 1).
The initial cases were traced back to 18 May 2015 in UN House PoC where the first cholera case was
confirmed on 1 June 2015. Most of the cholera cases in Juba have been reported from New site followed by
Juba 3 PoC, Gumbo, Gudele 2, Kor William and Munuki (Figure 4).
Table 1. Summary of cholera cases reported in Juba County, 18 May 27 June 2015
Reporting Sites

New
admisions

New
discharges

New
deaths

Total cases
currently
admitted

LAMA*

Total
facility
deaths

Total
community
deaths

Total
deaths

Total cases
discharged

Total cases

UN House PoC clinic

22

31

Hai Referendum IDP clinic

Juba Teaching Hospital

32

16

111

30

12

15

138

294

Al Sabah Hospital

Morobo 2 clinic

Nyakuron PHCC

Juba Military Hospital

Luri Military

St. Kizito clinic

Mauna Medical clinic

Juba Prison

Gumbo ORP

Total

32

16

117

30

14

12

26

172

347

*LAMA: LEAVE AGAINST MEDICAL ADVICE

A total of 32 new cholera cases were reported in Juba on 27 June 2015.

o Juba Teaching Hospital reported 32 new cases
o Most of the new cases were reported from New site, Gudele 2 and Tongping (Figure 1)
o One new village, Jebel Yesua reported cholera cases for the first time thus raising the number of
affected villages from 62 to 63.

Kator

Munuki

Rejaf

1
Lokiliri

Jebel Yesua

Gumbo 1

New site

Northern Bari

Digala

Mangatain IDP

Gurei

Gudele 2 Blk 9

Gudele 2

Nyakuron West

Nyakuron

Munuki Blk C

Mauna

Hai Kuwait West

Suk Jebel

Konyokonyo

Tongping

Airport
Juba

Lologo 1

Number of cases

Figure 1: New cholera cases by residence on 27 June 2015

8
7
6
5
4
3
2
3
3
1
2
2
1
1 1
1
1 1 1
1
0

Lokiliri

Cumulatively, 347 cholera cases including 26 deaths (14 facility and 12 community) have been reported since
the initial case was reported in Juba on 26 May 2015 (Tables 1 and 2).
Table 2: New cholera cases by facility and week in Juba, 18 May 27 June 2015
Reporting Facility
Al Sabah hospital
Hai referendum IDP clinic
JTH
Juba 3 IMC clinic
Juba Military hospital
Morobo 2 clinic
Nyakuron PHCC
Luri Military
St. Kizito clinic
Mauna Medical Clinic
Juba Prison
Gumbo ORP
Grand Total

New cases by epidemiological week of 2015

21
22
23
24
25
26
0
0
0
4
0
0
0
0
0
1
0
0
0
2
2
32
119
139
4
0
4
9
5
9
0
0
0
5
0
0
0
0
1
3
0
0
0
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
2
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
0
0
2
4
2
7
56
127
151

Grand Total
4
1
294
31
5
4
1
1
2
1
1
2
347

As seen from Figure 2, the initial and isolated cases were reported from UN House PoC starting on 26 May
2015. However, following epidemiological investigations on 27 May 2015, cases could be traced back to 18
May 2015. Cholera was eventually confirmed on 1 June 2015 after Vibrio cholerae inaba was isolated from
one of five samples tested in the National Public Health Laboratory.
Since 6 June 2015, sustained and consistently increasing community transmission has been established with
increasingly more suspect cases reported outside UN House PoC. There are three discernable transmission
peaks with the initial peak of 15 cases occurring on 13 June 2015 while the subsequent and higher peaks
occurred on 20 June and 26 June with 26 and 46 cases respectively (Figure 1).

Investigation adn Confirmation

of initial case in UN house Poc

Alive

Date of onset

6/28/15

6/26/15

6/24/15

6/22/15

6/20/15

6/18/15

6/16/15

6/14/15

6/12/15

6/10/15

6/8/15

6/6/15

6/4/15

6/2/15

5/31/15

5/29/15

5/27/15

5/25/15

5/23/15

5/21/15

5/19/15

Confirmation of initial
case in UN house Poc

5/17/15

50
45
40
35
30
25
20
15
10
5
0

5/15/15

Number of cases

Figure 2: Epidemic curve for suspect cholera cases in Juba, 18 May 27 June 2015

Died

Figure 3: Spot map for suspect cholera cases by residence in Juba, 18 May 27 June 2015

As of 27 June 2015, the sites reporting the majority of cases in Juba include New site, Juba 3 IDP, Gumbo,
Gudele 2, Kor William and Munuki (Figure 3 and 4). There are satellite cases distributed in eight payams and
63 villages in Juba County.
Figure 4: Cholera cases by residence in Juba, 18 May 27 June 2015
40
35
30
25
20

37
32

15

26

10
5
5
1

7
1

3 2 2
3 2
1 2 1 2 2 2 1 1

11
7 6
1

5
3 4

15
8 9

7
3 2 2

16

15

2 1 1 1 1

7
1 1 2

1 1

1 2 1

1 2 1

Jezira
Hai Amarat
Juba
Tongping
Korobou
Gabat
Hai Jalaba
Buluk
Hai Zendia
Nimra Talata
Makas Sabab
Game
Juba Prison
Airport
Hai Soura
Hai Malakal
Juba Nabari
Hai Kos
Kator
Lologo
Malakia
Giada
Atlabara
Suk Sita
Konyokonyo
Suk Jebel
Nyakuron West
Munuki
Gudele
Mauna
Jopa
Luri
Jebel Kujur
Nyakuron
Gudele 1
Dar es Salam
Hai Kuwait
Hai Tharawa
Mia Sava
Hai Seminar
Rock City
Juba Nabari
New site
Suk Zande
Walawalak
Bilpam
Gurei
Mangatain IDP
Gorom
Gudele 2
Hai Referendum
Lemon Gabah
Jebel Lado
Gumbo
Mijiki
Kor William
Checkpoint
Digala
Kor Romula
Juba 3 PoC
Jebel Yesua
Lokiliri
Nesitu

19

16
12

Gondokoro

Juba

Juba Nabari

Kator

Munuki

Northern Bari

Rejaf

Lokiliri

Interviews conducted on 27 June 2015 involving cases currently admitted in Juba Teaching hospital revealed
knowledge gaps on how cholera is spread. The cases from distant locations like Jebel Lado and Jezira in
Gondokoro reported using untreated water from the River Nile while cases from New site (that constitute the
majority in the CTC) reported getting their water from a combination of unprotected wells and water tankers.
Cases from the rest of the locations including Gudele, Gumbo, Jebel, Munuki, Kor William and Lologo are
getting their water from water tankers. None of the interviewed cases are doing household chlorination of
3

water using water purification tablets. Some cases, however, reported using Aluminum sulphate, which is only
good for reducing the turbidity of the water.
Intensive interventions in the form of social mobilization and health education on cholera presentation and
prevention, improving access to safe drinking water, latrine use and good personal and food hygiene are
therefore required to prevent further escalation in Juba and spread to other counties outside Juba.
Out of the 338 suspect cholera cases with known age, 46 (14%) were children less than five years of age,
while 292 (86%) were individuals five years and above (Figure 5).
Figure 5: Suspect case distribution by age in Juba, 18 May 27 June 2015

14%

<5yrs
5+yrs

86%

Out of the 338 cholera cases with known gender, 138 (41%) were female, while 200 (59%) were male (Table
3).
Table 3: Case distribution by gender and age in Juba, 18 May 27 June 2015
Gender and age
Female
<5yrs
5+yrs
Male
<5yrs
5+yrs
Grand Total

N (%)
138 (41)
15
123
200 (59)
31
169
338 (100)

The probable risk factors identified include: residing in a crowded IDP camp with poor sanitation and hygiene;
using untreated water from the Water tankers; lack of household chlorination for drinking water; eating food
from unregulated roadside food vendors or makeshift markets; and open defecation/poor latrine use.

Laboratory updates
Table 4: Cholera laboratory test results for Juba, 18 May 27 June 2015
Health Facility
1
2
3
4
5

Al Saba hospital
Juba Teaching Hospital
Juba 3 PoC clinic
Juba Military Hospital
Morobo 2 clinic
Total

Number of sample
collected
2
40
22
3
2
69

Number of cholera
RDT positives
0
33
24
2
2
61

Number of cholera
Culture positives
2
7
9
2
1
21

A total of 69 stool samples have been collected from suspect cholera cases in Juba and submitted to the
National Public Health Laboratory for testing (test results by facility shown in Table 4).
The National Public Health Laboratory has confirmed 21 cholera cases following the isolation on Vibrio
cholerae inaba. Most of the culture confirmed cases have been reported from Juba 3 PoC and New site
(Figure 6).
Figure 6: Number of culture positives by residence in Juba, 18 May 27 June 2015
10
Number of cases

9
8
7
6
5

4
3
2
1
0

4
1

Gudele 1

Jebel
Kujur

Juba 3
PoC

Juba
Nabari

Kator

Mangatain Munuki New site Nyakuron

IDP
West

Table 5: Cholera Alerts 23 to 27 June 2015

Date
of
notification
23-Jun-15
25-Jun-15

Details of the alert

Area

Action

Suspect cholera cases

reported from Rumbek Town
in Lakes State.
Suspect cholera case
reported from Torit State
Hospital.

Rumbek,
Lakes State

Report verified by the state surveillance team and

no suspect cases were identified by the team.

Torit, EES

State rapid response team conducted

investigations and obtained stool samples from the
suspect case and close contacts.
The sample was sent to Juba for testing; RDT kits
not available for onsite testing.
Refresher training on cholera conducted for the
state hospital healthcare workers.
Temporary isolation unit for at least 10 patients set
up in Torit State Hospital.
Epidemiological investigation conducted by the
county rapid response team.
Three samples have been sent to Juba for culture
and sensitivity.
Rapid diagnostic test for cholera was positive.
Stool samples have been shipped to Juba for
microbiological culturing.
Epidemiological investigation to follow.
Case verification and supervised burial conducted
by the state rapid response team.

26-Jun-15

Four suspect cholera cases

reported in Kajo Keji Civil
Hospital.

Kajo Keji,
CES

26-Jun-15

One suspect cholera case

reported by Bor State
Hospital.

Bor, Jonglei
State

27-Jun-15

Community death following

acute watery diarrhoea was
reported in Juba Prison.

Juba Prison

As seen from Table 5, at least five alerts of suspect cholera cases have been reported outside Juba and are
being followed up by the respective state and county rapid response teams with support from the national
cholera taskforce.

Cholera Response Highlights

1. Urgent and lifesaving cholera response activities have been initiated by the national cholera taskforce in
response to the increasing number of cases in Juba. The national cholera taskforce meeting takes place
weekly.
2. The cholera response strategy is being reviewed and updated to suit the current context and to facilitate
mobilization of resources to control the outbreak.
3. Oral cholera vaccination campaigns were conducted in Bentiu PoC and UN House PoCs with Bentiu PoC
implementing the second round, while UN House PoC carried out its first round of vaccinations. Both
campaigns took place from 22 to 26 June 2015.
4. With support from MedAir, a new oral rehydration point (ORP) has opened in Gumbo PHCC and is
already treating cases.

Urgent Response Needs

1. Intensive social mobilization and health education on cholera prevention in the transmission hotspots
using multimedia channels
a. Engaging all leaders political, religious, traditional and civic groups
b. Messages and talk shows on FM radios
c. Use of mobile broadcasting/film vans in transmission hotspots
d. Engaging institutions like schools and uniformed forces and the public in places like market areas
2. Stricter monitoring of water tanker chlorination at the Riverside and field surveillance to ensure water
delivered to households conforms to the minimum free residual chlorine levels.
3. Distribution of water purification tablets to facilitate treatment of water at household level in high
transmission areas.
4. Partners to support Juba Teaching Hospital cholera treatment center (CTC) and set up oral rehydration
points (ORP) in Gumbo, New site, Mangatain IDP, Gudele, Nyakuron, Munuki and Kator.
5. Standby ambulances to support the transfer of cases to designated treatment centers.
6. Urgently train and deploy more home hygiene promoters to cholera hotspots for house-to-house
sensitization on cholera prevention; active case finding and reporting; initiating oral rehydration treatment
for new cases and referral to oral rehydration point or cholera treatment center; and distributing water
purification tablets.

Planned activities
1. Finalizing sub-committee response strategies and plans to guide a coordinated response to the outbreak.
2. The next national cholera taskforce meeting is scheduled for Monday 29 June 2015 at 10:00 am in the
Ministry of Health Ministerial Boardroom.
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: [email protected] . The Toll free numbers for alerts
are: Zain: 0912000098.

Contacts
For more information please contact:
Dr. John Rumunu
Director General - Preventive Health Services
MoH, Republic of South Sudan
Tel: +211955668178

Dr. Thomas Akim Ujjiga

Ag. Director - IDSR
MoH, Republic of South Sudan
Tel: +211955150406