Creation date:31 August 2017 Sources: Ministries of Health and WHO

Bulletin: Cholera/ AWD Outbreaks in Eastern and Southern AfricaRegional Update - as at 31 August 2017HighlightsMore than 100,780 cholera / AWD cases and 1496 deaths (CFR: 1.5%) have been reported in 12 of 21 countries of Eastern and Southern Africa Region (ESAR) since the beginning of 2017. These countries include; Somalia, Kenya, South Sudan, Tanzania, Burundi, Malawi, Zimbabwe, Mozam-bique, Angola, Uganda, Zambia and Rwanda. Somalia accounts for 76.6% of the total cases reported in the outbreak in 2017, followed by South Sudan at 15.7%.

In the past 2/3 weeks (Week 32-34), 6 out of the 21 countries in ESAR have reported active transmission of cholera / AWD (Burundi, Malawi, Somalia, South Sudan, Kenya and Tanzania). Tanzania has recorded the highest CFR (1.8%) followed by South Sudan (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 decrease in the epidemic trend. During week 33 (week ending 20 August 2017), 222 new cases and no deaths were reported in the country; compared to 282 cases reported in week 32. Out of the 222 new cases, 97 were reported from South Central and 125 were from Somali land. Most affected regions are Banadir, Togdheer, Awdal, Mjeex and Lower Jubba.

Kenya: 4 out of the 47 Counties (Garissa, Nairobi, Turkana and Nakuru) have an active cholera outbreak. During week 33, 19 new cases were reported compared to 69 cases in week 32.

South Sudan: Most affected populations are nomadic pastoralists and communities living in hard to reach villages and cattle camps. There has been a decrease in the epidemic trend over the past 3 weeks. During week 32 (Week ending 13th August 2017), 30 new cases were reported; compared to 102 cases including 1 death (CFR 1%) in week 31. Active transmission reported in Kapoeta East, South and North, Tonj East, Yirol East, Nyirol, Ayod, Duk and Juba.

Tanzania: An increase in epidemic trend. During week 34 (Week ending 27th August 2017), 102 new cases have been reported in Tanzanian mainland; compared to 67 cases in week 33. Cases emerged from Mbeya, Iringa and Katavi regions.

Malawi: The current outbreak started within the catchment area of the Chikwawa Hospital. 11 New cases have been reported in week 34; compared to 2 cases reported in week 33.

Burundi: The first case of the current outbreak was identified on August 13, 2017 from Democratic Republic of Congo (DRC). Since then there has been an increase in the epidemic trend with 24 cases reported in week 34; as compared to 13 cases reported in week 33. No death has been reported and most of the cases emerged from the city center of Nyanza Lac.

Uganda: No confirmed case of cholera in 2017, only AWD cases reported

304

222

77,148412

6

102

2199

30

15, 851

19

2232

2122

389

10310311

4

24

211

1

0 / 33 0 / 1115

0 / 274

3

4

0 / 39

261

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 DeathsNo. of new cholera deaths (last 1 week) / 2017 Cumulative deaths

Distribution of new casesNo data

No new cases 1 to 500 cases > 500 cases

LegendTable: Beginning of the outbreaks by CountryCountry Duration Cumulative no. of cases Cumulative no. of deathsSomalia Mar 16 – Aug 17 92,848 1,663South Sudan June 16 – July 17 19749 355Kenya Oct 16 – July 17 2,332 37Tanzania 2016 – July 17 26,199 411Burundi Dec 16 – Jan 17 211 0Malawi 2016 – June 17 1895 47Zimbabwe 2016 - April 17 16 4Mozambique Jan 17– April 17 2122 4Angola Dec 16 – Aug 17 468 26Zambia 2016 - July 17 1482 33

12Countries

100,780 Cases

1496 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

3

60

No of cholera treatment centres still operational

No of tons of essential medicines and suppliesdistributed

Country Priorities Response Interventions

South Sudan

-Increase the number of CTCs, CTUs and ORP in affected areas-Increasie access to adequate amounts of safe water and appropriate sanitation-Conduct cholera vaccinations in hotspot areas-Engage community based integrated emergency response team in active case finding-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

1017961102816

46384401182690055640319214410595904012

# of aqua tabs distributed (30 tabs/HH)# of households level demonstrations on water treatment

# of CHV emrolled on Mlearning cholera module# of food handlers medically examined & Certified

# of households disinfected# of contacts traced and given prophylaxis

# of eateries Inspected# of community water tanks disinfected

# of eateries Closed# of Garbage dumps sites cleared

# of public toilets disinfected# of water trucks disinfected

# of open drains cleared and disinfectedNo. of sanitation facilities constructed

900,000

772,885

350,069

87,659

3,267

1,585

1,005

325

147

Litres of water provided per day through water tracking

No of oral cholera vaccine doses deployed

No of people vaccinated with OCV

No of people reached with hygiene promotion messaging

No of WASH kits distributed

No of buckets and Jerry cans chlorinated

No of stances of latrines constructed

No of buckets and Jerry cans distributed

No of boreholes and water points rehabilitated

130

98

93

50

46

22

5

5

No of cartons of PUR distributed

No of latrine stances disinfected

No of cartons of soap distributed

No of cholera treatment facilitiesoperational

No of households disinfected

No of cartons of aqua tabs distributed

No of drums of chlorine distributed

No of cartons of ORS distributed

• 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

-Training, supervision and mentoring of health workers in CTUs-Maintain adequate stock level of supplies and staff in CTUs-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 -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

• A water tank with a capacity of 10,000 litres was installed in the (CTC) located near Bukeye Heath center• Water trucking• Water supply system in Nyanza Lac center was repaired • Social mobilization was conducted to prevent cholera

200

200

100

90

10

No. of kgs of HTH chlorine powder available

No of portable latrine stances available

No of assorted water containers available

No. of cartons of water guard available

No of cartons of Laundry soap available

Country Priorities Response Interventions

Malawi

Tanzania

-Improve case management and water supplyBurundi

-Advocacy and partnerships for resource mobilization -Capacity building of sub-national partners on WASH related aspects of cholera planning and management-Provision of critical supplies like chlorine products, ORS and IEC materials in most at risk regions-Social Mobilisation to prevent and control cholera

800,000

10

Number of bottles of water guards available

Number of rectal swabs collected for testing

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: 31 August 2017 Sources: Ministries of Health and WHO

Annex 1: Distribution of Cholera/AWD outbreaks in the Horn of Africa - 31 August 2017

117

Tana

1

1

Garissa

KerichoNakuru

2540

111161

9

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

Vihiga Murang’aKiambuNairobi

2722

213070

65593

4

24852399

735

4686

123772

790

18881

SomaliOromia

Amhara

South Sudan

EthiopiaSomalia

Kenya

LegendStatus of outbreak

Outbreak containedOutbreak active

No outbreak reported

Cholera / AWD Cases

XXNew cases

Cumulative cases 2017

No data

Afar

Tigray

Beneshangul Gumuz

Gambela

SNNPR

626906

2587

656

Uganda

Addis AbabaHareri

Dire Dawa

301610

1684

4106

2491

5622

Bakool3880

14913

Western Equatoria

Western Bahr el Ghazal

Northern Bahr el Ghazal1

3178

328

16Kajiado

19

56

37

Siaya

Machakos30

105

22624

2

37

West Nile

Lango

Western

Central 2

Central 1

***Cases for Uganda are Acute Watery diarrhoea and are mapped by sub-region, no confimerd case of cholera in 2017

382

360311

6111846

Homa Bay

Kisumu

Siaya

- More sub-optimal coordination in responding to outbreaks- Limited resources such as water treatment chemicals- Limited laboratory capacity in some Counties for Cholera confirmation- Limited capacity in response as majority of the Rapid Response Teams especially at county level are not trained- Limited resources for health promotion and community engagement- Insecurity in various parts of the country including; Garissa

Kenya: Challenges

- Insecurity- Inaccessibility of the most affected areas in Bay, Bakol, Gedo and Lower Shabelle- Drivers of the current epidemic include limited access to safe water and poor sanitation in IDP settlements in all the affected regions

Somalia: Challenges

- 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- 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

4

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: 31 August 2017 Sources: Ministries of Health and WHO

Annex 2: Distribution of Cholera/AWD outbreaks in Southern Africa - 31 August 2017

303

300

83Pwani

132

86555

215

Dodoma

108

7

52

Singida

Mbeya

20

46

344

9244

Dar es Salam

Morogoro

Iringa

Kigoma

Dodoma

Mara

Tabora

Singida

Tanga

Rukwa

Unguja

1

Nsanje

Chikwawa

Mwanza

1183

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

- Treatment of water by boiling or using aqua tabs is not a common practice to over 80% of households - Low level of knowledge on control and prevention - 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- 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

LegendStatus of outbreak

Outbreak containedOutbreak active

No outbreak reported

Cholera / AWD Cases

XXNew cases

Cumulative cases 2017

Angola

South Africa

Tanzania

Burundi

Mozambique

Namibia Botswana

Zimbabwe

ZambiaMalawi Malawi

Rwanda

Rwanda

82Luapula

21

Northern Province

Cibitoke172

Bujumbura rural 2

Makamba Province 24

24

WesternProvince

4

Creation date: 22 August 2017 Sources: Ministries of Health, WHO and FEWS NET

Annex 3: Distribution of Acute Watery Diarrhea / Cholera in the Horn of Africa (Jan to Aug 2017) and Integrated Food Security Phase Classification for (June - September 2017)Somalia Country Priorities-Increasing the number of CTCs, CTUs and ORP, in affected areas-Increasing access to adequate amounts of safe water and appropriate sanitation-Conducting cholera vaccinations in hotspot areas-Using community based integrated emergency response team (IERT) in active case finding-Adopting standardized case management and infection prevention and control protocols -Providing integrated training in WASH and health at treatment sites-Providing adequate amounts of infection control materials at treatment sites -Targeted regular water quality testing-Behaviour change approaches that integrate WASH and Health messages-Orientation of food handlers to ensure adherence to public health standards

South Sudan Country Priorities-Strengthen coordination of cholera preparedness and responseactivities at all levels-Preposition cholera buffer stock and other medical supplies inaffected areas-Enhance surveillance activities at all levels to enable a rapid response to cholera-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

Kenya Country Priorities-Enhance multi-sector co-ordination through existing structures and resources-Strengthen district capacity for prompt case detection, confirmation and management by strengthening the National Laboratory coordinating mechanism -Ensure the availability of safe water and safe human waste disposal using appropriate locally feasible and acceptable technologies-Strengthen cholera prevention and health promotion in high risk areas

Uganda Country Priorities-Raise awareness and promote practices for cholera prevention nationally-Increase access to safe water, sanitation, and hygiene in cholera-prone districts-Strengthen weekly surveillance to improve cholera response-Improve the quality of case management to reduce mortality by 50% in cholera hotspots-Implementation of OCV in cholera hotspots and endemic communities-Enhance multi-sector coordination through local and national structures and resources at National and district level

Homa Bay

Kisumu

Siaya

VihigaCholera / AWD Cases

XXNew cases

Cumulative cases 2017

Acute Food Insecurity PhaseCrisis

Emergency

117

Tana

1

1

Garissa

KerichoNakuru

2540

111161

9

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

Warrap

Upper Nile

Murang’aKiambuNairobi

2722

213070

65593

4

24852399

735

4686

123772

790

18881

SomaliOromia

Amhara

South Sudan

EthiopiaSomalia

Kenya

Legend

Afar

Tigray

Beneshangul Gumuz

Gambela

SNNPR

626906

2587

656

Uganda

Addis Ababa

Hareri

Dire Dawa

301610

1684

4106

2491

5622

Bakool3880

14913

Western Equatoria

Western Bahr el Ghazal

Northern Bahr el Ghazal1

3178

328

16Kajiado

19

56

37

Siaya

Machakos30

105

22624

2

37

West Nile

Lango

Western

Central 2

Central 1

382

360311

6111846

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: 31 August 2017 Sources: Ministries of Health and WHO

Annex 4: Distribution of Acute Watery Diarrhea / Cholera in the Horn of Africa (January-Aug 2017)and Displacement Tracking Matrix Flow Monitoring for June 2017

117

Tana

1

1

Garissa

KerichoNakuru

2540

111161

9

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

Vihiga Murang’aKiambuNairobi

2722

213070

65593

4

24852399

735

4686

123772

790

18881

SomaliOromia

Amhara

South Sudan

EthiopiaSomalia

Kenya

Afar

Tigray

Beneshangul Gumuz

Gambela

SNNPR

626906

2587

656

Uganda

Addis AbabaHareri

Dire Dawa

301610

1684

4106

2491

5622

Bakool3880

14913

Western Equatoria

Western Bahr el Ghazal

Northern Bahr el Ghazal1

3178

328

16Kajiado

19

56

37

Siaya

Machakos30

105

22624

2

37

West Nile Lango

Western

Central 2

Central 1

***Cases for Uganda are Acute Watery diarrhoea and are mapped by sub-region, no confimerd case of cholera in 2017

382

360311

6111846

Homa Bay

Kisumu

Siaya

- More sub-optimal coordination in responding to outbreaks- Limited resources such as water treatment chemicals- Limited laboratory capacity in some Counties for Cholera confirmation- Limited capacity in response as majority of the Rapid Response Teams especially at county level are not trained- Limited resources for health promotion and community engagement- Insecurity in various parts of the country including; Garissa

Kenya: Challenges

- Insecurity- Inaccessibility of the most affected areas in Bay, Bakol, Gedo and Lower Shabelle- Drivers of the current epidemic include limited access to safe water and poor sanitation in IDP settlements in all the affected regions

Somalia: Challenges

- 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- 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

4DOOLOWBELET XAAWO

ELWAK

HelwenBuramino

KoboyMalkadida

Bokolmayo

HagaderaIfoDagahley

Dadaab

Kakuma

MoyoAdjumani

Arua

Assosa

Lamwo

Status of outbreakOutbreak containedOutbreak active

No outbreak reported

Cholera / AWD Cases

XXNew cases

Cumulative cases 2017

No data

Border crossing pointLocations of Arrival

Legend

Country Wk 1 to Wk 29 Week 30 Week 31 Week 32 Week 33 Week 34 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 58,367 830 306 2 321 2 282 0 222 0 77,148 1115 1.4% 92,848 1,663 1.8%

Kenya 834 9 63 2 69 0 19 0 2232 33 1.5% 2332 37 1.6%

South Sudan

5,910 182 109 3 102 1 30 0 15,851 274 1.7% 19,749 355 1.8%

Tanzania 1,886 29 198 4 94 0 67 0 102 0 2,199 39 1.8% 26,199 411 1.6%

Burundi 5 0 0 0 0 0 0 0 13 0 24 0 211 0 0 211 0 0

Malawi 90 1 0 0 0 0 0 0 2 0 11 0 103 1 1.1% 1895 47 2.5%

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

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

Uganda 412 0 412 0 0% 412 0 0%

Angola 0 0 0 0 0 0 0 0 389 26 6.6% 468 26 5.5%

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

Rwanda 0 0 0 0 0 0 0 0 4 0 0% 4 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 100,780 1496 1.5% 147,738 2580 1.8%

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