WHO/CDS/2001.5 Original: English Dist.: General
COMMUNICABLE DISEASE PROFILE
AFGHANISTAN AND NEIGHBOURING COUNTRIES
October 2001
Communicable Disease Working Group on Emergencies HQ Division of Communicable Disease Control EMRO Communicable Diseases EURO WORLD HEALTH ORGANIZATION
© World Health Organization, 2001
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The views expressed in documents by named authors are solely the responsibility of those authors. Communicable Disease Profile for Afghanistan and Neighbouring Countries
Contents
INTRODUCTION 2
FOOD OR WATER-BORNE DISEASES 1. Diarrhoeal diseases 3 2. Bacillary dysentery 6 3. Cholera 8 4. Typhoid fever 10 5. Poliomyelitis 12
RESPIRATORY-BORNE DISEASES 6. Acute Lower Respiratory Infections 14 7. Measles 17 8. Tuberculosis 20 9. Meningococcal disease 24
VECTOR-BORNE DISEASES 10. Malaria 26 11. Dengue 30 12. Crimean-Congo haemorrhagic fever 32 13. Plague 34
ZOONOTIC DISEASES 14. Rabies 36 15. Anthrax 38
ANNEXES Annex 1 : Syndromic Approach to Diagnosis of Communicable Diseases 40 Annex 2 : Steps for Management of a Communicable Disease Outbreak 45 Annex 3 : Safe Water and Sanitation 46 Annex 4 : Injection Safety 48 Annex 5 : Key WHO Contacts for Central Asia crisis 49 Annex 6 : List of WHO Guidelines on Communicable Diseases 53
WHO Communicable Disease WG on Emergencies/October 2001 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Introduction
This document is intended to provide health professionals working in Afghanistan and neighbouring countries with information on the major epidemic and endemic disease threats faced by the displaced population. Following an emergency, resettlement in temporary locations such as refugee camps may entail high population densities, inadequate shelter, poor water and sanitation, and lack of basic health care. This poses an increased threat of communicable diseases to the population and a high risk of epidemics. The document provides data on recent outbreaks in Afghanistan and neighbouring countries, outlines the burden of communicable diseases in the region, presents disease-specific guidelines on the prevention and control of these diseases and adapts them for use in an emergency situation.
The major causes of morbidity and mortality in Afghanistan and neighbouring countries are diarrhoeal diseases, acute respiratory infections and measles. Other communicable diseases such as meningococcal meningitis have caused large outbreaks among displaced populations. Malnutrition and trauma are the two main additional causes of illness and death. A systematic approach to the control of communicable diseases is a key component of humanitarian response. This profile seeks to provide local authorities, UN agencies and NGOs with a user friendly, concise summary on the prevention and control of the main communicable diseases among the emergency affected population.
The list of diseases has been selected on the basis of the potential threat to the population in terms of morbidity and mortality. Additional diseases will be added as data is received from the field. The profile will be updated in three months time.
This profile is a collaboration between the Communicable Disease Working Group on Emergencies (CD- WGE) at HQ, the Division of Communicable Disease Control (DCD) at EMRO and Communicable Diseases (CDS) at EURO. The CD-WGE supports the Department of Emergency and Humanitarian Action (EHA) on communicable disease control issues in emergencies and includes the Departments of Surveillance and Response (CSR), Control, Prevention and Eradication (CPE), Roll Back Malaria (RBM) and Stop TB (STB) in the Communicable Disease Cluster (CDS), the Department for Child and Adolescent Health (CAH), and the Department for Vaccines and Biologicals (VAB).
Compiled by Dr Claudio Beltramello (CPE), Mr Christopher Haskew (CPE), and Dr Maire Connolly (CSR) on Communicable Disease Working Group on Emergencies.
The following persons in HQ, EMRO and EURO contributed to the development of this document and their input is gratefully acknowledged:
Dr Samira Aboubaker (CAH), Mr Richard Allan (RBM), Dr Ray Arthur (CSR), Dr Karen Bradbury (MAL/EURO), Dr Sylvie Briand (CSR), Dr E Capobianco (STB/EMRO), Dr Daniel Lavanchy (CSR), Dr Claire-Lise Chaignat (CSR), Ms Claire Chauvin (VAB/Polio), Dr Otorino Cosivi (CSR), Dr Charles Delacollette (RBM), Dr Mikhail Ejov (MAL/EURO), Dr Taky Gaafar (DCD/EMRO), Dr Bernadus Ganter (CDS/EURO), Dr Malgosia Grzemska (STB), Dr Max Hardiman (CSR), Dr Hamid Jafari (EPI/EMRO), Dr Faizallah Kakar (CDS/Pakistan), Dr AnaMaria Henao-Restrepo (VAB), Dr Tony Mounts (EPI/Pakistan), Mr Jose Hueb (WSH), Dr Yvan Hutin (VAB), Mr Chris Maher (VAB/Polio), Dr Francois Meslin (CSR), Dr Rudi Nowak (CSR), Dr Aafje Rietveld (RBM), Dr Mike Ryan (CSR), Dr Guido Sabatanelli (RBM/EMRO), Dr Saleh Ottmani (STB), Dr Maria Santamaria (CSR), Dr Akihiro Seita (STB/EMRO), Dr Nadia Teleb (CSR/EMRO), Dr Eugene Tikomirov (CSR), Dr Shamim Qazi (CAH).
WHO would like to acknowledge the support of the Government of Ireland who funded the production of this document.
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Food or Water-borne Diseases 1. DIARRHOEAL DISEASES
DESCRIPTION
Infectious agent Bacteria: such as Salmonellae (commonly S. enteritidis, S. typhimurium) and Escherichia coli. The bacteria that cause the most severe outbreaks are Shigella dysenteriae type 1 and Vibrio cholerae (see Bacillary dysentery and Cholera) Protozoa: such as Giardia lamblia Viruses: such as Rotavirus and Norwalk virus Case definition Clinical case definition Three or more abnormally loose or fluid stools over 24 hours Mode of Fecal-oral route, particularly contaminated water and food transmission Incubation Salmonella generally requires an 8-48 hour incubation period, whereas E. coli is typically longer at 2-8 days (median of 3-4 days). Both usually last between 2-5 days The incubation period for rotavirus is about 48 hours, and symptoms may last for up to one week Period of During the acute stage of the disease and for duration of fecal excretion. Temporary communicability Salmonella carriers can continue to exist for several months
EPIDEMIOLOGY
Incidence in the No data available region Geographical Diarrhoeal diseases are endemic throughout the region distribution Seasonality No data available Alert threshold An increase in the number of cases above what is expected Recent epidemics See Bacillary dysentery and Cholera in the region
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Importation movement Overcrowding Yes Very important Poor access to Yes Early detection and containment of the cases are paramount to reduce transmission health services Food shortages Yes Malnutrition increases gastrointestinal tract susceptibility to invasiveness of the organism and severity of disease
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Lack of safe water Yes The most important risk factor. The prevention of diarrhoeal diseases depends on the and poor sanitation provision and use of safe water, adequate sanitation and health education. The supply of adequate quantities of water should be one of the highest priorities for camp planners. The emergency requirement is 20 litres/person/day. Common sources of infection in emergency situations are: S polluted water sources (e.g. by fecally contaminated surface water entering an incompletely sealed well) or during storage (e.g. by contact with hands soiled by faeces) S shared water containers and cooking pots Others Yes Lack of soap Risk assessment Diarrhoeal diseases are a major cause of morbidity and mortality in emergency conclusions situations. This is mainly due to an inadequate water supply in terms of quality and quantity; insufficient, poorly maintained sanitation facilities; and overcrowding. In camp situations, diarrhoeal diseases have accounted for between 25% and 40% of deaths in the acute phase of the emergency. Over 80% of deaths are among children under 2 years old.
PREVENTION AND CONTROL MEASURES
Case Management S The prevention and treatment of dehydration, using Oral Rehydration Salt (ORS) or i.v. fluids (ringer lactate) if severely dehydrated patient, is the mainstay of the management of diarrhoeal illness. Reduction of mortality due to diarrhoeal disease is primarily related to effective management of dehydration particularly in children. S Use of antibiotics is dependent on the infectious agent S Resume feeding with a normal diet when vomiting has stopped. It is important to separate those who are eating from those who are not. Food should be cooked on site. Continue breast feeding infants and young children Epidemic control S Inform the Health Authorities if a increase in the number of cases above what is expected is identified S Confirm the diagnosis and ensure prompt treatment S Confirm the outbreak following WHO guidelines Prevention Safe drinking water S Provision of an adequate supply, collection and storage system S Provision of information on the importance of clean water, also covering system maintenance and household storage See Annex 3 : Safe Water and Sanitation Safe disposal of human excreta S Provision of an adequate facilities for the disposal of human waste S Provision of information on the importance of human waste disposal, also covering use and maintenance of the facilities
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Food safety S Provision of adequate food storage facilities, (both uncooked and cooked), cooking utensils, adequate quantity of water and fuel to allow for cooking and reheating S Provision of information on the importance of food safety Hand washing with soap S Provision of soap, allowing for bathing and laundry S Provision of information on the diseases spread through lack of or poor hand washing. Demonstration of good hand washing Breastfeeding S Provision of information on: the protective qualities of breast-feeding. the importance of breast feeding ill children S Practical support for breast feeding ill children
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2. BACILLARY DYSENTERY (SHIGELLOSIS)
DESCRIPTION
Infectious agent Bacterium: Genus Shigella, of which Shigella dysenteriae type 1 causes the most severe disease and the largest epidemics Case definition Clinical case definition Diarrhoea with visible blood
Confirmed case Isolation of S. dysenteriae type 1 from stool Mode of Fecal-oral route, particularly contaminated water and food transmission Incubation Incubation period is usually 1-3 days. May be up to one week for S. dysenteriae type 1 Period of During acute infection and until 4 weeks after illness (without treatment). With appropriate communicability treatment 2-3 days. Asymptomatic carriers exist
EPIDEMIOLOGY
Incidence in the No data available region Geographical The disease is present throughout the region distribution Seasonality No data available Alert threshold Five or more linked cases must be investigated further Recent epidemics No data available in the region
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Importation movement Overcrowding Yes Very important Poor access to Yes S Early detection and containment of the cases are paramount to reduce health services transmission S Case fatality rate is high for S. dysenteriae type 1 in children under 10 years-old (10%) in absence of a proper treatment Food shortages Yes Malnutrition increases gastrointestinal tract susceptibility to invasiveness of the organism and severity of disease Lack of safe water Yes The most important risk factor. and poor sanitation Others No
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Risk assessment Risk of epidemics of S. dysenteriae type 1 is high in the refugee camps (up to one third conclusions of the population at risk may be affected) In the general population the risk is strictly related to the availability of safe water
PREVENTION AND CONTROL MEASURES
Case Management S S. dysenteriae type 1 is often more severe or fatal in young children, the elderly, and the malnourished, and prompt treatment with antibiotics is essential S Appropriate antibiotic therapy is very important. Selection depends on resistance patterns of the bacteria and drug availability S Nalidixic acid is first choice, and ciprofloxacin second choice in the region S A study performed in Pakistan, in 1990, showed that all shigella isolates were susceptible to nalidixic acid, 7% susceptible to cotrimoxazole, and 3.5% to ampicillin. No recent data on strain resistance are available, and selection of antibiotics must be tailored to reflect clinical response and anti-biogramme sensitivity results S Dehydration prevention and case management using ORS also plays an important role Epidemic control S Inform the Health Authorities if one or more suspected cases are identified S Confirm the outbreak, following WHO guidelines. Stool samples must be taken with a rectal swab and transported in Cary Blair medium. It is recommended that 10-20 cases be used to confirm the cause, identify antibiotic sensitivity and verify the outbreak. Once confirmed, it is not necessary to obtain laboratory confirmation for every patient as this depletes laboratory supplies. Do not wait for laboratory results before starting treatment/control activities S Confirm the diagnosis and ensure prompt treatment Prevention S See prevention of diarrhoeal diseases See Annex 3 : Safe Water and Sanitation See Guidelines for the Control of Epidemics due to Shigella dysenteriae type 1, WHO, 1995. Available at: http://www.who.int/emc-documents/cholera/whocdr954c.html
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3. CHOLERA
DESCRIPTION
Infectious agent Bacterium: Vibrio cholerae. Case definition Clinical case definition Person aged over 5 years with severe dehydration from acute watery diarrhoea. Person aged over 2 years with acute watery diarrhoea in an area where there is a cholera outbreak
Confirmed case Isolation of Vibrio cholerae O1 or O139 from diarrhoeal stool sample Mode of Fecal oral route, particularly contaminated water and food transmission Incubation Incubation period is usually between 1 and 5 days Period of During the symptomatic phase until 2-3 days after recovery. Very rarely for months communicability
EPIDEMIOLOGY
Incidence in the No data available region Geographical Cholera outbreaks have occurred in all the countries of the region during the past five distribution years Seasonality Higher risk from June until September Alert threshold One suspected case must be investigated Recent epidemics Afghanistan in the region June 2001 Samangan and Baghlan provinces 4499 cases including 114 deaths (CFR 2.5%) reported Vibrio cholerae serotype Ogawa, laboratory confirmed 2000 4330 cases and 198 deaths reported to WHO
Iran August 1998 Teheran, Qom, Espahan, and Sistan- Baluchistan 4300 cholera cases including 44 deaths. May 2000 Cholera suspected In Dol Avkurt camps, Kandil Moutain 76 deaths reported in the camps in North-eastern area. Number of cases unknown. 352 cases including 3 deaths were reported in 2000
Pakistan February 2000 Cholera suspected in Khairpur district 9 deaths (all children, age: 2-10) reported. Number of cases unknown August 2000 Cholera suspected in Muzaffarabad 4 deaths reported in north-eastern area. Number of cases unknown
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RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Importation movement Overcrowding Yes Very important Poor access to Yes S Early detection and containment of the cases are paramount to reduce health services transmission S Case fatality rate is extremely high (from 5% up to 40%) in absence of a proper treatment Food shortages No Lack of safe water Yes The most important risk factor and poor sanitation Others No Risk assessment Risk of cholera outbreaks is extremely high in the refugee camps conclusions In the general population the risk is related to the availability of safe water
PREVENTION AND CONTROL MEASURES
Case Management S The prevention and treatment of dehydration, using ORS or i.v. fluids (ringer lactate) if severely dehydrated patient, is the mainstay of the case management of cholera S Use of antibiotics (doxicycline/tetracycline) is not essential for disease treatment but may be used to shorten the duration of the diarrhoea Epidemic control S Inform the Health Authorities if one or more suspected cases are identified S Confirm the outbreak, following WHO guidelines. Stool samples must be taken with a rectal swab and transported in Cary Blair medium. It is recommended that 10-20 cases be used to confirm the cause, identify antibiotic sensitivity and verify the outbreak. Once confirmed, it is not necessary to obtain laboratory confirmation for every patient as this depletes laboratory supplies. Do not wait for laboratory results before starting treatment/control activities S Confirm the diagnosis and ensure prompt treatment S Isolate cases in cholera treatment centres Prevention S See prevention of diarrhoeal diseases See Annex 3 : Safe Water and Sanitation See Guidelines for cholera control, WHO 1993 Immunization Two oral vaccines are currently available: S killed cholera vaccine (WC/rBS, two doses); and S live attenuated vaccine (CVD103- HgR, single dose) They are licensed in a few countries only. Both might be used in carefully evaluated emergency situations, such as refugee camps or slum residents. Cholera vaccine has to be used in conjunction with other prevention and control measures
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4. TYPHOID FEVER
DESCRIPTION
Infectious agent Bacterium: Salmonella typhi Case definition Clinical case definition Clinical diagnosis is difficult. In absence of laboratory confirmation, any suspected case by a clinician is considered relevant
Confirmed case Laboratory blood examination (antibodies); Isolation of S. typhi from blood or stool Mode of Fecal oral route, particularly contaminated water and food transmission Incubation Incubation period is usually 8-14 days but may be from 3 days up to one month Period of From the symptomatic period for 2 weeks. 10% of untreated patients remain carriers for communicability several months. Chronic carriers are greatly involved in the spread of the disease
EPIDEMIOLOGY
Incidence in the No data available region Geographical The disease is present throughout the region (about 70 % of worldwide fatalities occur in distribution Asia) Seasonality No data available Alert threshold Two or more linked cases
Recent epidemics Tajikistan in the region December 2000 Kolkhozabad and Darband regions 225 cases, 1 death reported Laboratory confirmed
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Dissemination of multi-drug resistant strains of S. typhi movement Overcrowding Yes Very important Poor access to Yes S Early detection and containment of the cases are paramount to reduce health services dissemination S Case fatality rate is high (10-20%) in absence of a proper treatment Food shortages No Lack of safe water Yes The most important risk factor and poor sanitation
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Others Yes S Multi-drug resistant strains of S. typhi including resistance to ciprofloxacin (the epidemic in Tajikistan was due to this resistance) S Milk and dairy products are an important source of infection Risk assessment In the general population the risk is related to the availability of safe food and water conclusions In endemic areas, the incidence of typhoid fever peaks between the age of 5 and 12 years old (in the age group <5, in India)
PREVENTION AND CONTROL MEASURES
Case Management S Early antimicrobial treatment, selected according to the antimicrobial resistance pattern of the strain: ciprofloxacin; cotrimoxazole; chloramphenicol; ampicillin are usually used for typhoid fever S The strain in Tajikistan isolated in 1996 at the beginning of the outbreak was sensitive to chloramphenicol and resistant to cotrimoxazole and ampicillin. In 1997, multi-drug resistant strains (including ciprofloxacin) were isolated S Dehydration prevention and case management using ORS also plays an important role Epidemic control S Inform the Health Authorities if one or more suspected cases are identified S Confirm the outbreak, following WHO guidelines S Confirm the diagnosis and insure prompt treatment Prevention S See prevention of diarrhoeal diseases See Annex 3 : Safe Water and Sanitation Immunization S Mass immunization may be an adjunct for the control of typhoid fever during a sustained, high incidence epidemic. This is especially true when access to well functioning medical services is not possible or in case of a multi-drug resistant strain S A parenteral vaccine containing the polysaccharide Vi antigen is the vaccines of choice amongst displaced populations. An oral, live vaccine using S. typhi strain Ty21a is also available S Neither the polysaccharide vaccine nor the Ty21a vaccine is licensed for children under two years old. The Ty21a vaccine should not be used in patients receiving antibiotics
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5. POLIOMYELITIS
DESCRIPTION
Infectious agent Enterovirus group: types 1,2 ,3 Case definition Clinical case definition S Acute flaccid paralysis (AFP) in a child aged <15 years including Guillain Barré syndrome; or S Any paralytic illness in a person of any age when polio is suspected.
Confirmed case Laboratory-confirmed wild poliovirus infection in stool sample Mode of Poliovirus is highly communicable. Transmission is primarily person-to-person via the transmission fecal-oral route Incubation The time between infection and onset of paralysis is 10-21 days Period of From 36 hours after infection, for 4-6 weeks communicability
EPIDEMIOLOGY
Incidence in the Afghanistan region 9 confirmed polio cases in 2001 (120 cases in 2000) Pakistan 45 confirmed polio cases in 2001 (199 cases in 2000) Geographical Afghanistan and Pakistan are still polio endemic distribution Tajikistan and Turkmenistan are polio free The last viruses to be identified in Iran were in 2000, and were imported from Pakistan Seasonality Peak seasons in Afghanistan and Pakistan: September, October, and November Alert threshold One suspected case must lead to an alert S In Afghanistan & Pakistan, an outbreak can be suspected when there is a rapid increase in the reported number of AFP cases (greater than three times the expected number of AFP cases) within a district or in adjacent districts, occurring within a two month period S In Iran, Turkmenistan, & Tajikistan an outbreak can be suspected when there is a cluster of AFP cases with a high index of suspicion, or cluster of polio compatible cases (two or more compatibles with onset in the same or adjacent districts within a two month period) Recent epidemics Detection of wild poliovirus circulation in 2001 in Uruzgan, Quandahar, Helmand in the region (Afghanistan) Tajikistan 1991, Turkmenistan 1996, Iran 2000
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Importation movement
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Overcrowding Yes Very important Poor access to Yes S No access to routine immunization services health services S Risk of undetected poliovirus circulation Food shortages No Lack of safe water Yes Generally poor sanitation and poor sanitation Others No Risk assessment High risk of importation of wild poliovirus in polio free zone. Disturbance in the conclusions supplementary immunization activities, and surveillance system.
PREVENTION AND CONTROL MEASURES
Immunization S In refugee camps all children 0-59 months should be vaccinated on arrival, regardless of vaccination status, as part of a supplementary immunization activity S Upcoming supplementary immunization activities: C Pakistan & Afghanistan (November 2001, Jan, Feb & April 2002); C Iran (Oct & Nov. 2001 - Sub-national Immunization Days); C Tajikistan & Uzbekistan (Oct. & Nov. 2001 - National Immunization Days; April & May 2002 - Mop-up) Epidemic control S Immediate notification if one or more suspected cases are identified S Clinical and epidemiological investigation; rapid virological investigation (specimens prioritized in a WHO accredited laboratory); outbreak will be confirmed based on the isolation of wild poliovirus S Pakistan & Afghanistan C Enhanced surveillance; and large scale immunization response (province wide at least) in the area affected by the outbreak if no NIDs or SNIDs covering the area are planned within the next 3 months or if NIDs/SNIDs are planned, a major quality focus on the area of the outbreak and adjacent districts S Iran, Turkmenistan and Tajikistan C House to house mop-up immunization campaign in a wide geographic area (at least province involved and relevant neighbours); and CEnhanced surveillance (intensive monitoring of all reporting units, ensuring active surveillance and zero reports, extensive retrospective record reviews, active case search in surrounding areas)
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Respiratory-Borne Diseases
6. ACUTE LOWER RESPIRATORY INFECTIONS (ALRI)
DESCRIPTION
Infectious agent Bacteria: the most common are Streptococcus pneumoniae and Haemophilus influenzae. Several respiratory viruses Case definition Clinical case definition ALRI are bronchitis, bronchiolitis, and pneumonia. Pneumonia is the most severe and it is fatal in 10-20% of the cases if inappropriately treated
S Pneumonia Symptoms Cough or difficult breathing; and Signs Breathing 50 or more times per minute for infants aged 2 months to 1 year Breathing 40 or more times per minute for children aged 1 to 5 years; and No chest indrawing, stridor or general danger signs.
S Severe Pneumonia Symptoms Cough or difficult breathing and any general danger sign or Chest indrawing or stridor in a calm child.
In infants under 2 months of age the presence of any of the following indicates severe pneumonia: cough or difficult breathing and breathing 60 or more times per minute or grunting or nasal flaring or fever or low body temperature or any general danger sign.
General danger signs For children aged 2 months to 5 years: unable to drink or breast feed; vomiting; convulsions; lethargic or unconscious Mode of Air borne transmission Incubation Depends on the infective agent. Usually 2-5 days Period of Depends on the infective agent. Usually during the symptomatic phase. communicability
EPIDEMIOLOGY
Incidence in the Pneumonia is reported as one of the leading cause of death of children under five throughout region the region Geographical Throughout the region distribution Seasonality Higher incidence of pneumonia during the cold season Alert threshold An increase of the number of cases above what is expected
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Recent epidemics Afghanistan in the region February 2000 Darwaz district Of a total population of 12,000, 50-80% was affected by ARI and 1-2% was estimated to have died of secondary complications. This corresponds to some 240 deaths.
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Influx of non-immune population / infected individuals into areas of new pathogens movement Overcrowding Yes Very important Poor access to Yes S Prompt identification and treatment of the cases is the most important control health services measure S Without proper treatment fatality rate is high (20 % or more in emergency situations) Food shortages Yes Low birth weight, malnutrition, vitamin A deficiency, and poor breastfeeding practices are important risk factors for ALRI Lack of safe water No and poor sanitation Others Yes Indoor air pollution. Low temperatures during winter in region increases risk of pneumonia Risk assessment ALRI represent the leading cause of death between children under 5 in developing conclusions countries. The emergency situation now occurring in the region is likely to increase the number of cases and subsequently the number of deaths Highest priority must be given to early diagnosis and treatment of each case of ALRI
PREVENTION AND CONTROL MEASURES
Case Management S Priority is early recognition and adequate treatment of cases S Appropriate use of antibiotics (selection depends on national protocols and available drugs). The New Emergency Health kits contain co-trimoxazole which is broad spectrum and cost-effective. Alternatives are amoxicillin and chloramphenicol. For severe pneumonia, i.v./i.m. antibiotics such as ampicillin or chloramphenicol should be used S Supportive measures such as oral fluids to prevent dehydration, continued feeding to avoid malnutrition, anti-pyretics to reduce fever and protection from cold are essential S Signs of malnutrition should be assessed as this increases the risk of death due to pneumonia. Severely malnourished children must be referred to hospital S Any pneumonia in infants less than 2 months should be treated as severe pneumonia. S Any severe pneumonia in infants less than 2 months should be treated with penicillin/ampicillin plus gentamycin. These infants should be kept warm. S All children presenting with cough and/or difficult breathing should be carefully assessed
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Prevention S Community wide awareness campaign on early danger signs S Adequate feeding to avoid malnutrition S Protection from the cold Immunization S Measles, diphtheria and whooping cough immunization are effective to reduce impact of ARLI
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7. MEASLES
DESCRIPTION
Infectious agent Measles virus Case definition Clinical case definition S Any person with fever and maculopapular rash (i.e. non vesicular), and cough, coryza (i.e. runny nose) or conjunctivitis (i.e. red eyes); or S Any person in whom a clinical health worker suspects measles infection
Confirmed case S At least a fourfold increase in antibody titre; or S Isolation of measles virus; or S Presence of measles specific IgM antibodies Mode of S Airborne by droplet spread; or transmission S Direct contact with the nasal and throat secretions of infected persons or via object (e.g. toys) that has been in close contact with an infected person Incubation After infection there is an asymptomatic incubation period of 10-12 days, with a range from 7 to 18 days from exposure to the onset of fever Period of Measles is most infectious from 4 days before the rash until 1-2 days after rash onset communicability
EPIDEMIOLOGY
Incidence in the Afghanistan region 6532 reported cases in year 2000, and 5543 cases Jan-Sept 2001. (Reported age distribution: <1 year = 8%; 1-4 yrs =48%; 5-14 yrs= 41%; < 15 yrs= 3%) Data presented is from 222 sentinel sites reporting measles amongst a total of 237 existing sites, but not all are homogeneously distributed over the country (many districts located in the central, southern and south-eastern areas are not represented in this system). Geographical Measles is highly endemic throughout the region and the expected number of measles distribution cases is high. Seasonality Higher incidence during the winter period (November to March) Alert threshold One case must lead to an alert Laboratory confirmation of all cases is NOT REQUIRED. Only few cases from each outbreak should be laboratory confirmed. Recent epidemics Measles epidemics are reported each year throughout Afghanistan. in the region 1999-2000 Majority of epidemics located in the North-eastern districts. The two largest were reported in Darwaz and Badkhshan (323 deaths) and Darrasouf and Samangan (256 deaths) in January 2000
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Importation movement
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Overcrowding Yes Crowded conditions facilitate transmission Poor access to Yes Case-fatality rates can be reduced by effective case management, including the health services administration of vitamin A supplements Food shortages Yes Very important factor for the severity of the disease. Disease is more severe among children with malnutrition and vitamin A deficiency Lack of safe water No and poor sanitation Others Yes Low immunization coverage in the area of origin of the refugees or internally displaced people, and/or the host area. Risk assessment Extremely high risk of outbreaks in camps or where there is a high concentration of conclusions population. In Afghanistan, one third of districts have no EPI programme and measles vaccination coverage rates are estimated to be less than 50%. In addition measles vaccination coverage among the local Pakistani population is low. Measles immunization should be given the highest priority.
PREVENTION AND CONTROL MEASURES
Immunization S Immunize the population at risk as soon as possible. Children who are vaccinated against measles before 9 months of age must receive a second measles vaccination. This should be given at nine months with at least one month between first and second vaccination. Any child who received measles vaccine should also receive Oral Polio Vaccine. S The priority is to immunize children 6 months to 5 years old, regardless of vaccination status or history of disease. Expansion to older children is of less priority and should based on evidence of high susceptibility among this age group S All children 6 months -5 years of age should also receive prophylactic Vitamin A supplementation. If evidence of clinical vitamin A deficiency in older age groups, treatment with Vitamin A should be initiated as per WHO guidelines S To ensure safety of injection during immunization auto destructible syringes and safety boxes are recommended. Safe disposal of used sharps should be ensured Case Management For uncomplicated cases: S give Vit. A and advise to treat the child at home if no complications develop (control fever, treat mouth ulcers, provide nutritional feeding)
For complicated cases: S refer to health facility S ensure that 2 doses of Vit. A are given S clean eyes and treat with 1% tetracycline eye ointment S clean ear discharge and treat with antibiotics S treat malnutrition and diarrhoea with sufficient fluids and high quality diet S treat pneumonia with antibiotics S refer suspected encephalitis to hospital
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Epidemic control S Inform the Health Authorities if one or more suspected cases are identified S Confirm the suspected outbreak, following WHO guidelines S Investigate suspected case: check if it fulfils the case definition, record date of onset, age and vaccination status S Confirm the diagnosis: collect blood specimen from 5-10 initial reported cases S Assess the extent of the outbreak and the population at risk S Implement outbreak response measures. Give priority to case management and immunization of population in areas not yet affected where the outbreak is likely to spread
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TUBERCULOSIS
DESCRIPTION
Infectious agent Bacterium: Mycobacterium tuberculosis. This complex includes M. tuberculosis and M. africanum primarily from humans, and M. Bovis primarily from cattle
Case definition Pulmonary TB smear-positive (PTB+) Diagnostic criteria should include: - At least two sputum smear specimens positive for acid fast bacilli (AFB) or - One sputum smear specimen positive for AFB and radiographic abnormalities consistent with active pulmonary TB or - One sputum smear specimen positive for AFB and a culture positive for M. tuberculosis
Pulmonary TB smear-negative (PTB-) A case of pulmonary tuberculosis that does not meet the above definition for smear- positive TB. Diagnostic criteria should include: - At least three sputum smear specimens negative for AFB and - Radiographic abnormalities consistent with active pulmonary TB and - No response to a course of broad spectrum antibiotics and - Decision by a clinician to treat with a full course of anti-tuberculosis chemotherapy
TB suspect - Any person who presents with symptoms or signs suggestive of pulmonary TB, in particular cough of long duration - May also have haemoptysis, chest pain, breathlessness, fever/night sweats, tiredness, loss of appetite and significant weight loss - All TB suspects should have three sputum samples examined by light microscopy, early morning samples are more likely to contain the TB organism than a sample later in the day Mode of S Exposure to tubercle bacilli in airborne droplet nuclei produced by people with transmission pulmonary or laryngeal tuberculosis during expiratory efforts, such as coughing and sneezing S Bovine tuberculosis results from exposure to tuberculous cattle, usually by ingestion of unpasteurized milk or dairy products, and sometimes by airborne spread to farmers and animal handlers Incubation Incubation period is about 2-10 weeks, but latent infections may persist all life Period of As long as viable tuberculosis bacilli are being discharged in the sputum. Effective communicability treatment usually eliminates communicability within 2 weeks
WHO Communicable Disease WG on Emergencies/October 2001 20 Communicable Disease Profile for Afghanistan and Neighbouring Countries
EPIDEMIOLOGY
Incidence in the Afghanistan region Estimated number of cases : 71,000 (Incidence rate 325/100,000) Estimated new cases of smear positive TB: 32,000 equivalent to 146/100,000 Pakistan Estimated number of cases: 269,000 (Incidence rate 177/100,000) Estimated new cases of smear positive TB: 121,000 equivalent to 79/100,000 Iran Estimated number of cases: 36,000 (Incidence rate 52/100,000) Estimated new cases of smear positive TB: 16,000 equivalent to 24/100,000 Tajikistan Estimated number of cases: 6,400 (Incidence rate 105/100,000) Estimated new cases of smear positive TB: 2900 equivalent to 47/100,000 Uzbekistan Estimated number of cases: 23,200 (Incidence rate 97/100,000) Estimated new cases of smear positive TB: 10,400 equivalent to 43/100,000 Geographical Tuberculosis is widespread in the region distribution Seasonality No specific seasonality is reported Alert threshold An increase in number of cases in crowded settings must lead to an alert Recent epidemics No data available in the region
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Mainly due to the interruption in treatment and increased duration of movement communicability Overcrowding Yes Overcrowding is recognized as one of the most important factors leading to increase risk of transmission Poor access to Yes S People affected by TB who cannot access health services and be treated, health services remain infectious for a longer period S The fatality rate is high (about 50%) without proper treatment S The interruption of treatment is the most important cause of development of multi-drug resistant TB (MDR-TB) Food shortages Yes Poor nutritional status increases vulnerability to TB infection and development of active disease Lack of safe water No and poor sanitation Others No
WHO Communicable Disease WG on Emergencies/October 2001 21 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Risk assessment The risk of an epidemic of TB in Afghan refugees is high, particularly with the conclusions high incidence rates in the Afghan population, potential overcrowded conditions in camps and the poor nutritional status. TB is a chronic disease which requires supervised treatment for at least 6 months. During the emergency phase (death rates 1>100,000) priority should be given to issues like water, food, shelter, sanitation and to other acute diseases. TB control activities should be initiated only in the post emergency phase when refugees are settled and when security in, and stability of the camp is envisaged for at least 6 months. Laboratory services for sputum smear microscopy should be made available.
PREVENTION AND CONTROL MEASURES
Case Management The priority is the diagnosis and treatment of smear positive infectious cases of TB. To ensure the appropriate treatment and cure of TB patients, strict implementation of the DOTS strategy is important. The DOTS strategy has the following components: S Case detection through sputum smear microscopy S Standardized short-course chemotherapy to, at least, all smear positive cases under direct observation of treatment, at least, during the initial phase of treatment. S Regular supply of anti-TB drugs S Monitoring system for programme supervision and evaluation
There are primarily three types of regimens: category 1 regimen for new smear positive (infectious) pulmonary cases, category 2 regimen for retreatment cases, and category 3 regimen for smear negative pulmonary or extra-pulmonary cases.
The chemotherapeutic regimens are based on standardized combinations of 5 essential drugs: Rifampicin (R ), isoniazid (H), Pyrazinamide (P), Ethambutol (E) and Streptomycin (S).
Each of the standardized chemotherapeutic regimens consist of 2 phases: - Initial (intensive) phase: 2-3 months, with 3-5 drugs given daily under direct observation - Continuation phase: 4-6 months, with 2-3 drugs given 3 times a week under direct observation, or in some cases (e.g. during repatriation of refugees) 2 drugs for 6 months given daily unsupervised, but in fixed dose combination form.
All doses of rifampicin containing regimens should be observed by staff. Actual swallowing of medication should be checked.
See WHO guidelines for Recommended Treatment Regimen Also Treatment of Tuberculosis: Guidelines for National Programmes (WHO/TB/97.220) Tuberculosis control in refugee situations: an inter-agency field manual (WHO/TB/97.221) Immunization S BCG has been shown to be effective in preventing severe forms of TB such as meningitis in children. S BCG is strongly recommended for all newborn children and any children up to the age of 5 years who have not already received it. S The vaccination of newborns should be incorporated into the immunization programme for all children. Re-vaccination is not recommended.
WHO Communicable Disease WG on Emergencies/October 2001 22 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Prevention S Detection and treatment of smear positive TB cases is the most effective preventive measure S Health education to improve awareness and reduce stigma S Maintaining good ventilation and reducing overcrowding in health clinics, and ensuring hospitalized patients are kept in a separate ward for the first two weeks of treatment. S Isoniazid prophylaxis is not recommended in refugee situations, except for children being breast-fed by smear positive mothers. If the child is well, BCG vaccination should be postponed and isoniazid should be given to the child for 6 months. In the event of a sudden disruption to the programme, isoniazid may be stopped, and BCG should be given before the child leaves the refugee camp (preferably after a one week interval)
WHO Communicable Disease WG on Emergencies/October 2001 23 Communicable Disease Profile for Afghanistan and Neighbouring Countries
9. MENINGOCOCCAL DISEASE (MENINGITIS and SEPTICAEMIC FORM)
DESCRIPTION
Infectious agent Bacterium: Neisseria meningitidis serogroups A,B,C,Y,W135 Case definition Clinical case definition Person with sudden onset of fever (>38.0 °C axillary) and one of the following: S neck stiffness S altered consciousness S other meningeal sign or petechial or purpural rash In patients under one year of age meningitis is suspected when fever is accompanied by a bulging fontanelle
Confirmed case Positive cerebro-spinal fluid antigen detection or cerebro-spinal fluid positive culture or blood positive culture Mode of Direct contact with respiratory droplets transmission Incubation Incubation period varies between 2 to 10 days, most commonly 4 days Period of From the beginning of the symptoms till 24 hours after the institution of the therapy, but communicability the most important source of infection are asymptomatic carriers
EPIDEMIOLOGY
Incidence in the No data available region Geographical Sporadic cases throughout the region distribution Seasonality Increase in incidence during cold months Alert threshold Five cases per 100,000 per week or a cluster of cases in an area Recent epidemics Afghanistan in the region Spring 2000 Central highlands 175 cases and 7 deaths
May 2001 Kandahar 30 cases and 1 death
India 1985 New Delhi 6133 cases
WHO Communicable Disease WG on Emergencies/October 2001 24 Communicable Disease Profile for Afghanistan and Neighbouring Countries
RISK FACTORS FOR INCREASED TRANSMISSION
Population No movement Overcrowding Yes The most important Poor access to Yes S Cases identification is crucial to rapidly implement control measures health services S Case fatality ratio in absence of treatment is very high (50%) Food shortages No Lack of safe water No and poor sanitation Others No Risk assessment High risk of epidemics in overcrowded refugee camps conclusions Low risk of epidemics in the general population
PREVENTION AND CONTROL MEASURES
Case Management S Prompt treatment with oily chloramphenicol i.m. or benzylpenicillin i.v. or ampicillin i.v. S Treatment of convulsions with diazepam. S General supportive measures are important Epidemic control S Prompt identification, with laboratory confirmation, and management of cases. Mass immunization if applicable (see below) Immunization Refugee camp population Following confirmation (serogroup identified) of two cases mass vaccination is recommended if the serogroup/s identified is/are included in either the bivalent (A, C) or tetravalent (A, C, Y, W135) vaccine. At risk populations (e.g. 2-30 years of age) should be given priority General population If an outbreak is suspected vaccination should only be considered after careful investigation (including confirmation and serogroup identification) and the assessment of the population group at highest risk
WHO Communicable Disease WG on Emergencies/October 2001 25 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Vector-Borne Diseases
10. MALARIA
DESCRIPTION
Infectious agent Protozoan parasite: Plasmodium vivax (80-90% of cases in Afghanistan) Plasmodium falciparum (10-20% of cases). This is the most life threatening form of the disease. Case definition Clinical case definition S Uncomplicated Malaria Patient with fever or history of fever within the last 48 hours (with or without other symptoms such as nausea, vomiting and diarrhoea, headache, back pain, chills, myalgia) in whom other obvious causes of fever have been excluded. S Severe Malaria Patient with symptoms as for uncomplicated malaria, as well as drowsiness with extreme weakness and associated signs and symptoms related to organ failure such as disorientation, loss of consciousness, convulsions, severe anaemia, jaundice, haemo- globinuria, spontaneous bleeding, pulmonary oedema and shock.
Confirmed case Demonstration of malaria parasites in blood film by examining thick or thin smears, or by rapid diagnostic test kit for P. falciparum.
Mode of Mosquito bite: Anopheles superpictus is the main vector. Its breeding places are mountain transmission streams in foothills and rice fields. Other vectors are An. stephensi, An. culicifacies and An. pulcherrimus. Malaria may also be transmitted by injection of infected blood. Rarely, infants may contract malaria in utero due to trans-placental transfer of parasites, or during delivery. Incubation Average incubation period for mosquito-transmitted P. falciparum is 12 days and for P. vivax 13-17 days. However, malaria should be considered in all cases of unexplained fever that starts at any time between one week after the first possible exposure to malaria risk and 2 months (or even later in rare cases) after the last possible exposure. Period of Humans can remain infected for some years with P. vivax, if inadequately treated. communicability Communicability is related to the presence of infective Anopheles mosquitoes.
EPIDEMIOLOGY
Incidence in the Afghanistan region 2-3 million estimated clinical cases in 1999, however only 395,600 cases were reported by the health services in that year. Approximately 80-90% of malaria cases were due to P. vivax and 10-20% to P. falciparum (with 300,000-450,000 estimated falciparum malaria cases per year). Tajikistan P. vivax is the predominant species, but the proportion of P. falciparum has continued to increase in recent years. Recent WHO/EURO RBM studies estimate that the number of malaria cases (symptomatic and asymptomatic) in Tajikstan could come to 300,000- 400,000/year. There were very few reported malaria deaths in 2000, none as yet in 2001.
WHO Communicable Disease WG on Emergencies/October 2001 26 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Geographical Malaria is endemic throughout Afghanistan, mostly at altitudes below 1500m - especially distribution the rice growing areas - but it also occurs in urban areas such as Kabul and Jalalabad. The central highlands are malaria free. The duration and intensity of transmission depends upon altitude, temperature and rainfall. Eastern zone: transmission is highest (mesoendemic) in rice growing areas. Seasonality In Afghanistan, malaria transmission usually starts in April / May, peaking in October / November, and diminishing rapidly in December with the onset of winter and drop in temperature In Tajikistan malaria risk exists from June through October. In Pakistan, transmission in the southern part of the country is year-round, with seasonal peaks mostly after the July- August monsoon. In the northern part, peaks occur between April and December in areas below 2000m Alert threshold Any increase of the number of cases above what is expected for the time of year Recent epidemics Afghanistan in the region September 2000 Yakawlang district of Bamyan province 15 deaths reported from P. falciparum malaria September 1999 Nazian Eastern Afghanistan Prevalence of P.falciparum malaria was reported at 15% amongst a population of 8500 No deaths were recorded and the outbreak was controlled.
September 1999 Qalai Nao of Badghis province 293 cases of P.falciparum malaria, and 8 deaths were recorded.
November 1999 Narang in Kunar Province Prevalence of P.falciparum was reported as over 30% in a population of 23000 2 deaths were reported and the outbreak was controlled.
Other outbreaks have been reported from the north of the country, in Faryab (22% P.falciparum prevalence), Herat, Baghlan and Kundus. No details of numbers affected or control measures are known.
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes The potential for epidemics can increase due to: movement S The influx of non-immune populations (such as from the central highlands) into the malarious areas of the north (Faryab and Samangan provinces), the Northeast (the whole region at altitudes below 1500m), the east (Nangahar, Laghman and parts of Kunar province), the south (Helmand and Kandahar provinces), the west (parts of Farah province, Shindand and Torghundi districts in Herat province) S Introduction of a number of infected individuals into a malaria free area where conditions for malaria transmission still exist. This happened in the Badghis (1999) and the Yakawlang (2000) outbreaks. It is believed that displaced people from the neighbouring Faryab province introduced the P. falciparum to Qalai Nao of Badghis province, while merchants from Yakawlang district who used to travel to Baghlan and Saripul provinces are thought to have introduced the parasite to those remote malaria-free villages. Overcrowding Yes Due to increased population density and increased exposure to mosquito bites in temporary shelters
WHO Communicable Disease WG on Emergencies/October 2001 27 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Poor access to Yes S Delays in access to effective treatment increase the likelihood of severe disease health services and death S Delays in access to effective treatment also increase the pool of malaria gametocyte carriers (the mature sexual stage of the parasite in humans, that once picked up in the blood feed of a mosquito then develops into the infective stage for transmission to another human) Food shortages Yes Malnutrition increases vulnerability to severe malaria once infected. Case management also becomes more complicated, resulting in increased mortality Lack of safe water No However, temporary surface water bodies may increase malaria vector breeding and poor sanitation opportunities Others Yes S Breakdown of control measures, and lack of preventive interventions such as insecticide treated materials (bed nets, sheeting etc.) and residual insecticide spraying of shelters S Sudden increase in vectorial capacity as a result of unusual weather. Many parts of the country were stricken by drought and witnessed prolonged periods of abnormally warm weather during the past two years. Unusual / unseasonal favourable meteorological conditions can increase vector capacity and subsequent malaria transmission S Epidemics are usually severe when rains follow unusual drought / famine periods Risk assessment The majority of malaria cases in Afghanistan will be caused by P. vivax, which is conclusions rarely life threatening. 10-20% of cases will be P. falciparum which can cause severe disease and death. The peak malaria season is October / November in Afghanistan. There are estimated to be over 3 million displaced, many fleeing highland areas (with less or no malaria) and moving to, or through, areas where they are at risk of malaria transmission. This specific displaced group has low immunity to malaria and is at increased risk of severe disease if infected. Long term drought across the country has resulted in increasing malnutrition. All malnourished are at increased risk of severe disease, particularly young children. Those communities displaced to border regions of Pakistan and Tajikistan where malaria transmission is relatively higher are most at risk both during the remaining transmission period and from the start of the new transmission season in April/May.
WHO Communicable Disease WG on Emergencies/October 2001 28 Communicable Disease Profile for Afghanistan and Neighbouring Countries
PREVENTION AND CONTROL MEASURES
Case Management For patients with P. falciparum - sulfadoxine-pyrimethamine (SP) one dose, given as 25mg/kg body laboratory-confirmed weight of the sulfa component (i.e. 3 tablets stat for an adult) uncomplicated malaria plus - paracetamol 2 days to reduce the fever (by microscopy or dipstick) plus (in Tajikistan, Uzbekistan and Turkmenistan only) - anti-gametocyte treatment: primaquine, 0.75 mg/kg as a single
dose
P. vivax - chloroquine total 25 mg/kg body weight divided over three days, given as 10 mg/kg on the 1st and 2nd day, and 5 mg/kg on the 3rd day plus (in Tajikistan, Uzbekistan and Turkmenistan only) - anti-relapse treatment: primaquine, 0.25 mg/kg for 14 days Mixed infection - sulfadoxine-pyrimethamine plus chloroquine (as above) plus (in Tajikistan, Uzbekistan and Turkmenistan only) - anti-relapse treatment: primaquine, 0.25 mg/kg for 14 days Note : Due to compliance problems and ongoing transmission in most areas, primaquine antirelapse treatment for P.vivax infections is NOT indicated amongst refugees in Afghanistan, Pakistan and Iran. Clinical uncomplicated malaria Sulfadoxine pyrimethamine (SP) one dose, given as 25mg/kg body weight of the sulfa component (i.e. 3 tablets stat for an adult); plus Chloroquine total 25 mg/kg body weight divided over three days, given as 10 mg/kg on the 1st and 2nd day, and 5 mg/kg on the 3rd day Note: Applies to Afghanistan, Pakistan and Iran only
For treatment of cases presenting with suspected treatment failure or severe malaria see WHO Malaria Treatment Protocols for Afghanistan and surrounding areas, October 2001. Available at: www.rbm.who.int Prevention S Effective approaches to reduce the risk of infection include: residual insecticide spraying of shelters, insecticide-treated bednets and insecticide-treated materials, and cattle sponging with insecticides. Such interventions should be selected and guided by experienced malariologists
S Vigorous health education at community level to improve rapid treatment seeking behaviour for fever cases during the transmission season
WHO Communicable Disease WG on Emergencies/October 2001 29 Communicable Disease Profile for Afghanistan and Neighbouring Countries
11. DENGUE
DESCRIPTION
Infectious agent Flavivirus group Case definition Clinical case definition Acute febrile illness of 2-7 days duration with two or more of the following symptoms / signs: headache, retro-orbital pain, myalgia, rash, haemorrhagic manifestations, leucopenia
Confirmed case Most commonly immunoglobulin detection in sero samples (ELISA); virus detection in organic fluids/tissues requires high equipped laboratories Mode of Bite of infective mosquitoes, principally Ae. aegypti (day biting species) transmission Incubation From 3 to 14 days Period of Linked to the presence of the mosquito. Not directly transmitted from person to person communicability
EPIDEMIOLOGY
Incidence in the No data available for Afghanistan region Pakistan occasionally reports few cases Geographical The disease is mainly present in Pakistan distribution Seasonality Linked to the highest presence of the mosquito Ae. aegypti Alert threshold Two or more linked cases Recent epidemics Pakistan in the region 1994-1995 Baluchistan Thousands of cases and high case fatality rate due to Dengue haemorrhagic fever (DHF)
RISK FACTORS FOR INCREASED TRANSMISSION
Population No movement Overcrowding Yes Due to increased population density and increased exposure to mosquito bites in temporary shelters Poor access to Yes Increases fatality due to unavailability of case management health services Food shortages No Lack of safe water No However, temporary surface water bodies may increase malaria vector breeding and poor sanitation opportunities
WHO Communicable Disease WG on Emergencies/October 2001 30 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Others Yes S Open water storage provides favourable habitat for Ae. aegypti S Old tyres, old water containers, etc. increase vector breeding Risk assessment The risk of epidemics is low conclusions
PREVENTION AND CONTROL MEASURES
Case Management S Supportive treatment - there is no specific therapeutic agent; the disease is rarely fatal S Take blood precautions S Prevent access of day biting mosquitoes by screening patient or using a bednet S Investigate contacts - determine place of residence of patient for 2 weeks before onset of illness S Although the disease is generally rarely fatal, DHF is highly fatal Epidemic control S Use larvicide on all potential habitats of Ae. aegypti Ground applications of ultra-low volume insecticides can reduce the vector population in an outbreak Prevention S Conduct community survey to determine density of vector mosquitoes and identify and destroy mosquito larval habitats. S Protect against day biting mosquitoes including use of screening, protective clothing and repellents S Environmental sanitation (clear old tyres, old water containers, etc.)
WHO Communicable Disease WG on Emergencies/October 2001 31 Communicable Disease Profile for Afghanistan and Neighbouring Countries
12. CRIMEAN-CONGO HAEMORRHAGIC FEVER
DESCRIPTION
Infectious agent Nairovirus group Case definition Clinical case definition Sudden onset of fever, malaise, weakness, irritability, headache, severe pain in limbs and loins and marked anorexia. Vomiting, abdominal pain and diarrhoea occur occasionally. Flush on face and chest and conjunctival injection develop early. Haemorrhagic enanthem of soft palate, uvula and pharynx, and a fine petechial rash spreading from the chest and abdomen to the rest of the body are generally associated with the disease. There may be bleeding from gums, nose, lungs, uterus and intestine, but only in serious or fatal cases, associated with severe liver damage.
Confirmed case IgG and IgM antibodies detection in serum by enzyme-linked immunoassay (the "ELISA" or "EIA" methods) from about day six of illness or virus detection in blood /tissue samples. Mode of Tick-borne (Hyalomma genus); also direct contact with blood / tissue of infected people, transmission infected domestic animals (butcher) or the grinding of infected ticks Incubation Incubation period is usually 1 to 3 days, with a maximum of 9 days. The incubation period following contact with infected blood or tissues is usually 5 to 6 days, with a documented maximum of 13 days. Period of Humans are infective during all the acute phase of illness. Nosocomial infections are communicability common after exposure to blood and secretions.
EPIDEMIOLOGY
Incidence in the Sporadic cases in all the area are constantly reported region Geographical Throughout the region distribution Seasonality Higher incidence between June and September Alert threshold One case must lead to an alert Recent epidemics Afghanistan in the region July 2000 25 cases, 1 death
August 2001 9 cases, 4 deaths
April 1998 Rustaq District, Takhar Province 19 cases of which 12 fatal Tajikistan June 2000 Dangara district 15 cases (2 health care workers) including 4 deaths reported. Laboratory confirmed
WHO Communicable Disease WG on Emergencies/October 2001 32 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Iran April-October 2001 36 cases including 4 deaths January 2000 50 suspected cases (22 confirmed) including 4 deaths Pakistan October 2001 3 confirmed cases September 2001 4 confirmed cases March 2001 Chaman, Loralai, Ziarat districts, Balochistan 41 suspected cases (3 confirmed) including 12 deaths reported. All were sporadic cases with the exception of 2 infections in health care workers.
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes Related to the higher probability of being bitten by ticks movement Overcrowding Yes Living in close contact with animals Poor access to Yes Prompt identification of the cases is paramount to rapidly implement the control health services measures and for successful treatment Food shortages No Lack of safe water No and poor sanitation Others No Risk assessment The risk of mass epidemics, both for the general population and the refugees, is conclusions remote. The normal pattern of sporadic cases is likely to continue.
PREVENTION AND CONTROL MEASURES
Case Management S Patients with suspected or confirmed CCHF should be isolated and cared for using barrier nursing techniques. S Treatment with ribavirin is recommended S Specimens of blood or tissues taken for diagnostic purposes should be collected and handled using universal precautions. S Sharps (needles and other penetrating surgical instruments) and body wastes should be safely disposed of using appropriate decontamination procedures. Epidemic control S In areas where tick-borne diseases are endemic, treatments are directed to outdoor areas frequented by people and pets. Some of the acaricides which can be used for exterior residual treatments are: Ccarbaryl and propoxur at 2 kga.i./ha Cdeltamethrin and lambda-cyhalothrin at 0.003-0.3 kg a.i./ha Cpermethrin at 0.03-0.3 kg a.i./ha and pirimiphos-methyl at 0.1-1 kg a.i./ha S Liquid formulations are best applied using hand-operated compression sprayers, back- pack or vehicle-mounted power sprayers. S Exterior residual treatments remain effective for about one month. Care must be taken to avoid contamination of watercourses and adjacent areas, and to prevent hazard to non-target organisms
WHO Communicable Disease WG on Emergencies/October 2001 33 Communicable Disease Profile for Afghanistan and Neighbouring Countries
13. PLAGUE
DESCRIPTION
Infectious agent Bacterium: Yersinia pestis Case definition Clinical case definition Rapid onset of fever, chills, headache, severe malaise, prostration with: S for Bubonic form: extreme painful swelling of the lymph nodes (buboes) S for Pneumonic form: cough with blood-stained sputum, chest pain, difficult breathing
Confirmed case S cultural isolation of Yersinia pestis from buboes, blood, CSF, sputum S passive hemagglutination test (PHA) using Yersinia pestis Fraction-1 antigen is most frequently used for serodiagnosis Mode of S Bite of infected fleas especially Xenopsilla cheopis (rat fleas) transmission S Person to person transmission is rare but possible through direct exposure to infected tissues, or respiratory droplets for the pneumonic form Incubation From 1 to 7 days Period of Linked to the presence of the infected rodents and fleas. People remain infective communicability throughout the symptomatic phase of the disease, and tissues also post mortem.
EPIDEMIOLOGY
Incidence in the No cases reported in Afghanistan and Pakistan region Central Asia Republics of former Soviet Union have natural foci. Sporadic cases and/or clusters of human plague have been reported in Kazakstan during the last decade. Geographical Central Asia Republics of former Soviet Union distribution Seasonality Related to the higher presence of the rodents (if infected). Usually moderate climate leads to an increase in rodent population Alert threshold One case must lead to an alert Recent epidemics No recent epidemic in the area in the region
RISK FACTORS FOR INCREASED TRANSMISSION
Population Yes If people move into active natural foci of the disease movement Overcrowding Yes Only for pneumonic plague Poor access to Yes S Identification and treatment of cases is important to control transmission of health services disease S Case fatality rate is extremely high (50-60%) in absence of proper treatment Food shortages No
WHO Communicable Disease WG on Emergencies/October 2001 34 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Lack of safe water Yes Poor sanitation increases the presence of rodents and poor sanitation Others No Risk assessment No risk of natural epidemics in Afghanistan and Pakistan. conclusions Low risk of natural epidemics in the Central Asian Republics of former Soviet Union
PREVENTION AND CONTROL MEASURES
Case Management S Streptomycin is the most effective antibiotic against Y. pestis and the drug of choice for treatment of plague, particularly the pneumonic form. S Standard patient-care precautions should be applied to management of all suspected plague patients. These include prescribed procedures for handwashing, wearing of latex gloves, gowns, and protective devices to protect mucous membranes of the eye, nose and mouth during those procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions and excretions. S Isolation is necessary only in case of pneumonic form Prevention S Persons in close contact with pneumonic plague patients should receive antibiotic prophylactic therapy within 6 days if they have: Cbeen exposed to Y. pestis-infected fleas Chad direct contact with body fluids or tissues of a Y. pestis-infected mammal Cbeen exposed during a laboratory accident to known infectious materials S The preferred antimicrobials for prophylactic therapy are tetracyclines or chloramphenicol Immunization S Worldwide, live attenuated and formalin-killed Y. pestis vaccines are variously available for human use. They do not protect against primary pneumonic plague.
S In general, immunizing communities is not feasible; further immunization is of little use during human plague outbreaks, since a month or more is required to develop a protective immune response.
S The vaccine is indicated for persons whose work routinely brings them into close contact with Y. pestis, such as laboratory technicians in plague reference laboratories and persons studying infected rodent colonies
WHO Communicable Disease WG on Emergencies/October 2001 35 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Zoonotic Diseases
14. RABIES
DESCRIPTION
Infectious agent Rhabdovirus, genus Lyssavirus Case definition Clinical case definition An acute neurological syndrome (encephalitis) dominated by forms of hyperactivity (furious rabies) or paralytic syndrome (dumb rabies) that progresses toward coma and death usually by respiratory failure within 7-10 days
Confirmed case One or more of the following: S Detection of rabies viral antigens by direct fluorescent antibody (FA) in clinical specimens, preferably brain tissue (collected post mortem) S Detection by FA on skin or corneal smear (collected ante mortem) S FA positive after inoculation of brain tissue, saliva or CSF in cell culture, in mice or in suckling mice S Detectable rabies-neutralizing antibody titre in the CSF of an unvaccinated person S Identification of viral antigens by PCR on fixed tissue collected post mortem or in a clinical specimen (brain tissue or skin, cornea or saliva) S Isolation of rabies virus from clinical specimens and confirmation of rabies viral antigens by direct fluorescent antibody testing Mode of Usually by the bite of an infected mammalian species (dog, cat, fox, etc.). No human to transmission human transmission has been documented Incubation Usually 3-8 weeks, occasionally shorter or longer Period of The transmission is related to the bite of an infected animal communicability
EPIDEMIOLOGY
Incidence in the Afghanistan region No precise data, but on average 4 human cases are reported daily in Kabul Iran Disease present Pakistan Between 2000 and 5000 human deaths reported per year, over the past 5 years Geographical The disease is present throughout the region distribution Seasonality No specific seasonality reported Alert threshold One case in a susceptible animal species and /or human must lead to an alert
WHO Communicable Disease WG on Emergencies/October 2001 36 Communicable Disease Profile for Afghanistan and Neighbouring Countries
Recent epidemics Afghanistan in the region June 1999 Kabul, Maidan Shahr Total number of cases and deaths unknown
RISK FACTORS FOR INCREASED TRANSMISSION
Population No movement Overcrowding Yes An infected animal has the possibility to bite more people Poor access to Yes Prompt administration of vaccine post exposure (plus immunoglobulin if heavy health services exposure) is the only way to avoid death for an infected person Food shortages No Lack of safe water No and poor sanitation Others Yes S Availability of food sources for the dogs and wild susceptible animals increases their number S Children of 5 to 15 years are the group at major risk Risk assessment Risk of epidemics for humans is significant if cases of rabies are reported in dogs or conclusions other susceptible animals in the same zone
PREVENTION AND CONTROL MEASURES
Case Management S Immediate deep cleaning of the wound with a detergent and water. Then use a disinfectant. Wound should not be sutured, if possible. All exposure categories (I-III) S Prompt administration of a modern rabies vaccine (vero cell vaccine PVRV or the chick embryo cell vaccine PCECV). Exposure category II or III S Prompt administration of human rabies immunoglobulin, if category exposure III S Administration of tetanus vaccine S If a person develops the disease death is inevitable. Universal nursing barrier practices are necessary for the sick people. Epidemic control S Immediate notification if one or more suspected cases are identified S Confirm the outbreak, following WHO guidelines S Confirm diagnosis and insure prompt management Prevention S Identify and kill all the suspected infected animals in rabies foci S Identify and treat all those who have (or may have) been exposed
Immunization S Human preventive mass vaccination is generally not recommended but can be considered under certain circumstances for the age group 5 to 15 years
WHO Communicable Disease WG on Emergencies/October 2001 37 Communicable Disease Profile for Afghanistan and Neighbouring Countries
15. ANTHRAX
DESCRIPTION
Infectious agent Bacterium: Bacillus anthracis Case definition Clinical case definition An illness with acute onset characterized by several clinical forms:
(a) Localized form: S Cutaneous: skin lesion evolving over 1 to 6 days from a papular through a vesicular stage, to a depressed black eschar invariably accompanied by oedema that may be mild to extensive (b) Systemic forms: S Gastro-intestinal: abdominal distress characterized by nausea, vomiting, anorexia and followed by fever S Pulmonary (inhalation): brief prodrome resembling acute viral respiratory illness, followed by rapid onset of hypoxia, dyspnoea and high temperature, with X-ray evidence of mediastinal widening S Meningeal: acute onset of high fever possibly with convulsions, loss of consciousness, meningeal signs and symptoms; commonly noted in all systemic infections Confirmed case S Isolation of B anthracis from a clinical specimen (e.g., blood, lesions, discharges) S Demonstration of B. anthracis in a clinical specimen by microscopic examination of stained smears (vesicular fluid, blood, cerebrospinal fluid, pleural fluid, stools) S Positive serology (ELISA, Western blot, toxin detection, chromatographic assay, fluorescent antibody test (FAT) Mode of S Cutaneous infection is by contact with tissues of infected animals (cattle, sheep, goats, transmission etc.) often during slaughter procedures or by contact with infected or contaminated animal products (e.g. hides). S Intestinal and oropharingeal anthrax arises from ingestion of contaminated undercooked meat S Pulmonary inhalation is an occupational diseases of people working with contaminated wool and hides Incubation From 1 to 7 days, even if up to 60 days is possible Period of Related to the presence of infected animals. Direct transmission from person to person is communicability not recorded. Hides and soil contaminated by spores may remain infectious for decades
EPIDEMIOLOGY
Incidence in the Sporadic cases and outbreaks are reported region Geographical The disease is present throughout the region distribution Seasonality Highest incidence in the spring/summer Alert threshold One human case must lead to an alert Any animal outbreak must be followed up by the veterinary and health authorities
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Recent epidemics Tajikistan in the region July 2000 Khatlon Region 17 suspected cases. No deaths reported. Suspected source: infected cows
RISK FACTORS FOR INCREASED TRANSMISSION
Population No movement Overcrowding No Poor access to Yes Poor of veterinary services and lack of animal vaccination health services Food shortages Yes Consumption of animals who died due to illness Lack of safe water No and poor sanitation Others Yes S Slaughter of dead animals S Lack of disinfection of contaminated areas Risk assessment If not present in animals, very low risk of epidemics in human conclusions
PREVENTION AND CONTROL MEASURES
Case Management S Prompt antibiotic therapy with penicillin usually results in dramatic recovery of the individual or animal infected with anthrax Epidemic control S Following the first detection of anthrax in a herd, the remaining animals should be removed immediately from the field and checked regularly for signs of illness Prevention S Prevention of anthrax in both humans and animals is based on control measures in livestock in endemic areas such as the safe disposal of anthrax carcasses and vaccination of at risk herds/areas
S The most efficient method of disposal is incineration in a manner that ensures heat sterilization of the underlying soil Immunization S There is a vaccine against anthrax, but it is not approved for widespread use S The vaccine is sometimes given to people who are likely to be exposed to anthrax through their occupation, for example, tannery workers, or to military personnel S It is not recommended for mass immunization
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ANNEX 1 : Syndromic Approach to Diagnosis of Communicable Diseases
Suspected outbreak ACUTE DIARRHOEAL SYNDROME
Definition of syndrome Acute onset of diarrhoea AND severe illness AND absence of known predisposing factors
Watery Viral gastroenteritis Cholera Enterotoxigenic E. coli Giardiasis Cryptosporidium
Possible diseases/pathogens Dysentery Shigellosis Salmonellosis Campylobacteriosis Amoebic dysentery Enterohaemorrhagic E. coli Clostridium difficile * Ebola and other haemorrhagic fevers
Specimens required Faeces
Bacterial: Viral: Parasite: Faecal leukocytes Culture Macro- and microscopic Culture Antigen detection examination Laboratory studies Antimicrobial susceptibility Genome detection Serotyping Toxin identification
* Ebola and other haemorrhagic fevers may initially present as bloody diarrhoea. If such an aetiology is suspected, refer to “Acute Haemorrhagic Fever Syndrome” for appropriate specimen collection guidelines.
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Suspected outbreak ACUTE HAEMORRHAGIC FEVER SYNDROME
Acute onset of fever of less than 3 weeks duration AND any two of the following: S Haemorrhagic or purpuric rash S Epistaxis Definition of syndrome S Haemoptysis S Blood in stool S Other haemorrhagic symptom AND absence of known predisposing factors
Dengue haemorrhagic fever and shock syndrome Yellow fever Other arboviral haemorrhagic fevers (e.g. Rift Valley, Crimean Congo, Possible diseases/pathogens Tick-borne flaviviruses) Lassa fever and other arenoviral haemorrhagic fevers Ebola or Marburg haemorrhagic fevers Haemorrhagic fever with renal syndrome (hantaviruses) Malaria Relapsing fever
Specimens required Blood Blood smear Serum Post-mortem tissue specimens (e.g. skin biopsy and/or liver biopsy)
Laboratory studies Viral: Parasitic: Culture Demonstration of Antigen detection pathogen Antibody levels Genome detection
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Suspected outbreak ACUTE JAUNDICE SYNDROME
Definition of syndrome Acute onset of jaundice AND severe illness AND absence of known predisposing factors
Yellow fever Hepatitis A-E Leptospirosis and Possible diseases/pathogens other spirochaetal diseases
Blood culture Specimens required Post mortem liver biopsy Serum (urine*)
Viral: Leptospiral: Culture Culture Laboratory studies Antigen detection Antibody levels Antibody levels Serotyping Genome analysis
* Requires specialized media and handling procedures
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Suspected outbreak ACUTE NEUROLOGICAL SYNDROME
Acute neurological dysfunction with one or more of the following: S Deterioration of mental function S Acute paralysis S Definition of syndrome Convulsions S Signs of meningeal irritation S Involuntary movements S Other neurological symptoms AND severe illness AND absence of predisposing factors
Poliomyelitis or Guillain Barré Rabies Viral, bacterial, fungal, or Possible diseases/ syndrome pathogens parasitic meningo-encephalitis
Faeces CSF Serum Specimens required Blood Culture Post mortem specimens (e.g. Blood smears corneal impressions, brain Serum tissue, skin biopsy from neck) Throat swab
Viral: Bacterial Viral: Laboratory studies Culture (including Leptospiral): Culture Gram stain and other Antigen detection microscopic techniques Antibody levels Culture Genome analysis Antimicrobial susceptibility Antigen detection Serotyping
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Suspected outbreak ACUTE RESPIRATORY SYNDROME
Definition of syndrome Acute onset of cough OR respiratory distress AND severe illness AND absence of known predisposing factors
Possible diseases/pathogens
Influenza Hantavirus pulmonary Pertussis Bacterial pneumonia including: Diphtheria syndrome Respiratory syncytial Pneumococcal Streptococcal virus (RSV) Legionellosis pharyngitis and Scarlet Haemophilus influenzae fever Mycoplasma Respiratory anthrax Pneumonic plague Specimens required Throat Nasopharyngeal Serum swab swab
Blood culture Serum Sputum Urine (for Legionella)
Laboratory studies Bacterial or Viral: Culture Antimicrobial susceptibility (for bacteria) Antigen detection Antibody levels Genome analysis Serotyping Toxin identification
Adapted from: Guidelines for the collection of clinical specimens during field investigation of outbreaks. WHO/CDS/CSR/EDC/2000.4
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ANNEX 2 : Steps for Management of a Communicable Disease Outbreak
1. PREPARATION Health Co-ordination meetings Surveillance system – Weekly Health Reports to WHO Stockpiles – specimen kits, appropriate antibiotics, IV fluids Epidemic Investigation kits Contingency plans for isolation wards in hospitals Laboratory support
2. DETECTION If you diagnose a case of the following diseases/syndromes: Bloody diarrhoea Suspected cholera Measles Meningitis Acute haemorrhagic fever Suspected polio (acute flaccid paralysis) Or a cluster of deaths of unknown origin
Inform your Health Co-ordinator as soon as possible Health Co-ordinator should inform WHO Take clinical specimen for laboratory confirmation (e.g. stool, serum, CSF) Include case in Weekly Health report
3. RESPONSE S CONFIRMATION - WHO will investigate cases reported to verify outbreak exists Clinical specimens will be sent for testing WHO will set up Outbreak Control Team with membership from relevant organizations - health NGOs, water and sanitation NGOs, veterinary experts, UNICEF
S INVESTIGATION - Collect/analyse descriptive data to date (e.g. age, date of onset, location of cases) Develop hypothesis for pathogen/source/transmission Develop outbreak case definition Follow up of cases and contacts Conduct further investigation/epidemiological studies S CONTROL - Implement control measures specific for the disease Treat cases with recommended treatment as in WHO guidelines Prevent exposure (e.g. isolation of cases in cholera outbreak) Prevent infection (e.g. immunization in measles outbreak) 4. EVALUATION Assess timeliness of outbreak detection and response, cost Change public health policy if indicated (e.g. preparedness) Write outbreak report and disseminate
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ANNEX 3 : Safe Water and Sanitation
The following are effective methods to obtain safe drinking water:
Boiling To make water safe for drinking and hygiene purposes, bring water to a vigorous, rolling boil and keep it boiling for 1 minute. This will kill, or inactivate, most of the organisms that cause diarrhoea.
Household filtration Household filtration should considerably reduce the pathogens in the water. It should be followed by disinfection through chlorination or boiling.
Disinfection through chlorination The following guidelines should be translated into messages that take into account locally available products and measuring devices. To make water safe by chlorination, the first step is to make a stock solution of chlorine.
This can be prepared by adding the following products to one litre of water:
Product (% concentration by weight of available chlorine) Amount for 1 litre Calcium hypochlorite (70 %); or 15g Bleaching powder or chlorinated lime (30%); or 33g Sodium hypochlorite (5%); or 250 ml Sodium hypochlorite (10 %); or 110 ml
The stock solution must be stored in a closed container, in a cool dark place and used within one month. It should be used to prepare safe water as follows:
Stock solution Added volume of Water 0.6 ml or 3 drops 1litre 6 ml 10 litres 60 ml 100 litres
Mix by stirring and allow the chlorinated water to stand for at least 30 minutes before using it. The free residual chlorine level after 30 minutes should be between 0.1 to 0.5 mg/litre. If the free residual chlorine is not within this range the number of drops of the stock solution should be adjusted so the final product falls within this range.
If the water is cloudy or turbid it must either be filtered before chlorination or boiled vigorously rather than chlorinated. Chlorination of turbid water might not make it safe.
See guidelines for cholera control, WHO 1993 and Fact Sheets on Environmental Sanitation for Cholera Control, WHO 1996
Sanitation Good sanitation can markedly reduce the risk of transmission of intestinal pathogens, especially where its absence may lead to contamination of clean water sources. High priority should be given to observing the basic principles of sanitary human waste disposal, as well as to ensuring the availability of safe water supplies.
Appropriate facilities for human waste disposal are a basic need of all communities; in the absence of such facilities there is a high risk of water-related diseases. Sanitary systems that are appropriate for the local conditions should be constructed with the co-operation of the community.
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People will need to taught how to use latrines, about the dangers of defecating on the ground, or in or near waters, and about the importance of thorough hand-washing with soap or ash after any contact with excreta. The disposal of children's excreta in latrines needs to be emphasized.
See Fact Sheets on Environmental Sanitation for Cholera Control, WHO 1996 and A Guide to the Development of On-site Sanitation, WHO 1992
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ANNEX 4 : Injection Safety
Preliminary analysis of data collected as part of the Comparative Risk Assessment component of the Global Burden of Disease study suggests that the Region which includes Afghanistan, Iran and Pakistan faces a major challenge in terms of unsafe injection practices and transmission of blood-borne pathogens through injections. In this region, the estimated proportion of re-use of injection equipment in the absence of sterilization is 69%.
Prevalence in the region of Hepatitis B is 4.3%, of Hepatitis C is 5.5%, and of HIV is 0.03%. The proportion of new infections with Hepatitis B, Hepatitis C, and HIV that are attributable to unsafe injections practices are 59%, 81% and 4% respectively.
Thus, in any relief efforts to assist the population and the refugees in this region of the world, safe and appropriate use of injections should be ensured through: S Education of the population and of the healthcare workers regarding the need to observe the “one syringe / needle set - one injection” rule; S Provision of sufficient quantities of new disposable injection equipment and sharps waste collection boxes IN QUANTITIES THAT MATCH ANY PLANNED DELIVERIES OF INJECTABLES DRUGS OR VACCINES; and S Sharps waste management through open-air incineration of full sharps boxes
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ANNEX 5 : Key WHO Contacts for Central Asia crisis
Table 1: Relevant WHO Offices and Emergency Contacts
Office Contact address WHO Regional Co-ordinator for the Dr Mohamed Jama Central Asia crisis P.O.Box 1013. Islamabad. Pakistan Tel: 92 51 221 1224 / 221 1992 / 229 7931 Fax: 92 51 228 0830 Mobile: 201 2390 0536 e-mail: [email protected] WHO Afghanistan Office Dr Said Salah Youssef WHO Representative H # 218, Margalla Road, F-10/3 P. O. Box No. 1936. Islamabad. Pakistan. Tel: 92 51 221 1224 / 221 1992 / 229 7931 Fax: 92 51 228 0830 Mobile: 92 300 855 83 00 e-mail: [email protected] [email protected] [email protected] WHO Pakistan Office Dr Khalif Bile Mohamud WHO Representative P.O.Box 1013. Islamabad. Pakistan Tel: 92 51 925 5077 / 925 5075 / 925 5116 Fax: 92 51 925 5083 Mobile: 923 008 500 198 e-mail: [email protected] [email protected] WHO Iran Office Dr El Fatih Zeinelabdin El Samani WHO Representative P.O.Box 11365-3597. Teheran. Islamic Republic of Iran Tel: 98 21 670 0361 / 670 6786 Fax: 98 21 670 8969 Mobile: 98 911 205 6007 e-mail: [email protected] WHO Tajikistan Office Prof. Lyubomir Ivanov WHO Liaison Officer 106 Druzhby Narodov Str. 734000 Dushanbe. Tajikistan. Tel: 992 372 21 01 08 / 48 71 Fax: 992 372 214 871 Mobile: 992 91 901 06 16 e-mail: [email protected] WHO Turkmenistan Office Dr Batyr Berdyklychev WHO Liaison Officer c/o Ministry of Health and Medical Industry Dept. of External Relations Mahtumkuli pr. 90 744000 Ashgabat. Turkmenistan. Tel: 993 12 391 933 / 350 248 Fax: 993 12 350 248 e-mail: [email protected]
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WHO Uzbekistan Office Dr Jukka Pukkila WHO Liaison Officer c/o Ministry of Health Navoi Str. 12 700011 Tashkent. Uzbekistan. Tel: 998 71 241 5343 / 144 7534 Mobile: 998 71 131 92 40 / 131 75 35 / 130 37 93 Fax: 998 711 441 040 e-mail: [email protected] [email protected] WHO Eastern Mediterranean Dr Altaf Musani Regional Office WHO/EMRO P.O.Box 7608, Cairo 11371. Egypt Tel: 202 276 5027 / 276 5025 Mobile: 201 2390 0536 / 0537 Fax: 202 276 5428 e-mail: [email protected] [email protected] WHO European Regional Office Dr Jan Theunissen / Dr Vladimir Verbitski WHO/EURO 8, Scherfigsvej, DK-2100 Copenhagen 0. Denmark Tel: 4539 17 15 51 / 17 17 17 Mobile: 4521 20 47 20 / 4526 46 58 46 Fax: 4539 17 18 18 e-mail: [email protected] [email protected] WHO Headquarters Dr Khalid Shibib Duty Officer Avenue Appia 20 1211 Geneva 27. Switzerland Tel: 4122 791 2756 Mobile: 4179 475 5548 Fax: 4122 791 4844 e-mail: [email protected]
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Table 2: Relevant WHO Regional Offices and Headquarters Technical Staff
Disease/syndrome EMRO EURO HQ CD control in complex Dr T Gaafar (VPI and EED Dr.B.Ganter (CSR) Dr M Connolly (CSR) emergencies co-ordinator) [email protected] [email protected] [email protected] Bacillary dysentery Dr N Teleb (CSR) Dr.B.Ganter (CSR) Dr C-L Chaignat(CSR) [email protected] [email protected] [email protected] Dr T Gaafar (VPI and EED Dr.V.Mangiaterra Dr S Briand (CSR) co-ordinator) (CHD) [email protected] [email protected] [email protected] Cholera Dr N Teleb (CSR) Dr.B.Ganter (CSR) Dr C-L Chaignat [email protected] [email protected] [email protected] Dr T Gaafar (VPI and EED Dr.M.Ciotti (CSR) Dr S Briand (CSR) co-ordinator) [email protected] [email protected] [email protected] Typhoid Fever Dr N Teleb (CSR) Dr.B.Ganter (CSR) Dr C-L Chaignat(CSR) [email protected] [email protected] [email protected] Dr T Gaafar (VPI and EED Dr.M.Ciotti (CSR) Dr S Briand (CSR) co-ordinator) [email protected] [email protected] [email protected] Polio Dr H Wahdan (SAP) Dr.N.Emiroglu (CPE) Dr B Aylward [email protected] [email protected] (VAB/Polio) Dr F Kamel (POL) Dr.S.Wassilak (POL) [email protected] [email protected] [email protected] Mr C Maher (VAB/Polio) [email protected] ARI Dr S Farhoud (CAH) Dr V Mangiaterra Dr S Qazi (CAH) [email protected] (CHD) [email protected] [email protected] Dr S Aboubakar(CAH) Dr.B.Ganter (CSR) [email protected] [email protected] Measles Dr T Gaafar (VPI and EED Dr.N.Emiroglu (CPE) Dr AM Henao-Restrepo co-ordinator) [email protected] (VAB/EPI) [email protected] Dr.R.Peabody (CPE) [email protected] [email protected] Meningococcal disease Dr N Teleb (CSR) Dr.B.Ganter (CSR) Dr M Santamaria (CSR) [email protected] [email protected] [email protected] Dr T Gaafar (VPI and EED Dr.N.Emiroglu (CPE) Dr M Hardiman (CSR) co-ordinator) [email protected] [email protected] [email protected] Tuberculosis Dr A Seita (STB) Dr.R.Zaleski (TUB) Dr S Ottmani (STB) [email protected] [email protected] [email protected] Mrs.E.Nathanson (TUB) [email protected] Malaria Dr G Sabatinelli (RBM) Dr.M.Ejov (MAL) Dr C Delacollette (RBM) [email protected] [email protected] [email protected] Dr.B.Ganter (CSR) [email protected] Plague Dr N Neouimine (CTD) Dr.B.Ganter (CSR) Dr D Lavanchy (CSR) [email protected] [email protected] [email protected] Dr.M.Ciotti (CSR) Dr M Santamaria (CSR) [email protected] [email protected]
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Dengue Dr N Teleb (CSR) Dr.M.Ejov (MAL) Dr R Arthur (CSR) [email protected] [email protected] [email protected] Dr T Gaafar (VPI and EED Dr.B.Ganter (CSR) co-ordinator) [email protected] [email protected] Viral haemorrhagic Dr N Teleb (CSR) Dr.B.Ganter (CSR) Dr R Arthur (CSR) fevers (including [email protected] [email protected] [email protected] CCHF) Dr T Gaafar (VPI and EED Dr.M.Ciotti (CSR) Dr C Roth (CSR) co-ordinator) [email protected] [email protected] [email protected] Anthrax Dr N Neouimine (CTD) Dr.B.Ganter (CSR) Dr O Cosivi (CSR) [email protected] [email protected] [email protected] Dr.M.Ciotti (CSR) [email protected] Rabies Dr N Neouimine (CTD) Dr.B.Ganter (CSR) Dr F Meslin (CSR) [email protected] [email protected] [email protected] Dr.M.Ciotti (CSR) [email protected] Outbreak Alert and Dr T Gaafar (VPI and EED Dr.B.Ganter (CSR) Dr M Ryan (CSR) Response co-ordinator) [email protected] [email protected] [email protected] Dr.M.Ciotti (CSR) Mr P Drury (CSR) [email protected] [email protected] [email protected] Injection safety Dr N Teleb (CSR) Dr.N. Emiroglu (CPE) Dr Y Hutin (VAB) [email protected] [email protected] [email protected] Dr T Gaafar (VPI and EED Mr.D.Maire (CPE) co-ordinator) [email protected] [email protected] Safe water Dr H Abouzaid (SHE) Mr.R.Aertsgeerts Mr J Hueb (WSH) [email protected] (WSN) [email protected] [email protected]
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ANNEX 6 : List of WHO Guidelines on Communicable Diseases
Title Publication No./Date FACT SHEETS
Anthrax Fact Sheet No 264 October 2001 http://www.who.int/inf-fs/en/fact264.html Cholera Fact Sheet N107 Revised March 2000 http://www.who.int/inf-fs/en/fact107.html Crimean-Congo Haemorrhagic Fever Fact Sheet No 208 December 1998 http://www.who.int/inf-fs/en/fact208.html Dengue and Dengue Haemorrhagic Fever Fact Sheet No 117 Revised November 1998 http://www.who.int/inf-fs/en/fact117.html Epidemic Dysentery Fact Sheet No 108 Revised October 1996 http://www.who.int/inf-fs/en/fact108.html Hepatitis B Fact Sheet WHO/204 Revised October 2000 http://www.who.int/inf-fs/en/fact204.html Hepatitis C Fact Sheet No 164 Revised October 2000 http://www.who.int/inf-fs/en/fact164.html Influenza Fact Sheet No 211 February 1999 http://www.who.int/inf-fs/en/fact211.html Influenza A(H5N1) Fact Sheet No 188 January 1998 http://www.who.int/inf-fs/en/fact188.html Epidemic Meningococcal Disease Fact Sheet No 105 Revised December 1998 http://www.who.int/inf-fs/en/fact105.html Smallpox http://www.who.int/emc/diseases/smallpox/factsheet.html Typhoid Fever Fact sheet No 149 March 1997 http://www.who.int/inf-fs/en/fact149.html GUIDELINES/PUBLICATIONS/REPORTS
Protocol for the Assessment of National Communicable Disease Surveillance and WHO/CDS/CSR/ISR/2001.2 Response Systems. Guidelines for Assessment Teams English only http://www.who.int/emc-documents/surveillance/whocdscsrisr20012c.html Strengthening Implementation of the Global Strategy for Dengue Fever/Dengue WHO/CDS/(DEN)/IC/2000.1 Haemorrhagic Fever Prevention and Control English only http://www.who.int/emc-documents/dengue/whocdsdenic20001c.html WHO Report on Global Surveillance of Epidemic-prone Infectious Diseases WHO/CDS/CSR/ISR/2000.1 http://www.who.int/emc-documents/surveillance/whocdscsrisr20001c.html English only Guidelines for the collection of clinical specimens during field investigation of WHO/EDC/2000.4 outbreaks English only http://www.who.int/emc-documents/surveillance/docs/whocdscsredc2004.pdf Hepatitis A WHO/CDS/EDC/2000.7 http://www.who.int/emc-documents/hepatitis/whocdscsredc20007c.html English only WHO Guidelines for Epidemic Preparedness and Response to Measles Outbreaks WHO/CDS/CSR/ISR/99.1 http://www.who.int/emc-documents/measles/whocdscsrisr991c.html English only
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Influenza Pandemic Preparedness Plan. The Role of WHO and Guidelines for WHO/CDS/CSR/EDC/99.1 National and Regional Planning English only http://www.who.int/emc-documents/influenza/whocdscsredc991c.html Plague Manual: Epidemiology, Distribution, Surveillance and Control WHO/CDS/CSR/EDC/99.2 http://www.who.int/emc-documents/plague/whocdscsredc992c.html English and French Laboratory methods for the diagnosis of meningitis caused by Neisseria WHO/CDS/CSR/EDC/99.7 meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae English and French http://www.who.int/emc-documents/meningitis/whocdscsredc997c.html Infection Control for Viral Haemorrhagic Fevers in the African Health Care WHO/EMC/ESR/98.2 Setting English and French http://www.who.int/emc-documents/haem_fevers/whoemcesr982c.html Control of epidemic meningococcal disease. WHO practical guidelines 2nd edition WHO/EMC/BAC/98.3 http://www.who.int/emc-documents/meningitis/whoemcbac983c.html English and French Guidelines for the Surveillance and Control of Anthrax in Human and Animals. WHO/EMC/ZDI/98.6 3rd edition Guidelines for the safe transport of infectious substances and diagnostic WHO/EMC/97.3 specimens English, French and http://www.who.int/emc-documents/biosafety/whoemc973c.html Spanish Dengue haemorrhagic fever: Diagnosis, treatment, prevention and control. 2nd 1997 edition English only http://www.who.int/emc/diseases/ebola/Denguepublication/index.html Guidelines for the control of epidemics due to Shigella dysenteriae type 1 WHO/CDR/95.4 http://www.who.int/emc-documents/cholera/whocdr954c.html English only Guidelines for Cholera Control 1993
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