Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 2, Issue 31, Monday 8 August, 2011

Highlights Priority diseases

under surveillance Epidemiological week no. 31 (29 July - 4 August, 2011) in DEWS

• 92 districts and 3 agencies provided surveillance data to the DEWS this week Acute Flaccid Paralysis (AFP)

from 3,288 health facilities. Acute Jaundice Syndrome (AJS)

• A total of 1,073,830 consultations were reported through DEWS of which Acute Respiratory Infections (Upper and Lower) (ARI) 18% were acute respiratory infections (ARI), 13% skin disease, 10% acute diar- Acute Watery Diarrhoea (AWD)/ rhoea, and 6% suspected Malaria. Suspected Cholera

• A total of 129 alerts with 33 outbreaks were reported in week-31, 2011: Alto- Acute Bloody Diarrhoea (BD)

gether 56 alerts were for AWD; 27 for Measles; 12 for Neonatal tetanus and Other Acute Diarrhoeas (AD)

Tetanus; six for Leishmaniasis; five each were for Pertussis, malaria; four for Suspected Viral Hemorrhagic Fever (VHF) chicken pox; two each for AD, AJS, Meningitis and mumps; three for bloody diarrhoea, while one each for DHF, diphtheria, and typhoid. Suspected Malaria (Mal)

Suspected Measles (MS) • National Polio Eradication Initiative reported three new confirmed polio Suspected Meningitis (MG) cases this week from Kohlu, Pishin and Quetta districts in Balochistan. Total 63 (62=type1, and 1=type3) confirmed polio cases have been reported in 2011 Others from 26 districts.

Figure‐1: Three years trend of Acute diarrhoea in Pakistan (2009, 2010, and 2011)

2009 2010 2011

12 Percentage 8

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

Epi‐week

Disease Wk-24 Wk-25 Wk-26 Wk-27 Wk-28 Wk-29 Wk-30 Wk-31

Acute Diarrhoea 102,217 (10%) 103,978 (10%) 107,924 (10%) 100,320 (10%) 104,413 (10%) 107,861 (10%) 103,098 (10%) 108,437 (10%)

Total consultation 1,028,090 1,019,724 1,087,368 994,345 1,025,647 1,034,504 1,015,788 1,073,830

Since July 29, 2010, approximately 39,491,736 patient consultations have been reported to the DEWS from five provinces and three agencies and state of AJK. In this week 31, 2011 (29 July to 4 August, 2011) reports were received from 3,288 health centers and the major causes for seeking health care by the communities in almost all of the provinces were diarrheal diseases, acute respiratory infections 190,147 (18%), skin diseases 138,269 (13%) and suspected malaria 65,625 (6%). The above graph shows the trend of acute diarrhoea cases out of total consultations reported to DEWS in 2009, 2010 and 2011 up until now.

This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan . For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083, E-mail: [email protected]. 01 Epidemiological Bulletin: DEWS, Pakistan, Week no. 31 (28 July to 4 August, 2011) Current week's Outbreaks: Date Disease Province District Area M F Action Taken An alert of AWD/Suspected Cholera reported from BHU ‐ Batdara (31 July to 4th August 222 cases was reported), Village Chimiyan, UC sample collected and sent to NIH Islamabad. Essential medicines supplies provided at BHU. Medical camp established at 2‐Aug AWD AJK Muzaffarabad 39 21 89 73 Machara , Tehsil Patikka village Chimiya for three days. Water sample was also taken & sent for testing. During active surveillance community awareness session conducted, IEC material distributed. Village Takiyan , UC An alert of AWD/Suspected Cholera reported from BHU ‐ Komikot (2nd—4th August 236 cases reported), sample col‐ 3‐Aug AWD AJK Muzaffarabad Komikot, Tehsil Muzaf‐ 27 31 80 98 lected and sent to NIH Islamabad. Water sample was also taken & sent for testing. active surveillance done, community farabad awareness session conducted, IEC material distributed and DHO was informed about alert. An alert was generated from RHC Arja for increase in no of diarrhoea cases from Ghaziabad. After analyzing the situa‐ tion a medical camp was held at RHC Ghaziabad and 145 patients were treated. Health education session were con‐ Village karnota, Riala‐ ducted with the community. One week later there was still increase in number of cases and meanwhile two deaths 31‐Jul AWD AJK Bagh UC Makhyilan Ghazia‐ 21 55 18 47 occurred due to AWD, one at a FAP and one at private clinic. DTC was established at RHC Arja. Stool sample was taken bad, Tehsil Dhirkot from 1 patient and sent to NIH and was found positive for V.c. Ogawa. Water sampling was also done and 11/12 were found contaminated. Aqua tabs distributed and health hygiene sessions conducted. An AWD alert was reported from BHU Serrian, 125 AWD cases with three deaths were reported. Stool sample found Village Serrian, UC positive for V.c. Ogawa. Three water samples were taken, health education session were conducted, aqua tabs and IEC 30‐Jul AWD AJK Haveli 15 50 18 42 Sangal, Tehsil Haveli material were distributed in the community through LHWs. Daily reporting is being done by center and new cases are declining. 22 cases of AWD were reported from BHU Oba Lakhra. Area was visited and investigated with health team and DSM Balochis‐ Village Oba Lakhra PPHI. Medicines provided from WHO store of DSM, One stool sample was collected and sent to NIH and was found 1‐Aug AWD Lasbela 5 6 1 10 tan Tehsil Lakhra positive for V.c. Ogawa, 3 water samples were also collected. Aqua tabs and extra packs of ORS were distributed as well as health and hygiene session was conducted with community and information shared with DHO. 79 cases of suspected Malaria were reported and 52 tested. 31/52 found positive for malaria (10 P. Falciparum, 17 P. Balochis‐ 4‐Aug Malaria Jhal Magsi BHU Khichi 17 27 12 23 Vivax, 4 Mix) and treated (SPR = 59.6%, while FR = 46.6%). The alert is in continuation of last week alert which reported tan the 36 cases. RDT kits supplied and DSM PPHI informed to take further preventive measures. Malaria alert was observed after analysis of weekly data. The cases were treated and 13/21 verified positive (P. Falcipa‐ Balochis‐ BHU Mir Hassan, tehsil 4‐Aug Malaria Nasirabad 11 17 9 15 rum 7, P.Vivax 4); SPR = 61.9% while FR = 53.8%. The DHO and Merlin representative was informed and requested for tan D.M.J provision of ACT and bednets. Mohmand 1‐Aug AWD FATA Marina Khel, Yakshund 0 2 0 1 Stool swab sample taken and sent to NIH which were found positive for V.c. Ogawa. Agency Leishma‐ Bajaur UC Malangai, Tehsil Alert investigated, 12 cases with probable Leishmaniasis identified. Health education done. Plan for treatment with 3‐Aug FATA 2 2 0 8 niasis Agency Mamoond WHO meds / partners organized. On routine surveillance two cases of AWD were found admitted in emergency ward of DHQH. 2/2 samples sent to NIH found positive for V.c. Ogawa. Active surveillance in the field carried out. 110 patients with mild to moderate dehydra‐ Vill Surkhali Banda, UC 29‐Jul AWD KPK Battagram 0 1 0 1 tion and 10 patients with severe dehydration were treated by the district response team. Water source identified was Gajjbori the spring which was contaminated due to heavy rains EDO H, MS DHQH and Program manager health Save the Children informed. Alert for acute diarrhea were reported from UC Gokand by MT of BHU. A mobile medical team of Merlin Int. went to Vill Kalail Kandao, UC 30‐Jul AWD KPK Buner 0 0 0 1 assess and reported treating 120 cases of acute diarrhea from the area. One case was admitted in DHQH. Sample was Gokand, Tehsil Dagar taken from the case and sent to NIH. Health education was given to the community. A case of AWD was reported by DHQ from Afghan Refugee camp 20 Haripur. Stool sample was taken and sent to NIH Afghan Refugee camp which was found positive for V.c. Ogawa. 6 cases with acute diarrhoea were found during active surveillance in the 29‐Jul AWD KPK Haripur 2 1 1 2 20 vicinity. Health and hygiene session was conducted. Soap and aqua tabs were distributed. Save the children and EDO Health were informed. A death of child with AWD was reported by DHQ. On active case finding 22 patients were identified and treated. 1 stool Village Shurak, UC sample was collected and found positive for Non 01 V. Cholera, water sample was also found contaminated. Aqua tabs, 30‐Jul AWD KPK Haripur 2 5 2 13 Kakotree ORS and soaps were distributed door to door by LHW in 854 households. Health and Hygiene session was conducted for the affected community. EDO Health was informed. Weekly analysis found high number of cases of AD from village Brug with 20 patients reporting with AD on a single day from one area. Water samples were found contaminated. Emergency field dispensary was established in collaboration Village Brug, UC Bait with PPHI and DoH in the area. In three days more than 200 cases were treated. 30 patients were given I/V fluids and 16 31‐Jul AWD KPK Haripur 41 73 37 121 Gali patients presented with severe dehydration. 1 death was also reported. Aqua tabs, ORS and soaps were distributed. Health and hygiene sessions were conducted for the affected community. 2 stool samples were taken and sent to NIH. EDO Health was informed of the suspected cases. A suspected outbreak of cholera was cross reported by SO Islamabad as AWD patients from village Dhanna Ferozpur presented to Poly Clinic Hospital Islamabad. Sample was found positive for Vibrio Cholera at a private lab. On active FGSH (Village Dhanna case finding 27 cases were identified. Water samples were found contaminated. The source (tube well) was chlorinated. 4‐Aug AWD KPK Haripur 3 7 4 8 Ferozpur, UC Barkot) 13 patients were treated. No case with severe dehydration was found. Aqua tabs, ORS and soaps were distributed. Health and Hygiene session was conducted for the affected community. EDO Health was informed of the suspected cases. Alert for 35 cases of diarrhoea from one BHU. Most cases were with Mild to Moderate dehydration with few cases proceeding to Severe dehydration and were referred to LMH hospital. One death reported from the same area, 3 sam‐ Village Kamal Khel, UC ples collected results pending. Families provided with ORS, Aqua Tabs and hygiene kits, water samples from all house‐ 30‐Jul AWD KPK Kohat 7 5 8 15 Dhoda holds collected for Microbial investigations. 9 households of IDP's were effected, MDM‐F requested for establishing Mobile Health Clinic, EDO‐H informed and Alerted, No LHW's in the area for Health and Hygiene messages, detailed Health and hygiene sessions done with all families. Follow up planned. Village Utala, UC Gall Case Investigated, 2 Stool samples collected and both found positive for V.c. Ogawa, Water samples also collected, EDO‐ 1‐Aug AWD KPK Lower Dir (Maidan), Tehsil Lal 0 0 0 4 H was informed, During active surveillance ORS & Hygiene kits provided, Aqua tabs distributed, Health & Hygiene Qilla promotion Session conducted with family members, ORT Corner established at RHC Lal QIlla. Alert for 7 cases of AD from one village reported. Surveillance Officer found cases admitted with a private practitioner, 2 Ahl Kar Near Kodar UC stool samples found positive for V.c. Ogawa, LHS and LHWs of the area sensitized, water samples taken, HE session 29‐Jul AWD KPK Mansehra 1 1 1 4 Sachan Kalan, CH Batal conducted; ORS, Aqua tabs and IEC material distributed among the community, 8 more cases found, water sources are springs and cleaning of some reservoirs done by EHE. Mohallah Gul Wahab, UC Mohib Banda; Mohallah Khattak, Near Alert for AWD reported from four locations. The cases were investigated and samples were sent to NIH which was found girls high school, UC positive for V.c. Ogawa. Relevant partners informed. Water samples taken & being tested. Health Education conducted 29‐Jul AWD KPK Mardan 0 3 0 1 Sawal Dher; Mohallah with households and community. Aqua tabs and IEC material distributed. On active surveillance in each area no other Mashkee Kali, Gujar case found . Ghari; Mohallah Suda‐ garo, UC Mohib Banda; Alert for 12 AWD cases. Samples taken & sent to NIH for confirmation. Health Education imparted to community elders. New Madina Colony, PPHI & NP Coordinator taken on board. EDO Health informed. Diarrhea Treatment Kit provided to PPHI, Nowshera. 3‐Aug AWD KPK Nowshera 0 5 3 4 Jahangira Water quality tests conducted by EHE, WHO‐EHA. UNICEF informed and shock chlorination done in the water sources. The situation in the area is being followed on daily basis. Alert was picked from local newspaper. Jala bella is one of the worst flood affected area of district Peshawar. EDOH was coordinated and a team of LHWs and sanitary inspectors along with the SO visited the area. Eight cases from two Vill Jala bella, UC Mian different locations were found on active surveillance. All the cases had mild symptoms and received treatment from the 2‐Aug AWD KPK Peshawar Gujjar; Mohallah 0 6 1 1 hospital. Health and hygiene education was provided through LHWs. IEC material, Soaps and aqua tabs were distrib‐ Yousafzai, UC Regi uted. Health facility staff was sensitized about the situation. LHW were asked to do daily H&H sessions with the commu‐ nity. water samples were taken and sent to public health laboratory for analysis. DCO was coordinated for informing the water supply systems. This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan . For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083, E-mail: [email protected]. 02 Epidemiological Bulletin: DEWS, Pakistan, Week no. 31 (28 July to 4 August, 2011) Current week's Outbreaks: Continued Date Disease Province District Area M F Action Taken BMC Swabi, Mohal‐ lah Mian Banda, UC Alert of AWD from two different locations, During field investigation treatment given, health education sessions conducted 29‐Jul AWD KPK Swabi marghuz; RHC Yar 0 1 0 1 to the families as well as in the community. 2 samples collected and found positive for V.c. Ogawa. EDO and MS of BMC Hussain, Mohallah informed. District Response team and all the PPHI staff were trained on Cholera management. Aman Abad, Dakai

Alert for 7 cases of AWD. Sample taken and send to NIH, health education sessions conducted, provision of medicine at near 29‐Jul AWD Punjab Mianwali Chah Khalil Walla 2 1 2 2 health facility, ORS, Soap, Filters and aqua tabs provided, water sample taken for quality testing. Pourani Chain Alert of AWD case was investigated and sample was taken and sent to NIH and found positive for V.c Ogawa. Health educa‐ 1‐Aug AWD Punjab Multan 0 1 0 0 Amrhi tion sessions conducted, provision of medicine at near health facility, ORS, Soap, Filters and aqua tabs provided.

Alert for one case of AWD sample was collected and sent to NIH. In the locality/area 20 households were interviewed and 7 Nearby Permit more cases of diarrhea were found and referred to health facility for treatment. Health education to family members in Chowk, Basti Gujjar households visited. Distribution of Aqua Tabs, ORS & IEC among them. 30‐Jul AWD Punjab Muzaffargarh 1 2 5 1 Abad, UC Jhalarein, Nearest RHC Sher Sultan was visited & SMO was given briefing on the situation, control measures & importance of aware‐ Jatoi ness among general masses about safe drinking water, food & personal hygiene & it was also suggested along with continu‐ ous strict surveillance.

Village Katho Alert for 10 cases of AWD reported. Reinforced case management, during active surveillance health education provided, ORS 2‐Aug AWD Sindh Tharparkar 0 1 1 8 Pathai, distributed, EDO‐H informed and 1 sample taken and sent to NIH. Suspected Pertussis notified by Medical Officer RHC Jarwar from village sultan Gabol. Upon field investigation 20 more cases 3‐Aug Pertussis Sindh Ghotki Village Sultan Gabol 0 0 0 0 were found and treated with erythromycin informed DHO & DSV for vaccination and health education in the area. Table‐1: Total number of alerts and outbreaks reported and investigated with appropriate response Post Flood 2010 2011 Current Week Total Disease A O A O A O A O Acute Watery Diarrhoea 209 85 494 209 56 29 759 323 Acute Jaundice Syndrome 5 2 32 12 2 ‐ 39 14 Bloody Diarrhoea 10 1 49 9 3 ‐ 62 10 Measles 48 6 1206 80 27 ‐ 1281 86 Pertussis 1 ‐ 179 18 5 1 185 19 NNT + Tetanus 5 ‐ 115 ‐ 12 ‐ 132 ‐ Malaria 12 7 49 35 5 2 66 44 Leishmaniasis 1 ‐ 71 17 6 1 78 18 Others 156 43 398 37 12 ‐ 566 80 Total 447 144 2593 417 128 33 3168 594 Province Khyber Pakhtunkhwa: Figure-2: Three years trend of Acute diarrhoea, province KPK • This week 21 districts reported to DEWS from 695 health facilities with a total of 160,109 patients con- 25 sultations. 2009 2010 2011 20 • AD cases reported were showing a consistent upward 15 trend and accounted for 16% of the total consulta-

tions in last 4 weeks. 10 Percentage • 42 alerts were reported in this week, 30 were for 5 AWD, 10 for measles, while one each for Diphtheria 0 and DHF. 1 4 7 101316192225283134374043464952 Epi‐Week Province Sindh: Figure-3: Three years trend of Acute diarrhoea, province Sindh • This week 23 districts reported to DEWS from 1,091 health centers with a total of 494,208 patient consul- 25 tations during the reporting period of week 31, 2011. 2009 2010 2011 20 • In Sindh, AD cases reported were 44,293 (9%), same proportional morbidity as compared with last week. 15

10 • 39 alerts were reported from Sindh in this week: 12 Percentage

were for AWD, nine for Neonatal tetanus and Teta- 5 nus, six for measles, five for Pertussis, three for Chicken pox, two for Malaria, while one each were 0 for Bloody diarrhoea and Leishmaniasis. 1 4 7 101316192225283134374043464952 Epi‐Week

• AD cases reported were 20,270, and stabilized at 7% 15 from last four weeks. 10 Percentage • 17 alerts were reported in this week from Punjab; Six 5 for Measles, five for AWD, two each were for Acute diar-

rhoea and Neonatal tetanus, while one each for Acute jaun- 0 dice syndrome and Bloody diarrhoea. 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

Epi‐week Province Balochistan: Figure-5: Three years trend of Acute diarrhoea, province Balochistan • In this week, 18 districts reported to DEWS from

Balochistan province. 445 health centers reported a 25 total of 68,026 patient consultations. • AD reported in 8,867 (13%) of the total consulta- 20 tions, 1% higher proportional morbidity as compared 15 with last week.

10 • 19 alerts were reported in this week from Balochis- Percentage tan, four were for Leishmaniasis, three for Measles, two each were for AWD, Malaria, Meningitis and 5 Mumps, while one each for AJS, Chicken pox, Ty- 2009 2010 2011 0 phoid, and Neonatal tetanus. 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Epi‐week Gilgit Baltistan:

Figure-6: Trend of priority communicable diseases, Gilgit Baltistan (25 March to 4 August 2011)

• In this week, 63 health centers from 7 districts in 45 AD BD ARI S. Malaria Gilgit Baltistan sent weekly report with a total of 40

25,889 patient consultations. 35

30 • ARI cases reported were 2,672 (10%), while Acute 25

Diarrhoea 5,492 (21%). Percentage 20 15 • Three alerts received and responded this week, one 10 5 each for Bloody diarrhoea, Measles and Malaria. 0 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

State of Azad Jammu and Kashmir: FATA:

• In this week, weekly report received from 85 health centers from 10 • This week 44 health centers in 3 agencies reported from FATA, districts, with a total of 31,173 patient consultations. with a total of 8,253 patient consultations. • ARI cases reported were 3,775 (12%), while Acute diarrhoea reported • ARI cases reported were 1,233 (15%), while Acute diarrhoea re- 3,195 (10%) cases. ported 1,189 cases (14%) • Five alerts were received and responded this week, four were for • Three alerts, two for AWD and one for measles were received and AWD and one for measles. responded this week.

45 45 AD BD ARI S. Malaria AD BD ARI S. Malaria 40 40 35 35 30 30 25 25 20 20

15 Percentage 15 10 10 Percentage 5 5 0 0 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

Current week's Alerts: Province Balochistan Number of alerts detected by week, Kh yber Pkhtunkhwa (Wk 28 ‐31 , 20 11 ) <5M >5M <5F >5F 35 Date Disease District Area 30 1‐Aug AJS Chagai Killi Shareenab Chaghi Village 1 1 0 1 30 23 22 2‐Aug AWD Kech Dashtuk UC Nag Zamoran, Buleda 0 1 0 1 25 20 16 alerts 1‐Aug AWD Lasbela Village Oba Lakhra Tehsil Lakhra 5 6 1 10 of 15 12 30‐Jul Chicken Pox Sibi Sibi City 0 1 0 0 # 10 10 10 7 Leishmani‐ 4 3‐Aug Awaran Waja Bagh Jhaoo 0 1 o 0 22 asis 5 11 Leishmani‐ Union Council Chitkan, Mohallah Gareeb 0 2‐Aug Panjgur 0 2 0 0 asis Abad Wk‐28 Wk‐29 Wk‐30 Wk‐31 Leishmani‐ 2‐Aug Panjgur Union Council Tasp 0 1 0 0 Epi‐week AWD Leishmaniasis Measles Pertussis asis Leishmani‐ 2‐Aug Sibi Sibi City 0 1 0 0 asis Number of alerts detected by week, Sindh (Wk 28 ‐ 31 , 20 11) 4‐Aug Malaria Jhal Magsi BHU Khichi 17 27 12 23 25 AWD Leishmaniasis Malaria Measles Pertussis 4‐Aug Malaria Nasirabad BHU Mir Hassan, tehsil D.M.J 11 17 9 15 20 16 30‐Jul Measles Awaran koto UC Korak Jhaoo 1 0 0 0 14 13 15 12 alerts 3‐Aug Measles Lasbela Village Kangar, UC Uthal 1 0 0 0 10 of

# 10 8 2‐Aug Measles Nasirabad Ghot Swali khan Bugti, Tehsil D.M.J 3 0 3 0 6 5 4 33 1‐Aug Meningitis Kech Jusak UC Sarikhan, Turbat 0 1 0 0 5 2 2 1 1 4‐Aug Meningitis Ziarat Kawas 1 0 0 0 0

29‐Jul Mumps Khuzdar Kehn UC Ornach Tehsil Nall 0 1 0 1 Wk‐28 Wk‐29 Wk‐30 Wk‐31 Qadir Abad UC Zereena Kattan tehsil Epi‐week 1‐Aug Mumps Khuzdar 0 0 0 1 Khuzdar 1‐Aug NNT Nasirabad Nursery ward of DHQ‐ Hospital D.M.J 0 0 1 0 Number of alerts detected by week, Punjab (Wk 28 ‐31, 2011) 25 3‐Aug Typhoid Chagai Killi georgage yak mach UC Chilghazi 0 2 0 2 AWD 20 Measles Current week's Alerts: AJK; FATA; GB and ICT Pertussis 15 13 alerts <5M >5M <5F >5F Date Disease District Area of 10

# 9 Muzaffara‐ Village Chimiyan, UC Machara , Tehsil 10 2‐Aug AWD 39 21 89 73 6 bad Patikka 5 5 4 Muzaffara‐ 5 3‐Aug AWD Village Takiyan , UC Komikot 27 31 80 98 1 1 bad 0 Village karnota, Riala‐UC Makhyilan 31‐Jul AWD Bagh 21 55 18 47 Ghaziabad, Tehsil Dhirkot Wk‐28 Wk‐29 Wk‐30 Wk‐31 Epi‐week 30‐Jul AWD Haveli Village Serrian, UC Sangal, Tehsil Haveli 15 50 18 42

Number of alerts detected by week, Balochistan (wk‐28 to 31, 2011) 2‐Aug Measles Bagh Village Capriyan UC Rangla Dist Bagh 1 0 0 0 25 AWD Leishmaniasis Malaria Measles Pertussis Khyber 20 1‐Aug AWD CH Lowara Maina, Molagam 0 0 0 1 Agency 15 Mohmand 1‐Aug AWD Marina Khel, Yakshund 0 2 0 1 Agency alerts 10 7

of 6

Leishmani‐ Bajaur # 5 4 4 3‐Aug UC Malangai, Tehsil Mamoond 2 2 0 8 33333 3 asis Agency 5 222 2 2 1 1 3‐Aug BD Gilgit Basin Khari Tehsil & District Gilgit 0 2 0 0 0

Wk‐28 Wk‐29 Wk‐30 Wk‐31 2‐Aug Malaria Ghizer Village Thaus Tehsil Yasin District Ghizer 0 2 0 1 Epi‐week

29‐Jul Measles Ghizer Village Sultanabad UC Thaus Tehsil Yasin 0 1 0 0 Number of alerts detected by week, Gilgit Baltistan (Wk 28 ‐31 , 20 11 ) 25 4‐Aug AWD ICT CH PIMS (Raheem abad Tarlai) 0 0 0 1 AWD Malaria Measles 20

Distribution of alerts by disease, Wk 31 (29 Jul ‐ 4 Aug), 2011 (n= 129) 15

NNT + Tetanus, 12 alerts 10

5 # 4 Measles, 27 Leishmaniasis, 6 5 2 111 1 S. Malaria, 5 0

Wk‐28 Wk‐29 Wk‐30 Wk‐31 Pertussis, 5 Epi‐week

Chicken pox, 4 Number of alerts detected by week, AJK (Wk‐28 ‐ 31 , 201 1) 25 BD, 3 AWD Measles AD, 2 20

AJS, 2 15 alerts Meningitis, 2 of

# 10 Mumps, 2 4 DHF, 1 5 3333 1 Diphtheria, 1 0

Typhoid, 1 Wk‐28 Wk‐29 Wk‐30 Wk‐31 AWD, 56 Epi‐week

2‐Aug AWD Karachi Maula Labour colony, Sherpao Colony, 1 0 0 0 30‐Jul AWD Haripur Village Krum, UC Kakotree 2 5 2 13 Near Madni Masjid, Old Kamela Slaughter 3‐Aug AWD Karachi 1 0 1 1 house, Lyari town 31‐Jul AWD Haripur Village Brug, UC Bait Gali 41 73 37 121

2‐Aug AWD Mirpur Khas Block# 90, Near Mustafa Masjid, Power 0 1 0 0 4‐Aug AWD Haripur FGSH (Village Dhanna Ferozpur, UC Barkot) 3 7 4 8 Naushahro Village Haji Muharram Nangore, UC Cha‐ 4‐Aug AWD 2 0 0 0 Feroze heen, Bhiria 30‐Jul AWD Kohat Village Kamal Khel, UC Dhoda 7 5 8 15 Village Utala, UC Gall(Maidan), Tehsil Lal 4‐Aug AWD Qambar Village Abdul Wahid Khoso UC dost Ali 1 0 0 0 1‐Aug AWD Lower Dir 0 0 0 4 Qilla Shahdadpur Institute of Medical Science 4‐Aug AWD Sanghar 0 1 1 1 Taluka Shahdadpur 3‐Aug AWD Lower Dir Village Shako, UC Hayaserae, Tehsil Balmbat 0 0 0 1 4‐Aug AWD Shikarpur BHU Haji Khan Kalhoro 0 0 0 1 Village Katho Pathai, UC Gadhro, Taluka 31‐Jul AWD Mansehra Village Paras Balakot 0 1 0 0 2‐Aug AWD Tharparkar 0 1 1 8 Chachro Ahl Kar Near Kodar UC Sachan Kalan, CH 29‐Jul AWD Mansehra 1 1 1 4 1‐Aug BD S. Benazirabad Police Line Colony,Taluka Nawabshah 0 0 2 1 Batal

3‐Aug Chicken Kashmore Village Todal Malik BHU DMK 0 1 2 1 4‐Aug AWD Mansehra Gia Mera Road College Doraha 0 0 1 0 Chicken Qambar 4‐Aug Khosa Village, Qambar 0 3 0 0 Pox Shahdadkot 29‐Jul AWD Mardan Vill. Jamra, Kandaro Kilay, UC Bakhshali 0 1 0 0 4‐Aug Chicken Sukkur Old Sukkur 0 0 1 0 30‐Jul AWD Mardan Mohallah Mechanay, UC Mohib Banda 0 0 0 1 Leishma‐ Qambar 4‐Aug Village Qazi Khan Chandio, Mero Khan 0 0 0 1 niasis Shahdadkot 29‐Jul AWD Mardan Mohallah Gul Wahab, UC Mohib Banda 0 0 0 1 Village Ghulam Hussain Nohani, UC Khann, 3‐Aug Malaria Thatta 2 0 1 1 Mohallah Khattak, Near girls high school, UC Taluka Ghorabari 29‐Jul AWD Mardan 0 1 0 0 Sawal Dher 3‐Aug Malaria Thatta Village Karim Chandio, UC Karampur, 1 0 0 1 29‐Jul AWD Mardan Mohallah Mashkee Kali, Gujar Ghari 0 1 0 0 29‐Jul Measles Badin Ward # 4, UC and Taluka Talhar 0 0 0 1 Solangi Mohalla opposite Boys High School, 1‐Aug Measles Shikarpur 1 0 0 0 29‐Jul AWD Mardan Mohallah Sudagaro, UC Mohib Banda 0 1 0 0 UC Lakhi 4‐Aug Measles Shikarpur Village Sanhro Jafri UC Karan 1 0 0 0 3‐Aug AWD Nowshera New Madina Colony, Jahangira 0 5 3 4 4‐Aug Measles Tando Allah Meva Colony, Chamber road city 0 0 1 0 1‐Aug AWD Peshawar Baghwanano Kanday, UC Sarband 0 1 0 0 2‐Aug Measles Thatta Chandio Mohalla, Var City Taluka Ghorabari 1 0 1 0 Village Gul Chandio, UC Karampur, Taluka 2‐Aug Measles Thatta 1 0 1 0 29‐Jul AWD Peshawar Mohallah Yousafzai, UC Regi 0 0 1 0 Mirpur Sakiro 3‐Aug NNT Ghotki Village Lal Bux Chhagan UC I Mirpur 1 0 0 0 2‐Aug AWD Peshawar Vill Jala bella, UC Mian Gujjar 0 6 0 1

4‐Aug NNT Karachi Ibrahim Haidery, Korangi Town 1 0 0 0 1‐Aug AWD Shangla Aloch, puran 3 0 0 0 4‐Aug NNT Karachi Scheme 33, Gulzar Hijri, Gadap Town 1 0 0 0 3‐Aug AWD Shangla Shaga, Martung, tehsil Puran 0 0 1 0 4‐Aug NNT Naushahro Village Khado Mari, Near Darya Khan Mari 1 0 0 0 Village Dost Muhammad Jamali, UC Man‐ 29‐Jul NNT S. Benazirabad 1 0 0 0 30‐Jul AWD Swabi BHU Zaida 0 0 1 0 haro, Kazi ahmed BMC Swabi, Mohallah Mian Banda, UC 4‐Aug NNT Thatta Shorkis farm, UC Mehar Taluka Ghorabari 0 0 1 0 29‐Jul AWD Swabi 0 0 0 1 marghuz 3‐Aug Pertussis Ghotki Mudarasa Muhalla Jarwar village UC jarwar 0 0 2 0 RHC Yar Hussain, Mohallah Aman Abad, Village Sultan Gabol UC Jarwar Taluka 30‐Jul AWD Swabi 0 1 0 0 3‐Aug Pertussis Ghotki 0 0 0 0 Dakai Mirpur Mathelo 4‐Aug Pertussis Matiari Village Chando Memon 1 0 0 0 4‐Aug AWD Swabi RHC Yar Hussain, Mohallah Jango 0 1 0 0 2‐Aug Pertussis S. Benazirabad Goth Ali Akbar, UC Ammerji, Taluka Daur 1 1 0 0 3‐Aug AWD Tank Alikhel 0 0 1 0 2‐Aug Pertussis S. Benazirabad Goth Karam ali Chandio, UC Bandhi Taluka 0 0 1 0

3‐Aug Tetanus Ghotki Village Tharo Khan Laghari UC Jarwar 0 1 0 0 4‐Aug AWD Tank Gara Pattar 0 0 1 0 4‐Aug Tetanus Karachi Jhat yar Goth, Super highway, Gadap Town 0 1 0 0 Kuz Bahar Adda, Dehgaan,Khugiani, Nin‐ 5‐Aug DHF Peshawar 0 1 0 3 garhar, Afghanistan 4‐Aug Tetanus Qambar Village Peer Mohammad Lakho 0 1 0 0 Village Zarey Manglor, UC Aka Maruf Bami 4‐Aug Diphtheria Swat 0 0 0 1 Current week's Alerts: Province Punjab Khel, Tehsil Babuzai. Village Devlai near thana colony, UC Devlai, Date Disease District Area <5M >5M <5F >5F 31‐Jul Measles Swat 1 0 0 0 Tehsil Kabal. 3‐Aug AD Bhakkar Litten city, UC Litten, Tehsil Mankera 2 7 1 2 Village Kota Saidano Kale, UC Kota, Tehsil 31‐Jul Measles Swat 1 0 0 0 4‐Aug AD RY. Khan BHU Unran,Tehsil Liaqatpur 21 12 17 8 Barikot. 29‐Jul AJS Mianwali Mohallah Islamabad,Near BHU Bala,UC 1 0 3 2 Village Malam Jaba near Khwar, UC & Tehsil 2‐Aug Measles Swat 1 0 0 0 3‐Aug AWD Layyah Mohalla Muhammadpura ward number 6 0 1 0 0 Charbagh. Village Marghuzar Qilla, UC Islampur, Tehsil 29‐Jul AWD Mianwali Chah Khalil Walla, UC Swance 2 1 2 2 2‐Aug Measles Swat 1 0 0 0 1‐Aug AWD Multan Pourani Chain Amrhi, Nazde Farooq Pura 0 1 0 0 Babuzai. Village Nawey Kale near Bypass , UC Nawey 2‐Aug AWD Muzaffargarh Moza Inayatpur, UC Jaggatpur 0 1 0 0 2‐Aug Measles Swat 1 0 0 0 Kale,Tehsil Babuzai. 30‐Jul AWD Muzaffargarh Basti Gujjar Abad, UC Jhalarein, Jatoi 1 2 5 1 Village Kokarai Kach Kot, UC Kokarai,Tehsil 3‐Aug Measles Swat 0 0 1 0 4‐Aug BD Layyah Awan abad UC Khairay wala 2 0 1 0 Babuzai 30‐Jul Measles Bhakkar Chak 42‐43 TDA, UC Peer Ashab 1 0 0 0 3‐Aug Measles D. G. Khan Ada Ghausabad uc Ghausabad 0 0 0 1 3‐Aug Measles Swat Village Labat, UC Barthana, Tehsil Matta. 1 0 0 0 3‐Aug Measles D. G. Khan Basti Loharwala Shumali uc Paigan 1 0 1 2 Village Sangota near Qabristab, UC Sangota, 3‐Aug Measles Swat 1 0 0 0 1‐Aug Measles Layyah Moaza deenpur,UC Wara sehra Tehsil karoor 2 1 0 2 Tehsil Babuzai. 2‐Aug Measles Layyah Bhait Mongar, UC Wara sehra Tehsil karoor 1 0 0 0 Village Balogram, UC Udigram, Tehsil Ba‐ 4‐Aug Measles Swat 1 0 1 0 2‐Aug Measles Layyah Dhapi Makori,UC Wara sehra Tehsil karoor 1 0 0 0 buzai 30‐Jul NNT D. G. Khan PeerAdil uc Pir Adil 1 0 0 0 4‐Aug Measles Swat Village Manyar, UC Ghalegey, Tehsil Babuzai. 1 0 0 0 2‐Aug NNT Multan Muza Shakani Wala, Jampur 0 0 0 1

Diseases Total 4000 Mobile Fixed 6 6 6 7 2

3500 2 7 3 8 6 7 7 7 6 Skin Diseases 4,237,456 (11%) 8 13 3000 6 6 6 8 8 8 8 8

2500 11 11 8 Acute Respiratory Infection 9,057,939 (23%) 11 8 11

2000 8 12 411 400 375 331

11 361 1500 215

Acute Diarrhoea 3,711,790 (10%) 192 26

3375 3363 3354 153 3288 3259 3259 3251 3250 3234 26 3215 3196 3120 3092 128 3058 3021 3022 2982 2935 2909 105 46 2785 2745 81 58 1000 2547 2466 2450 2404 2349 2322 2262 2255 2251 2199 2022 2021

Bloody Diarrhoea 338,899 (1%) 1797 500 1680 1463 1289 1215 999 1167 1158 967 1143 949 1130 1113 1111 1073 1067 879 Suspected Malaria 2,310,148 (6%) 0 854 3 5 7 9

11 33 35 37 39 41 43 45 47 49 51 11 13 15 17 19 21 23 25 27 29 31 ‐

1 Wk Wk Wk Wk Unexplained Fever 1,506,858 (3%) Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Total Consultations 39,491,736 Wk

Focus on: Basic messages about cholera treatment and prevention Through collaboration of the Ministry of Health at district and provincial levels, NIH and the Disease Early Warning System (DEWS) teams supported by WHO, cholera has been detected and controlled in all provinces of the country. DEWS teams respond to calls from health providers reporting cases of suspected cholera: “severe dehydration or death due to acute diarrhea in a person over age five years old.” Severe cholera is characterized by a sudden onset of profuse, watery diarrhea along with nausea and vomiting. Cholera diarrhea can look like cloudy rice water. Chol‐ era can cause death from dehydration (the loss of water and salts from the body) within hours if not treated. With prompt, effective treatment, mortality is less than 1%, but without treatment 50% of the most severe cases die within a few hours.

Treatment Any person with diarrhea should drink more fluids, such as water, juice, and soup. The best drink is a balanced so‐ lution of sugar and salts called ORS (oral rehydration salts) which is provided at public health facilities or can be purchased in the market and mixed with safe water to provide quick fluid replacement. Zinc supplement is also rec‐ ommended. If diarrhea is continuous or vomiting prevents drinking fluids, the patient should go urgently to a hospi‐ tal or clinic to receive intravenous fluids. Patients who are promptly treated respond rapidly and recover.

Prevention Cholera is spread via the fecal‐oral route, most commonly by drinking water or eating food which is contaminated by sewage. Always be sure you are drinking water which has been tested for quality – filtered, chlorinated, or bot‐ tled. Avoid ice in restaurants and drinks and ice cream sold in the market because they may not be made with safe water. “Boil it, cook it, peel it or leave it” is good advice about raw fruits and vegetables in countries endemic for cholera. Cook food well, eat it hot, keep it covered, and peel fruits and vegetables. Wash hands after using the toi‐ let and before eating, or use an antiseptic hand gel.

Distribution of Wild Polio Virus cases Pakistan 2010 and 2011 Year 2010: The total number of polio cases reported in 2010 is 144 includ‐ ing 120 type‐1 cases and 24 type‐3 from 40 infected districts/towns/ agencies. Year 2011: The total number of polio cases confirmed by the laboratory is 63 (62=type‐1, and 1=type3) till date from 26 districts.

Province Cases 2010 Cases 2011 P1 P3 P1 P3 Punjab 6 1 - -

Sindh 26 1 14 -

Khyber Pakhtunkhwa 19 5 6 - FATA 63 11 19 1 Balochistan 6 6 22 - AJK - - - - Gilgit‐Baltistan - - 1 - Islamabad - - - - Total 120 24 62 1 This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan . For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083, E-mail: [email protected]. 07 Epidemiological Bulletin: DEWS, Pakistan, Week no. 31 (28 July to 4 August, 2011) Alerts and outbreaks, week 31, 2011