Weekly-Epidemiological Bulletin-19-26122010.Pub

Weekly Epidemiological Bulletin Flood Response in Pakistan Volume 1, Issue 19 Monday 27 December 2010

Highlights Priority diseases under surveillance Epidemiological week no 51 (17 - 23 December 2010) in the flood affected areas

• Between 17 - 23 December 2010 (epidemiological week no. 51), 56 districts in 4 provinces provided Acute Flaccid Paralysis (AFP) surveillance data to the DEWS system. Acute Jaundice Syndrome (AJS) • 1,960 fixed health and 8 mobile medical outreach centres provided surveillance data for this week. As people move back to their homes, the mobile teams are winding down. DEWS Surveillance Officers Acute Respiratory Infections (ARI)

are establishing new reporting flows from fixed centers. Acute Watery Diarrhoea/ (AWD) Suspected Cholera • A total of 530,551 consultations were reported through DEWS of which 30% were acute respiratory infections (ARI), 8% skin disease, 7% acute diarrhoea, and 7% were suspected Malaria. Bloody Diarrhoea (BD)

Acute Diarrhoea (AD) • Total 13 alerts were received and responded in this week: 6 were for Measles, 2 for suspected Influ- enza, and 1 each for Acute Flaccid Paralysis, Acute Watery Diarrhoea, Bloody Diarrhoea, suspected Suspected Hemorrhagic Fever Viral Hemorrhagic Fever, and Neonatal Tetanus. (VHF)

Suspected Malaria (Mal) • No case of confirmed poliomyelitis reported this week from the flood affected district Suspected Measles (Ms)

Note: All presented data are based on the number of patient consultations and include information on priority diseases Suspected Meningitis (Mg) under surveillance as well as major health events reported through DEWS. Others

Figure-1: Weekly trend of leading priority diseases in flood affected districts of Pakistan, 29 July to 23 December 2010 (Epi week 31 - 51, 2010)

Table-1: Priority diseases reported during the week 44 - 51, 2010 Diseases Wk‐44 Wk‐45 Wk‐46 Wk‐47 Wk‐48 Wk‐49 Wk‐50 Wk‐51

Skin Disease 25, 920 (9%) 27,009 (8%) 23,784 (8%) 29,056 (8%) 38,022 (9%) 40,533 (8%) 35,376 (8%) 42,449 (8%)

ARI (URI and LRI) 72,582 (24%) 93,704 (27%) 79,391 (28%) 98,719 (27%) 126,265 (29%) 156,168 (30%) 129,087 (30%) 160,928 (30%)

Acute Diarrhoea 22,923 (8%) 24,915 (7%) 20,138 (7%) 27,007 (7%) 34,377 (8%) 33,188 (6%) 27,433 (6%) 36,423 (7%)

Bloody Diarrhoea 2,843 (1%) 2,889 (1%) 2,578 (1%) 3,422 (1%) 2,972 (1%) 3,943 (1%) 3,024 (1%) 3,818 (1%)

Suspected Malaria 24,589 (8%) 26,843 (8%) 21,726 (8%) 27,198 (7%) 30,633 (7%) 31,780 (6%) 26,854 (6%) 34,655 (7%)

Total consultation 300,924 340,761 280,676 364,543 428,159 522,284 436,771 530,551

Diseases Total Skin Diseases 1,513,470 (13%) Acute Respiratory Infection 2,356,167 (21%) Acute Diarrhoea 1,253,886 (11%) Bloody Diarrhoea 121,706 (1%) Suspected Malaria 655,926 (6%) Unexplained Fever 534,422 (5%) Total Consultations 11,324,767

Figure-3: Leading causes of seeking health care in the flood affected districts by province, 29 July to 23 December 2010

Number of cases 900,000 851,480 849,283 Skin Ds. 800,000 ARI 705,600 677,987 AD 700,000 UF

600,000 534,140 S. Mal 494,382 500,000 BD 411,232 400,000 372,748 363,437 300,000 234,407

118,276 200,000 133,355 123,297 124,033 93,131 74,045 66,003 74,107 100,000 43,575 24,344 27,887 19,054 18,758 1,016 - Punjab Sindh Khyber Pakhtunkhwa Balochistan

Figure-4: Acute Diarrhea trends, Disaster affected districts, Pakistan 2009 and 2010

20 2009 2010 Since July 29, 2010, a total of 1,253,886 acute diarrhea patient consultations 18 have been reported to DEWS from the flood affected districts of 4 provinces in 16 Pakistan. 14 12 Proportional Morbidity in Provinces: 10 Khyber Pakhtunkhwa: Reported 6% (1% decreased) as compared with last 8 Percentage week. 6 4 Punjab: Reported 8% (3% increased) as compared with last week. 2 Sindh: Remains 6% as compared with last week. 0 Balochistan: 8% (1% decreased) as compared with last week. 1 3 5 7 9 111315171921232527293133353739414345474951 Epi-week

Figure-5: Acute Respiratory Infection trends, Disaster affected districts, Pakistan 2009 and 2010

40 2009 2010 Since July 29, 2010, approximately 2,356,167 Acute Respiratory Infection 35 patient consultations have been reported to DEWS from the flood affected 30 districts of 4 provinces in Pakistan. 25

20 Proportional Morbidity in Provinces: 15 Khyber Pakhtunkhwa: Reported 41% (3% increased) as compared with last Percentage week. 10 Punjab: Reported 24% (1% increased) as compared with last week. 5 Sindh: Remains 29% as compared with last week. 0 Balochistan: reported 32% (3% increased) as compared with last week. 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epi week

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: Flood Response in Pakistan Table-3: Follow-up alerts reported in week 50, 2010. Age Date of alert Alert Province District Location (detailed) Sex Action taken / Notes (yr) Samples were negative for DF. Raised awareness in the community MCH Centre (Taluka F, M, 4, 8, 3 10‐Dec‐10 VHF Sindh Ghotki Ghotki) M for prevention of mosquito bites and early referral of Hemorrhagic cases. Upon field investigation 5 cases including 1 death (2‐year old) were IDP Camp Main Primary 2,5,7, M,M,M, 11‐Dec‐10 Measles Sindh Kamber School 6,5 M,M found. From active cases two samples were collected and one was found positive for Measles. Active surveillance was done. Ayub Teaching Hospital 16 M 11‐Dec‐10 VHF KP Abbottabad (Khola Kehal) Sample was declared negative for CCHF by NIH. Suspected cases were reported but upon field investigation no 11‐Dec‐10 Measles Punjab Mianwali DHQ Mianwali ** ** Measles cases were found. Qasim Bela, Masud‐Pur, Suspected cases were reported but upon field investigation no BD 11‐Dec‐10 BD Punjab Multan ** ** 5‐Faiz cases were found.

Lady Reading Hospital, Probable diphtheria case diagnosed with post diphtheric neuropa‐ 12‐Dec‐10 Diph KP Nowshera Peshawar (UC Misri 8 F thy, case was hospitalized but died. Active surveillance in the field Banda‐Nowshera) is on going.

KTH (Shabi Khel Probable diphtheria case, died on 18 Dec. Field investigation re‐ 13‐Dec‐10 Diph KP Tank Koroona, UC Jata Thar ‐ 15m F vealed 20 household contacts, sample of one contact collected, Tank) and all contacts treated prophylactically with antibiotics. DHQ Haripur (Bandi Suspected AFP case was found. Polio team is investigating the 13‐Dec‐10 AFP KP Haripur 16m M Sher Khan) case. MCH Center (UC Suspected case was identified and cultured. Contacts treated pro‐ 15‐Dec‐10 Pertussis Sindh Ghotki Hussain Beli ‐ Piral 3 M Village) phylactically. Active surveillance ongoing in the community.

KTH (Mohalla Probable diphtheria case from new district. Contacts treated pro‐ 16‐Dec‐10 Diph KP Mardan Sikandaray‐ Bar 11 M phylactically with antibiotics. So far 12 districts have reported with Kanday) suspected diphtheria cases. 13 blood samples were tested by the health facility and 8 were Balochistan CD Manjhi Pur 16‐Dec‐10 Malaria Jaffarabad ** ** found positive. LLINs, RDT Kits and anti malarial medicines have

already been distributed. Table-4: Alerts and Outbreaks (Week 51, 2010) Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes Afghan Refugee Camp 3 Upon field investigation a mild urticaria patient was found which was 18‐Dec‐10 Measles KP Haripur 4 M (Khalabut Township) misdiagnosed as measles.

Imamia Chowk (Khalabut Upon field investigation a acute diarrhoea patients were found which 18‐Dec‐10 AWD KP Haripur ** M, F Sector 4) were misdiagnosed as Cholera.

20‐Dec‐10 AFP Sindh Ghotki MCH Center (UC Qadirpur) 3 F Suspected AFP case was found. Polio team is investigating the case.

F,F,F,F,M, Upon field investigation 11 cases including 5 deaths were found. From TH Johi (UC Tando Rahim 5,4,*,*,3,5,3, 21‐Dec‐10 Measles Sindh Dadu F,F,M, active cases 2 samples were collected and sent to NIH. Active surveil‐ Khan) 5,3,7,4 F,F,M lance is ongoing.

Upon field investigation 10 suspected cases were found. From active 5,45,10,14,3d, M,F,M,F,M, 21‐Dec‐10 BD Punjab Jhang THQ Shorkot 40,5m,4m,10m cases 4 samples were collected and sent to NIH. Active surveillance is F, F,M,M,F ,2m ongoing.

DHQ Timergara (Petto Dara 21‐Dec‐10 VHF KP Lower Dir 24 M Sample was declared negative for DF by NIH. Intervention as above. Village) Jinnah Clinic (Sardar Khan Suspected NNT case was found. TIG has been provided and active 22‐Dec‐10 NNT Sindh Ghotki 14d F Chachar Village) surveillance is ongoing. Upon field investigation 1 suspected case was found. Sample was 22‐Dec‐10 Measles KP Malakand CH Thana ‐ Batkhela 2 M collected and sent to NIH. Active surveillance is ongoing.

MMC (Umerabad ‐ Takht Upon field investigation 1 suspected case was found. Sample was 22‐Dec‐10 Measles KP Mardan 23 M bai) collected and sent to NIH. Active surveillance is underway. Upon field investigation 7 cases plus 9 unconfirmed deaths were UC Gublo (Mahboob Khan F,M,F,M,F, 23‐Dec‐10 Measles Sindh Kashmore 8,6,5,7,8,6,3 found. From active cases 3 samples were collected and sent to NIH. Sundrani Village) F,M Active surveillance is ongoing.

H1N1 BKMC (Kalal Village, Kota Suspected cases were found with typical flu like symptoms. Sample 24‐Dec‐10 KP Swabi 24,41 M,F (2009) Village) tested at NIH showed positive H1N1 (2009). H1N1 Rawal‐ Suspected case was found with typical flu like symptoms. Sample 24‐Dec‐10 Punjab CMH ** ** (2009) pindi tested at NIH showed positive H1N1 (2009). Swabi Upon field investigation 1 suspected case was found. Sample was 24‐Dec‐10 Measles KP BKMC (Panjpir Village) 3 M collected and sent to NIH. Active surveillance is underway.

Table-5: List of confirmed Polio Cases from flood affected districts, week 51-2010

There was no case of confirmed poliomyelitis reported this week from any of the flood affected district. Altogether, polio program has reported a total of 138 confirmed wild polio cases and one death including 2 more cases from Khyber Agency, FATA this week.

• Seven alerts were received and investigated this week; 4 alerts were for Suspected Measles, 1 each was for Influ- enza, Viral Hemorrhagic Fever, and Acute Watery Diar- rhoea.

Diseases Wk-48 Wk-49 Wk-50 Wk-51

Skin Diseases 5,648 (5%) 5,488(4%) 4,537(4%) 4,174(4%)

ARI (URI and LRI) 45,734 (37%) 47,993(38%) 42,136(38%) 48,781(41%)

Acute Diarrhea 9,970 (8%) 8,769(7%) 7,348(7%) 7,145(6%)

Bloody Diarrhea 998 (1%) 1,199(1%) 867(1%) 804(1%)

Suspected Malaria 2,861 (2%) 2,928(2%) 2,144(2%) 1,507(1%)

Total consultations 124,631 125,766 108,713 118,745 Province Punjab Figure-7: Trend of priority communicable diseases, province Punjab (3 August - 23 December 2010) • 11 districts reported data to DEWS from Punjab province • 759 fixed health centers and 3 mobile medical outreach centers reported to DEWS • A total of 166,799 patient consultations were reported during this reporting period • In Punjab a higher proportion of ARI (24%) was reported compared with 23% last week. This is consistent with expected seasonal trends. • Two alerts were reported and responded this week; 1 each for suspected Bloody Diarrhoea, and Influenza.

Diseases Wk-48 Wk-49 Wk-50 Wk-51

Skin Diseases 16,349 (13%) 12,754 (9%) 13,491 (10%) 16,341 (10%)

ARI (URI and LRI) 29,304 (23%) 39,249 (27%) 30,854 (23%) 39,456 (24%)

Acute Diarrhea 11,305 (9%) 7,422 (5%) 7,272 (5%) 13,295 (8%)

Suspected Malaria 9,119 (7%) 4,587 (3%) 5,437 (4%) 8,473 (5%)

Total consultations 124,881 144,799 135,438 166,799

Diseases Wk-48 Wk-49 Wk-50 Wk-51

Skin Diseases 13,777 (10%) 20,093 (10%) 14,629 (10%) 19,121 (10%)

ARI (URI and LRI) 40,538 (29%) 56,702 (27%) 42,351 (29%) 55,771 (29%)

Acute Diarrhea 8, 545 (6%) 12,607 (6%) 8,641 (6%) 11,604 (6%)

Bloody Diarrhea 863 (1%) 1,383 (1%) 1,034 (1%) 1,417 (1%)

Suspected Malaria 13, 273 (10%) 18,955 (9%) 14,271 (10%) 18,348 (10%)

Total consultations 138,362 208,806 145,293 191,328

Province Balochistan Figure-9: Trend of priority communicable diseases, province Balochistan (6 August - 23 December 2010) • In this week, 11 districts reported to DEWS from Balochistan province. • 313 fixed and 5 mobile medical outreach centers reported to DEWS • A total of 53,679 patient consultations were reported during the reporting period of week 51, 2010 • High number of Malaria cases were reported from different areas of Jaffarabad district. A total of 1,027 malaria samples were tested on which 427 were positive (slide positivity rate 41.5%). Falciparum Rate was 64.4%.

Diseases Wk-48 Wk-49 Wk-50 Wk-51

Skin Diseases 2,248 (6%) 2,198 (5%) 2,719 (6%) 2,813(5%)

ARI (URI and LRI) 10,689 (27%) 12,224 (28%) 13,746 (29%) 16,920(32%)

Acute Diarrhea 4,557 (11%) 4,390 (10%) 4,172 (9%) 4,379(8%)

Bloody Diarrhea 1,084 (3%) 1,323 (3%) 1,100 (2%) 1,597(3%)

Suspected Malaria 5,380 (13%) 5,310 (12%) 5,002 (11%) 6,327(12%)

Total consultations 40,285 42,913 47,327 53,679

While most children in the flood-affected districts were immunized against Measles in campaigns soon after the flood, unfortu- nately some areas were not accessible, and we are seeing measles outbreaks in some areas of Sindh.

• From August to December in Pakistan, DEWS has investigated 43 Measles alerts from 18 districts. • There were 24 alerts where lab-confirmed cases were identified involving 140 confirmed cases from 11 districts in two provinces – KP and Sindh. • After investigation, 5 outbreaks were evident with five or more cases in 4 districts, involving 103 cases with 18 deaths – all Sindh. • Two more outbreaks under investigation involve 18 clinical cases and 5 deaths in 2 districts of Sindh.

The confirmed outbreaks are as follows:

Week 42, UC Khawand Bux Sundrani, Ghotki District, Sindh: 14 cases, 3 deaths Week 45, Village Kabil Khan Bhayo, Kashmore District, Sindh: 11 cases, 0 deaths Week 46, UC Mounder, Taulka Dadu, Dadu District, Sindh: 20 cases, 10 deaths Week 48, UC Qadarpur, Ghotki District, Sindh: 52 cases, 3 deaths Week 50, IDP Camp Main Primary School, Kamber District, Sindh: 6 cases, 2 deaths

Outbreaks of clinical measles waiting lab confirmation:

Week 51, UC Tando Rahim Khan, Taulka Johi, Dadu District, Sindh: 11 cases, 5 deaths Week 51, UC Gublo, Kashmore District, Sindh, 7 cases, plus 9 unconfirmed deaths

Confirmed cases have also been identified in one other district of Sindh:

Week 46, Nowsheroferoz, Sindh: 3 cases

While Ghotki, Kamber and Kashmore were among the districts covered in the first phase of the campaign, Phase 2 of the Mass Immunization Campaign is planned for Dadu, MirpurKhas, Jacobabad, Sanghar, Tando M Khan, Tando Allahyar, Tharparkar, and Umer Kot districts during 5-15 January 2011. In addition, measles immunization campaigns have been conducted in the IDP camps in Dadu and villages surrounding affected areas in Ghotki.

For measles cases, vitamin A can be life-saving. Make sure that all patients with measles receive 2 doses of vitamin A • Give the first dose in the clinic • Give parents one dose to give at home the next day • Use the following chart to determine the dosage. For example, if you have 100,000 IU capsules, one dose for an infant 6-12 months old would be one capsule. • Show the mother how to open the capsule and place the drops in the child’s mouth. Give her the second capsule(s) to give the child the next day at home.

Dose for each age and each type of Vitamin A capsule Age Cap 200,000 IU Cap 100,000 IU Cap 50,000 IU

Up to 6 months 1/2 capsule 1 capsule 6 months up to 12 months 1/2 capsule 1 capsule 2 capsules 12 months up to 5 years 1 capsule 2 capsules 4 capsules

The objective of this weekly epidemiological bulletin is to provide a snap shot on selected health events reported from the communities affected by the current flood in Pakistan. While every attempt is made to present the weekly trend of the epidemic prone diseases, the information presented in the bulletin needs to be interpreted in the context that precise information on the reference populations is not always available, The bulletin also includes information collected by DEWS teams established during earlier emergencies, including 2005 earthquake, 2007 floods and 2008 ID crises. The primary focus of DEWS is the early detection of epidemic prone diseases, to facilitate a rapid public health response. We would like to thank all the numerous national and international partners who have contributed to the Disease Early Warning System.