DISEASES EARLY WARNING SYSTEM th February 22, 2010 WEEKLY MORBIDITY & MORTALITY REPORT 4 Year , Issue –07

Flu Updates: The following Activities have been done Epid Week 07, 2010 HIGHLIGHTS

- So far we have 953 confirmed cases of AH1N1 in the country. ¾ Out of 182 Sentinel sites, 182 sentinel sites have sent their -The total number of deaths reported till now is 17. reports in Week-07 of 2010; 22 treatment sites activated in province and all provincial and regional ¾ Out of total 169,766 events recorded in week-07 of 2010, hospitals have facilities for treatment and sample collection, the tamiflu and PPEs distributed to all provinces. 53,311(31.4%) consultations were reported due to DEWS target diseases. The positive cases reported from the below provinces: Kabul,,Hirat,Kandahar,Nangarhar,Bamyan,Hilmand,Takhar, ¾ Main causes of consultations this week are ARI (26.5%) and Panjsher,Baghlan,,Ghazni,Parwan,Kundoz,Badakhshan,Faryab,Ghor, ADD (3.9%) from total clients in a continuing trend from Badghis,Jawzjan,Nooristan,Konar, Daikundi, Samangan the week before. - CCC (command and control center) is functional ¾ 80 death cases caused due to Pneumonia, Meningitis/SIC - Three telephone hotlines are open to help people, 0798644004 and Diarrheal diseases, so that 67 cases due to 0798665085 – 0798660829 - Intensive surveillance to detect A H1N1 in the country is functional; daily pneumonia/ARI, 1 death cases due to diarrheal diseases reports are allocated, compiled and shared with all stakeholders. and 12 deaths cases reported due to Meningitis and Severely - 177 sentinel sites are functional in the country and reporting on the Ill Children. weekly basis Reported/Investigated Outbreaks in this Week: - All rapid response teams are on alert to investigate /detect the A H1N1 cases throughout the country Sus. Disease District/province in which OB took place in - About 1196 Health Care workers have been trained concerning the AI Outbreaks (OB) this week H5N1 and A H1N1 case management during the fourth quarter of 2009. Measles OB In Zormat district of Paktia, In Gurboz district of - All the needed data regarding training of AH5N1 and AH1N1 collected, Khost, in Panjab/Waras districts of Bamyan, in analyzed and compiled as country wise by training Coordinator of AI of Nangarhar and in project. of .

Reports received from reporting Sites: As of February 19, 2010, 182 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of . In the reporting week, all sentinel sites have sent their reports on new cases of DEWS target diseases that were recorded during the reporting period (Week-07 of 2010 or 13th to 19th February 2010). Out of all events recorded in DEWS sentinel sites, 15 target diseases (priority diseases) are being included in weekly reports. The status of reports in the reporting week has been indicated in the table below:

Table-1: Status of Reports Received from DEWS Regions During Epidemiological week-07, 2010 Kabul Bamya Balkh Badakhsha Herat Kandah Nangarh Pakt Total n n ar ar ia No. of Expected Reports from Sentinel Sites 36 19 23 19 22 20 22 21 182

No. of Reports 36 19 23 18 22 20 22 21 182(100%) Received in this week

DEWS Sentinel Sites: The Epidemiological map indicates the DEWS sentinel sites, already established in the relevant regions/ provinces till February 19, 2010 by type of health facilities, from which data on 15 DEWS target diseases are being collected. The symbols on the map showing the number of sentinel sites in each region/province and not the GPS of the locations.

Table-2: DEWS Epidemiological Regions and types of Sentinel Sites in Week 07 of 2010 Type of Kabul Bamyan Balkh Badak Herat Kand Nanha Pakti Total DEWS Data at a Glance W7: SS h ar r a Dis/Cases <5 5+ Tot CHC 9 11 9 8 12 12 14 13 88 C&C 16115 20459 36574 DH 11 4 9 7 5 3 5 4 48 Pneumonia 6296 2264 8560 Pn(Deaths) 64 3 67 PH/RH/ 14 4 5 4 4 5 3 4 43 Tot Clients 49150 120616 169766 NH DEWS 26544 26767 53311 Poly 2 0 0 0 1 0 0 0 3 Diseases Clinic Total 36 19 23 19 22 20 22 21 182

DEWS Data in Epidemiological Week No.07 of 2010 Out of total, 169,766 clients recorded in week-07 of 2010, 21.5% (36564) of consultations were reported due to cough and cold and 5.5% (8560) of consultations was reported due to pneumonia. In the same week, 3.9% or 6582 events were reported due to diarrheal Illnesses (2.5% due to Acute Watery Diarrhea, 1.2% due to Bloody Diarrhea and 0.2% due to acute watery diarrhea with dehydration). In comparison with previous week (W06) of 2010, the percentage of ARI diseases has increased slightly from 26.0 to 26.5%, whereas the percentages of Acute Diarrheal diseases decreased from 4.1% to 3.9%.The percentages of total cases of DEWS target diseases reported by all regions in week-07 of 2010 makes 31.4% of total clients. The chart above shows the events of DEWS target diseases as percentages of total clients, by age groups in Week-07 of 2010.

Percentage of ARI Morbidities from all consultations during last 11 weeks In the epidemiological week-07 (13th to 19th February 2010), a total of 45,134 events of ARI were reported. 32.8% of total clients less than 5 years of age were cough & Cold patients and 17.0% among the age group 5 years and over. The percentage of Table-3: Percentages of ARI Diseases during 11 recent weeks by age groups and by weeks

Disease Age Week Week Week Week Week Week Week Week Week Week Week 49-09 50-09 51-09 52-09 01-2010 02-2010 03-10 04-10 05-10 06-10 07-10 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 Yr. 31.9 33.4 34.1 32.2 33.0 38.4 31.1 32.8 32.0 30.6 32.8 5+ 15.6 14.8 18.2 17.1 17.2 17.4 16.3 15.8 16.0 16.5 17.0 ARI-Pneumonia <5 Yr. 9.1 9.4 9.1 9.0 9.6 10.2 9.8 11.0 10.9 13.3 12.8 >=5 Yr 1.7 1.7 1.9 2.0 1.8 1.9 1.7 1.7 1.8 2.0 1.9 C&C (<5 years) consultations in week-49 of 2009 in comparison with the percentage of C&C in week-7 of 2010, increased by 0.9%, whereas in case of 5 years and above increased by 1.4% in last 11weeks. The trend of ARI diseases in last 11 weeks can be read in table-3. The percentages of consultations on Pneumonia cases of age group less than 5 years increased by 3.7% in last 11 weeks, whereas the percentage of age group 5 years and over increased by 0.2% in last 11 weeks. In the reporting week, the highest percentage of ARI-C&C has been recorded in Badghis and Parwan provinces with 32% and 31% respectively, whereas the lowest percentages of ARI-C&C has been recorded in Urozgzn and Nimroz provinces with 14% each of total clients. The highest percentages of pneumonia have been recorded in Jawzjan province with 12%, whereas the lowest percentage of pneumonia has been recorded in Urozgan province with 1.1%. Among the DEWS regions Bamyan region recorded the highest percentage of ARI with30.3%, whereas Kandahar region recorded the lowest %( 22) of ARI in W07 of 2010. Percentage of Diarrheal Diseases by weeks and by Age Groups The table-4 below shows the percentages of diarrheal diseases (Acute watery Diarrhea, Bloody Diarrhea and Acute watery diarrhea with dehydration) from week-49 of 2009 to week-07 of 2010 from the total clients. Acute watery diarrhea among children less than five years, decreased from 7.4% in week-49 of 2009 to 5.2% in week-07 of 2010, whereas acute watery diarrhea among age group 5 years and above remains almost the same from week-49 of 2009 to week-07 of 2010 by 1.4% (Please refer to Table #4, below). Bloody diarrhea, in age group less than 5 years decreased from 1.9% in week-49 to 1.7 % in week-07 of 2010, whereas in age group 5 years and above increased slightly from 0.7% in week 49 of 2009 to 1% in week-07 of 2010. Acute watery diarrhea with dehydration among age group less than five years has remained the same in last 11 weeks by 0.5%, whereas the percentages of age group greater and equal 5 years decreased by 0.1 % in the same period. Tabl-4: Percentages of Diarrheal Diseases from Total Clients during 11 recent weeks by age groups. Disease Age Week Week Week Week Week Week Week Week Week Week Week 49-09 50-09 51-09 52-09 01-10 02-10 03-10 04-10 05-10 06-10 07-10 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 7.4 6.9 7.6 6.4 6.3 6.0 5.6 6.2 5.6 5.8 5.2 Diarrhea >= 5 Years 1.4 1.2 1.5 1.5 1.4 1.4 1.2 1.3 1.2 1.4 1.4 Bloody Diarrhea <5 Years 1.9 2.1 1.7 2.0 1.8 1.7 1.6 1.6 1.7 1.7 1.7 >=5 Years .7 0.7 0.9 0.9 .9 0.8 0.9 0.8 0.9 1.0 1.0 Acute W. Diarrhea with <5 Years .5 0.5 0.5 0.5 0.4 0.4 0.5 0.5 0.5 0.5 0.5 Dehydration ≥5 Years 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 In the reporting week-07 of 2010, Nangarhar region recorded the highest percentages of Acute Diarrheal Diseases (ADD) from total clients with over 4%, whereas Badakhshan region recorded the lowest percentages of ADD with 3.1% in the reporting week. Percentages of suspected Meningitis/SIC, Malaria and Typhoid Fever by Region in week-07 of 2010 In the epidemiological week-07 of 2010, a total of 123 suspected cases of Meningitis/Sever Ill Child were reported from all regions and the highest percentages of Men/SIC reported from Balkh region with 0.3%. In the reporting week, in national level 400 consultations were reported to be malaria and the highest percentage of Malaria cases were reported from Nangarhar and Badakhshan regions with 0.5% and 0.4% respectively. Out of the total clients, 787 cases or 0.5% were reported to be Typhoid Fever and the highest percentages of Typhoid Fever were reported from Kandahar and Paktia regions with 0.93% and 0.74% respectively.

Suspected Cases of Vaccine Preventable Diseases in Death Cases by Main Causes of W07 of 2010 by Region Mortality and by Region in W07 of Men Teta/ 2010 (SIC) AV H Meas Pert Diphth NNT AFP Pn ADD Men/SIC

Bdk Reg 10 3 9 0 0 0 1 Bdk 7 0 5 Blk Reg 62 0 21 0 0 0 0 Blk 18 0 3 Bmn Reg 4 6 16 0 0 0 3 Bmn 6 0 0

Hrt Reg 14 13 2 0 0 0 2 13 0 3 Hrt Kbl Reg 16 69 74 0 0 0 1 Kbl 10 1 0 Kndr Reg 5 7 12 0 0 2 0 Kndr 2 0 0 Ngr Reg 7 8 22 0 0 0 2 Ngr 7 0 1 Pktya Reg 5 12 0 0 0 0 0 Pktya 4 0 0 Total 123 118 156 0 0 2 9 Total 67 1 12

Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks (from W36 of 2009 to W07-2010) Among the DEWS target diseases, Acute Respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) as leading causes of morbidity and mortality, having the highest frequency of consultations. The following Line-Chart shows the trend of ADD and ARI in last five months (from week-36 of 2009 to week 07 of 2010) to date; the percentages of consultations of Acute Diarrheal Diseases (ADD) and Acute Respiratory Infections(ARI) from total clients reached the same level and crossed each other in week-36 of 2009, but in week-38 ARI started to increase, whereas the percentages of ADD decreased and in week 45 ARI diseases recorded the highest percentage of total clients with 31.1% and then gradually decreased/ declined up to reporting week-07 of 2010. Acute diarrheal diseases from week 36 to week-07 of 2010 have been decreased smoothly without any considerable changes. In the reporting week the percentages of ARI in comparison with a week before increased by 0.5% and in comparison week-45 of 2009 decreased by 4.6%.

Outbreak Investigation and Response in the epidemiological weeks 06-07/2010

Reported Investi- Clinic- Epidemiological Week 06: gated Rumor ally/lab • Suspected Measles Outbreak reported from, Dabali village, Pertussis 0 1 0 of , on February 10.2010 Avian/Swine Flu 0 0 0 and investigated on the following day, during the ARI 1 0 1 investigation there were 15 suspected cases of measles Measles 15 3 12 and specimen collected and send to CPHL, and for Diarrhea 0 0 0 patients Vit A administrated and vaccination campaign Meningitis 0 0 0 conducted in the surrounding area of outbreak, outbreak Hepatitis 1 0 1 controlled. Malaria 0 0 0 • Suspected Measles Outbreak reported from, Panjab and Typhoid 0 0 0 Waras Districts of , on February CCHF 0 0 0 11.2010 and the team dispatched to the area, and when Bl. Diarrhea 0 0 0 the team returned we will update the report, Chickenpox 0 0 0 • Suspected Measles Outbreak reported from, Kant village, Other 0 0 0 Wantweagle District of Nooristan province, on February 04.2010 and investigated on the following day, during the investigation there were 12 suspected cases of measles and specimen collected and send to CPHL, and for patients Vit A administrated and vaccination campaign conducted in the surrounding area of outbreak, outbreak controlled.

Epidemiological Week 07:

• Suspected Measles Outbreak reported from, Neknam village, of Paktya province, on February 13.2010 and investigated on the following day, during the investigation there were 9 suspected cases of measles and specimen collected and send to CPHL, and for patients Vit A administrated and vaccination campaign conducted in the surrounding area of outbreak, outbreak controlled. • Suspected Measles Outbreak reported from, Mirmandi village, Gurbaz District of , on February 12.2010 and investigated on the following day, during the investigation there were 13 suspected cases of measles and specimen collected and send to CPHL, and for patients Vit A administrated and vaccination campaign conducted in the surrounding area of outbreak, outbreak controlled. • Suspected Measles Outbreak reported from, Panjab and Waras Districts of Bamyan province, on February 11.2010 and the team dispatched to the area, and according to the team report there was just some sporadic cases, and not in same clusters, the team doing vaccination campaign in surrounding area and also administrating the Vit A for patients. • Suspected Measles Outbreak reported from, Kabul Camp, Rodat District of Nanghrahar province, on February 14.2010 and investigated on the following day, during the investigation there were 17 suspected cases of measles and specimen collected and send to CPHL, and for patients Vit A administrated and vaccination campaign conducted in the surrounding area of outbreak, outbreak controlled. • Suspected Measles Outbreak reported from, Paradoli village, Alishing District of Laghmanprovince, on February 17.2010 and investigated on the following day, during the investigation there were 6 suspected cases of measles and specimen collected and send to

CPHL, and for patients Vit A administrated and vaccination campaign conducted in the surrounding area of outbreak, outbreak controlled.