Epidemiological Week No. 52 (23 Dec – 29 Dec) 10 Jan 07/ Vol. 59/ DEWS 2006-52

The affected districts are in the grip of Reporting Units...... 2 winter Total number of consultations ...... 2 Photo by Torgrim Halvari DEWS Data, Epidemiological Week No. 52, 2006...... 3 DEWS Data, Monthly Summary (Epidemiological Weeks No. 49-52)...... 4 Acute Watery Diarrhoea ...... 5 Bloody Diarrhoea...... 6 Acute Jaundice Syndrome...... 6 Malaria ...... 7 Measles ...... 7 Acute Respiratory Infection ...... 8 Other Reportable Diseases and Conditions ...... 8 Outbreak Alert and Response ...... 9 Number of reported cases and deaths per District, AJK ...... 10 Number of reported cases and deaths per District, NWFP ...... 11

ƒ In the past month (Epidemiological ƒ In week 52, there were 8 deaths weeks 49-52 inclusive), 186,769 health reported from acute respiratory events under surveillance were reported infections in three of the districts. including 49 deaths ƒ Three cases of measles were reported from Mansehra ƒ This week, there were 270 reporting units contributing to the report. ƒ The number of suspected hepatitis cases increased 65% over week 51. ƒ In week 52, Total 56,855 consultations were reported, with 19 deaths

The Weekly Morbidity and Mortality Report (WMMR) is published by the Ministry of Health of Pakistan (MOH) and the World Health Organization (WHO). The WMMR is built on surveillance data that health service providers and NGOs transmit on a weekly basis from health facilities and hospitals in those areas affected by the earthquake that struck Pakistan on 8 October 2005.

The WMMR objectives are to monitor the trend of health conditions over a period of time and provide vital information to all health partners. The WMMR is only a snapshot of the health conditions in those facilities where events are registered and data collected and does not necessarily reflect the situation from other health facilities.

The WMMR is a publication that has been developed for emergencies and previously used in other areas such as the Darfur Crisis.

The WMMR is produced with the financial support of AAI Australia, Americares, CIDA, Denmark, DFID, ECHO, Ireland, Italy, Japan, Korea, Monaco, Norway, SIDA, Slovak Republic, Switzerland, Turkey, USAID

The WMMR is published by the World Health Organization (WHO), Health Emergency Operation Centre, House #6, Street #20, F-7/2, Islamabad, Pakistan For More Information, please contact: Dorcas Taylor, Epidemiologist, WHO/EHA/Pakistan; [email protected] or Dr. Birjees Mazher Kazi, Chief, Public Health Laboratories Division, NIH MOH; [email protected] or WHO Webpage: http://www.whopak.org/disaster WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

Reporting Units

The number of sites able to report decreased by 52 this week and the reporting timeliness of the DEWS systems has also decreased compared with last week. This is most likely to do with the Eid ul-Azha which took place at the beginning of the following week, and resulted in many closures of facilities. Some facilities in NWFP were also unable to report because security threats against NGOs resulted in the evacuation of staff from NGO run faciltities. See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 2 Dec -29 Dec. Reporting Health Facilities Area Population 2-8 Dec 09-15 Dec 16-22 Dec 23-29 Dec Week 49 Week 50 Week 51 Week 52 Muzaffarabad 894,364 80 100 87 82 Bagh 452,532 44 45 42 32 Poonch 633,712 67 70 63 67 Mansehra / Balakot 1,154,804 58 64 56 61 Battagram / Shangla 592,256 43 40 36 28 Total 3,727,668 292(90%) 319(99%) 284 (88 %) 270 (84 %)

Total number of consultations

In week 52 there was a decrease in the number of reporting sites, and the number of consultations also decreased to 56,855. The highest number of consultations by district was in Muzaffarabad, with 14,884 and the lowest was in Battagram, at 4,136.

No. Unit Reporting Units and Consultations No. Consult. 200000 300 Reporting Unit Consultation

250 150000

200

100000 150

100 50000

50

0 0 W42 W43 W44 W45 W46 W47 W48 W49 W50 W51 W52 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40 W41 W42 W43 W44 W45 W46 W47 W48 W49 W50 W51 W52

Week

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 – 29 December 2006.

2 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

DEWS Data, Epidemiological Week No. 52, 2006

Between 23 and 29 December 2006, 56,855 consultations were reported through DEWS. Overall, 29% (16,567) were due to acute respiratory infections (ARI), 6% (2,986) due to acute watery diarrhoea (AWD), 6% (2,995) due to fever of unknown origin (FUO), and 4% (2,416) due to injuries (INJ). ARI accounted for 39% and 26% of consultations in the less than 5 years old and 5 or more years old respectively. All other reportable conditions each represented less than 2 % of the total consultations in week 52.

AWD AWD AWD 4% 5% 10% ARI 26% ARI ARI 29% 39%

FUO OTH* 5% 42% OTH* OTH* FUO 60% INJ FUO 55% INJ 5% 5% INJ 6% 4% 3% ≥ 5yrs (n=41,888) < 5yrs (n=14,944) All Ages (n=56,855) Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 23 – 29 December 2006. *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

DEWS Data, Epidemiological Week No. 52, 2006: Consultations by age

ARI in patients under five years old continues to remain steady in most districts. Bagh has seen a decrease in the percent of all ARI cases that are in young children, from a high of 43% to 38% in week 52. Other districts have not fluctuated more than approximately three percentage points either up or down in the past four weeks. See figure 3.

50.0 40.0 30.0

old 20.0 10.0

Percent of all ARI ARI all of Percent 0.0 in patients < 5 years consultations that are 2006-49 2006-50 2006-51 2006-52 Week

BAGH BATTAGRAM MA NSERA MUZAFFARABAD POONCH

Figure 3: Proportion of all ARI consultations by that are in children under five, by district, Earthquake Affected Areas, Pakistan 2 – 29 December, 2006

3 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

DEWS Data, Monthly Summary (Epidemiological Weeks No. 49-52)

In the past four weeks, between 2 Dec to 29 Dec 2006 (Epidemiological weeks 49-52 inclusive), 301,057 consultations for health conditions under surveillance were reported, out of a total 335,432 consultations. 28% (85,735) of consultations were due to acute respiratory infection (ARI), 6% (16,616) acute watery diarrhoea (AWD), 6% (18,403) unexplained fever (FUO) and 5% (13,566) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 2 – 29 Dec 2006. Week WEEK 49 WEEK 50 WEEK 51 WEEK 52 TOTAL CFR% Event C D C D C D C D C D AWD 4099 2 5011 1 4020 1 2986 0 16116 4 0.024 BD 319 0 371 0 240 0 232 0 1162 0 0.000 AFP 1 0 3 0 1 0 0 0 5 0 0.000 MAL 444 0 478 0 376 0 312 0 1610 0 0.000 ARI 20772 0 25013 7 23391 7 16567 8 85743 22 0.025 MES 2 0 8 0 0 0 3 0 13 0 0.000 MEN 7 0 7 0 7 0 2 0 23 0 0.000 JAU 26 0 42 1 23 0 38 1 129 2 1.53 TET 1 0 0 1 1 1 0 0 2 2 100.0 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 4667 0 5494 0 5247 0 2995 0 18403 0 0.000 INJ 3446 0 4014 0 3690 1 2416 0 13566 1 0.007 OTH 38249 13 51871 10 42371 18 31303 13 163794 54 0.032 TOTAL 72033 15 92312 20 79367 28 56855 23 300567 86 RU 292 319 284 270

C – Cases, D – Deaths, AWD - Acute Diarrhoea, BD - Bloody Diarrhoea, AFP - Acute Flaccid Paralysis, MAL – Malaria, ARI - Acute Respiratory Infection, MES – Measles, Men - Meningitis, JAU - Acute Jaundice Syndrome, TET - Neonatal Tetanus, AHF Acute Hemorrhagic Fever, FUO –Unexplained fever, INJ – Injuries, OTH – Others, RU – Reporting Units. Please note data from late reporting in previous weeks has been updated. During the same reporting period 79,715 consultations were reported in the less than 5 years old group, (29% of the total consultations), of which 37% (28,887) were due to ARI, 9% (8,685) due to AWD, 7% (5,932) due to FUO and 3% (3,190) were reported as injuries (INJ). Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 2 – 29 Dec 2006 Week WEEK 49 WEEK 50 WEEK 51 WEEK 52 TOTAL CFR% Event C D C D C D C D C D AWD 1932 2 2356 1 1765 1 1442 0 7495 4 0.053 BD 115 0 115 0 72 0 71 0 373 1 0.268 AFP 1 0 1 0 1 0 0 0 3 0 0.000 MAL 63 0 60 1 37 0 44 0 204 1 0.490 ARI 7263 0 8864 6 8218 6 5862 7 30207 13 0.043 MES 1 0 5 0 0 0 3 0 9 0 0.000 MEN 2 0 1 0 2 0 1 0 6 0 0.000 JAU 5 0 8 1 7 0 6 1 21 2 9.523 TET 0 0 0 0 1 1 0 0 1 0 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 1342 0 1533 0 1485 0 919 0 5279 0 0.000 INJ 695 0 735 0 762 0 452 0 2644 0 0.000 OTH 8434 6 10329 7 8546 5 6164 5 33473 18 0.053 TOTAL 19853 8 24007 16 20896 13 14944 14 79715 39 RU 292 319 284 270

4 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

In the current week, there was a decrease in the number of cases of AWD with 4,020 last week and 2,986 this week. In the current week, ARI decreased in the total number of cases as compared with the previous week, (23,391 last week and 16,559 this week). The weekly proportion of ARI and AWD is shown in figure 4.

% Consultation ARI and AWD percent of total consultations 40 ARI AWD 35 30 25 20 15 10 5 0 W45 W46 W47 W48 W49 W50 W51 W52 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40 W41 W42 W43 W44 W45 W46 W47 W48 W49 W50 W51 W52

Week

Figure 4. Weekly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 5 November 2005 – 29 December 2006.

Acute Watery Diarrhoea

In week 52 there were 4,020 cases of AWD reported, with no associated deaths. The rate of AWD is now below 6% of consultations in most tehsils in the affected areas, however there are a few tehsils with higher rates. The highest rate in week 52 is in Allai tehsil, Battagram, at 11%. The lowest rate is in Bagh tehsil, at just below 3%. See Figure 5.

12.0 10.0 8.0 6.0 4.0 2.0 0.0 consultations OGHI BAGH ALLAI HAJIRA AWD as a percent of all AWD HATTIAN DHIRKOT KHAUTTA BALAKOT SHANGLA MANSERA ABBASPUR ATHMUQAM BATTAGRAM RAWALAKOT MUZAFFARABAD BAGH BATTAGRAM MANSERA MUZA'BAD POONCH District and Tehsil

Figure 5: AWD as a percent of all consultations, by district and tehsil, Earthquake Affected Areas, Pakistan, 23 – 29 December, 2006

5 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

Bloody Diarrhoea

In week 52, there were 232 cases of bloody diarrhoea reported, an small decrease over week 51. There were no associated deaths. In the initial months of recording, bloody diarrhea constituted a up to one fifth of all of the diarrhea cases recorded, however it is now consistently in the range of 5% of all diarrhea cases. See figure 6

25.0 20.0 15.0 10.0 5.0

of all diarrhea cases 0.0 2005-42 2005-46 2005-50 2006-02 2006-06 2006-10 2006-14 2006-18 2006-22 2006-26 2006-30 2006-34 2006-38 2006-42 2006-46 2006-50 Bloody diarrhea as a percent

Week

Figure 6: Average proportion of all consultations that are for bloody across reporting sites, by district, Earthquake Affected Areas, Pakistan, 15 October 2005 – 29 December 2006

Acute Jaundice Syndrome

In week 52 there were 38 cases of suspected hepatitis, a 65% increase over week 51. There was one associated death, in a child under 5 in Muzaffarabad. The rate of suspected hepatitis has been lower in weeks 49, 50, and 51 of 2006 than in the same weeks of 2005, however, in week 52 of 2006, the rate is higher than that seen in 2005. See figure 7.

0.08 0.07 0.06 0.05 0.04 0.03 0.02 0.01 consultations a percent of all 0.00 2005-49 2006-49 2005-50 2006-50 2005-51 2006-51 2005-52 2006-52 Acute jaundiceAcute as syndrome

Week

Figure 7: Suspected hepatitis as a percent of all consultations, Earthquake Affected Areas, Pakistan, 3 December 2005 – 30 December 2005 and 2 December 2006 – 29 December 2006

6 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

Malaria

In week 52, there were 312 malaria cases reported, with no associated deaths. Malaria rates differ considerably from district to district, with Poonch district having the highest overall rate of malaria, at over 3 cases per reporting site in week 52. See figure 8.

3.50 3.00 2.50 2.00 1.50 1.00 0.50 site 0.00 BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH Malaria per reporting cases

District

Figure 8: Malaria as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 23 29 December 2006

Measles

There were 3 cases of measles reported in week 52, all in Mansehra district. In the past four weeks, there have been only a small number of measles cases reported, in only three of the five districts. Battagram has had the most cases, with 7 in total, while both Poonch and Bagh have had no reported measles cases in the previous 4 weeks. See figure 9.

6 5 4 3 2 1 0 Count of measles cases 2006-49 2006-50 2006-51 2006-52 Week

BAGH BATTAGRAM MA NSERA MUZAFFARABAD POONCH

Figure 9: Measles cases by district, Earthquake Affected Areas, Pakistan, 2 – 29 December 2006

7 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

Acute Respiratory Infection

In week 52, there were 16,567 consultations for ARI reported through the DEWS. There were eight associated deaths, 5 in Mansehra, 2 in Muzaffarabad, and one in Poonch. Seven of the deaths were in patients under five, and one in a patient five or over. The rate of ARI has remained relatively steady in most of the districts in the last four weeks, with only Muzaffarabad and Poonch seeing modest increases. See figure 10

40.0

30.0

20.0

10.0 consultations 0.0 ARI as a percent of all all of percent a as ARI 2006-49 2006-50 2006-51 2006-52 Week BAGH BATTAGRAM MA NSERA MUZAFFARABAD POONCH

Figure 10: Trend in ARI as a percent of consultations, by district, Earthquake Affected Areas, Pakistan, 2 – 29 December, 2006

Other Reportable Diseases and Conditions

There were 2 cases of suspected meningitis in week 52, 1 in Battagram and 1 in Muzaffarabad. There were no cases of acute flaccid paralysis, tetanus, or hemorrhagic fever. There were 2,995 cases of fever of unknown origin, and 2,416 injuries.

In week 52, the rate of unexplained fever varies by district, with Bagh and Muzaffarabad having the lowest rate, and Poonch and Battagram having the highest. See figure 11.

12.0 10.0 8.0 6.0 4.0 2.0 0.0 BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH Unexplained fever as a percent of all consultations

District

Figure 11: Unexplained fever as a percent of all consultations, Earthquake Affected Areas, Pakistan, 23 – 29 December 2006

8 WMMR Weekly Morbidity and Mortality Report Pakistan 10 Jan 2007 / Vol. 59/ DEWS 2006 -52

Outbreak Alert and Response1

Acute Jaundice: Rawalakot An alert for suspected hepatitis was received from RHC Abbaspur in week 52, and was investigated on 4th January, 2007 (week 1 of 2007). The patient was a 70 year old woman from village Chaffar. Though suffering from slight jaundice, her symptoms were not consistent with acute viral hepatitis. Case definitions were discussed with the reporting physician.

Mansehra An increased number of cases of suspected hepatitis were reported from RHC Shinkiari. The cases could not be investigated, initially because the treating doctor had left, and subsequently because there had been no records kept of the addresses to enable the patients to be visited. The issue of keeping address records was discussed with the doctor and with the EDO-Health.

Acute Respiratory Infection: Muzaffarabad An alert was received from village Bandi Kathanna for ARI, including one death. The alert could not be immediately investigated due to roadblocks. When the road was clear, the alert was investigated by the DHO team, which found that there was no significant rise in cases in the area and the death was several weeks previous.

Measles Mansehra Three cases of measles were reported from RHC Shinkiari. Please see the report from Mansehra for acute jaundice (above) for investigation details.

Malaria Mansehra

An increased number of malaria cases was reported from RHC Shinkiari. Please see the report from Mansehra for acute jaundice (above) for investigation details.

1 Outbreak Investigation and response of Suspected Viral Hepatitis, Malaria, and Bloody Diarrhoea and Watery Diarrhoea would only take place when a cluster of cases is identified or there is an increase in the incidence of the disease. (Note: Single death due to Diarrhoea and single case of reported severe dehydration among >5 years would be investigated) 9 WMMR Weekly Morbidity and Mortality Report Pakistan 10 January 2007 / Vol. 59/ DEWS 2006 -52

Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, Bagh District, Earthquake Affected Areas, Pakistan, 2 – 29 December 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 49 463 0 29 0 0 0 7 0 3021 0 0 0 0 0 0 0 0 0 0 0 253 0 633 0 9514 0 50 555 0 44 0 0 0 10 0 3442 0 0 0 0 0 2 0 0 0 0 0 253 0 672 0 10995 0 51 400 0 27 0 0 0 3 0 3411 0 0 0 0 0 0 0 0 0 0 0 192 0 551 0 10842 6 52 358 0 32 0 0 0 6 0 2421 0 0 0 0 0 0 0 0 0 0 0 179 0 559 0 7892 6 Total 1776 0 132 0 0 0 26 0 12295 0 0 0 0 0 2 0 0 0 0 0 877 0 2415 0 39243 12

Table 7. Number of reported cases and deaths, Poonch District, Earthquake Affected Areas, Pakistan, 2 – 29 December 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 49 990 0 21 0 0 0 209 0 3507 0 0 0 0 0 2 0 0 0 0 0 1728 0 539 0 5334 2 50 1080 0 32 0 0 0 304 0 4537 1 0 0 0 0 2 0 0 0 0 0 1691 0 688 0 6835 3 51 925 0 21 0 0 0 263 0 3529 3 0 0 0 0 6 0 0 0 0 0 1577 0 562 0 5018 2 52 906 0 29 0 0 0 213 0 3969 1 0 0 0 0 1 0 0 0 0 0 1405 0 608 0 5523 2 Total 3901 0 103 0 0 0 989 0 15542 5 0 0 0 0 1111 0 0 0 0 0 6401 0 2397 0 22710 9

Table 8. Number of reported cases and deaths, Muzaffarabad District, Earthquake Affected Areas, Pakistan, 2 – 29 December 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 49 1567 1 152 0 0 0 158 0 8442 0 0 0 7 0 9 0 0 0 0 0 1605 0 1667 0 10996 5 50 1869 1 211 0 2 0 128 0 9680 6 2 0 6 0 18 1 0 0 0 0 2205 0 1992 0 14474 3 51 1661 0 130 0 0 0 88 0 9405 1 0 0 7 0 6 0 1 1 0 0 2252 0 2007 0 12899 6 52 916 0 106 0 0 0 25 0 5235 2 0 0 1 0 5 1 0 0 0 0 383 0 766 0 7444 0 Total 6013 2 599 0 2 0 399 0 32762 8 2 0 21 0 38 2 1 1 0 1 6445 0 6432 0 45813 14

10 WMMR Weekly Morbidity and Mortality Report Pakistan 10 January 2007 / Vol. 59 DEWS 2006 -52

Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 2 – 29 December 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 49 521 0 71 0 0 0 31 0 1855 0 2 0 0 0 8 0 1 0 0 0 397 0 222 0 2560 1 50 593 0 46 0 0 0 16 0 2149 0 5 0 0 0 15 0 0 0 0 0 414 0 230 0 4720 0 51 361 0 37 0 0 0 3 0 2060 0 0 0 0 0 3 0 0 0 0 0 296 0 195 0 2149 3 52 281 0 32 0 0 0 5 0 1026 0 0 0 1 0 7 0 0 0 0 0 350 0 114 0 2319 1 Total 1756 0 186 0 0 0 55 0 7090 0 73 0 1 0 33 0 1 0 0 0 1457 0 761 0 11748 5

Table 10. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 2 – 29 December 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 49 558 1 46 0 1 0 39 0 3947 0 0 0 0 0 7 0 0 0 0 0 684 0 385 0 9845 5 50 914 0 38 0 1 0 20 0 5205 0 1 0 1 0 5 0 0 1 0 0 931 0 432 0 14847 4 51 673 1 25 0 1 0 19 0 4986 3 0 0 0 0 8 0 0 0 0 0 930 0 375 1 11434 1 52 525 0 33 0 0 0 63 0 3908 5 3 0 0 0 24 0 0 0 0 0 678 0 369 0 8125 2 Total 2670 2 142 0 3 0 141 0 18046 8 4 0 1 0 44 0 0 1 0 0 3223 0 1561 1 44251 12

11