Weekly-Epidemiological Bulletin-13-14112010.Pub

Weekly Epidemiological Bulletin Flood Response in Pakistan Volume 1, Issue 13 Monday 15 November 2010

Highlights Priority diseases under surveillance Epidemiological week no 45 (5 - 11 November 2010) in the flood affected areas

• Between 5 - 11 November 2010 (epidemiological week no. 45), 41 districts in 4 provinces provided Acute Flaccid Paralysis surveillance data to the DEWS system. As people move back to their homes, the mobile teams are winding. DEWS Surveillance Officers are establishing new reporting flows from fixed centers and will Acute Jaundice Syndrome

focus on sentinel site surveillance using sites that are report weekly on time. Acute Respiratory Infections

• 881 fixed health and 46 mobile medical outreach centres provided surveillance data for this week. Acute Watery Diarrhoea/ Suspected Cholera 274,201 consultations were reported through DEWS of which 27% were acute respiratory infections • Bloody Diarrhoea (ARI), 8% were skin disease, 7% were acute diarrhoea, and 8% were suspected Malaria. Other Diarrhoea • 15 alerts were received and responded to this week: 5 alerts were for Suspected Measles, 3 were for Suspected Hemorrhagic Fever Acute Watery Diarrhoea (AWD), 2 for Neonatal tetanus and 2 for Viral Hemorrhagic Fever (VHF), 2 for Diphtheria and 1 for Acute Flaccid Paralysis. Suspected Malaria

Suspected Measles • 1 of the 2 cases of poliomyelitis confirmed this week was from the flood-affected district Suspected Meningitis

Note: All presented data are based on the number of patient consultations and include information on priority diseases Unexplained Fever

under surveillance as well as major health events reported through DEWS. Others

Figure-1: Weekly trend of leading diseases in flood affected districts of Pakistan, 29 July to 11 November 2010 (Epi week 31 - 45, 2010)

Table-1: Priority diseases reported during the week 38 - 45, 2010 (17 September - 11 November 2010) Diseases Wk‐38 Wk‐39 Wk‐40 Wk‐41 Wk‐42 Wk‐43 Wk‐44 Wk‐45

Skin Disease 58,583 (12%) 61,206 (12%) 46,510 (12%) 37, 541 (10%) 33,129 (10%) 29, 452 (9%) 25, 920 (9%) 21, 978 (8%)

ARI (URI and LRI) 101,286 (20%) 105,559 (21%) 89,909 (23%) 80,073 (22%) 79,860 (23%) 78,580 (23%) 72,582 (24%) 73,169 (27%)

Acute Diarrhoea 67,641 (13%) 60,744 (12%) 45,794 (12%) 37,298 (10%) 33,317 (10%) 27,686 (8%) 22,923 (8%) 20,110 (7%)

Bloody Diarrhoea 7,693 (2%) 7,462 (1%) 6,898 (2%) 5,764 (2%) 4,659 (1%) 4,306 (1%) 2,843 (1%) 2,697 (1%)

Suspected Ma‐ 45,299 (9%) 41,192 (8%) 29,102 (7%) 27,473 (8%) 32,153 (9%) 30,345 (9%) 24,589 (8%) 20,723 (8%) laria

Total consultation 508,339 498,217 396,092 361,817 344,085 341,661 300,924 274,201

Table-2: DTCs functioning with WHO and health partners Table-3: Leading causes of seeking health care in the support flood affected districts as of 11 November

Province Targeted Districts Functioning Handed over Diseases Total

KPK 16 14 14 Skin Diseases 1,296,224 (15%)

Punjab 8 9 3 Acute Respiratory Infection 1,580,367 (18%)

Balochistan 7 11 2 Acute Diarrhoea 1,068,233 (12%)

Sindh (Sukkur) 7 1 9 Bloody Diarrhoea 101,399 (1%) Suspected Malaria 473,434 (5%) Sindh (Hyderabad) 5 5 0 Unexplained Fever 451,303 (5%) Gilgit / Baltistan 2 2 0

Total 45 42 28 Total Consultations 8,668,227

Figure-4: Leading causes of seeking health care in the flood affected districts by province, 29 July to 4 November 2010

• Each alert below was responded within 24 hours.

1. In case of VHF alert, the team raised awareness in the household and community regarding mosquito control and pre‐ vention of bites and early referral of hemorrhagic cases. At hospital level, the team shared information regarding case management of DHF. 2. In case of AWD alert, the team visited the community and assessed the source of drinking water for the affected popu‐ lation and provided Aqua‐tabs and /or Life Straw filters for household purification. The team provided materials to the LHWs for IEC regarding hygiene and personally conveyed the messages door‐to‐door while distributing soap. ORS was provided for early treatment of mild cases in the community. Referrals were arranged to the DTC or local hospital for severe cases. The Environmental Health unit arranged chlorination of water source or other appropriate intervention.

Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes

Upon active surveillance, VHF cases were found and 31-Oct-10 VHF AJK Bagh DHQ Bagh 4, 29 F,M patients were referred to PIMS. See number 1 above.

DHQ Sibi, Dehpal F, F, Sample collected and all found positive for V. chol‐ 1-Nov-10 AWD Balochistan Sibi 3, 60, 8 camp, Kurrak, Khojak F era Ogawa. See number 2 above.

F, SGTH, College Col- 70, 42, M, Sample collected and 2 out of 4 were found positive 2-Nov-10 VHF KPK Swat ony, Zarakhel, Rang- 25, 30 M, mohalla, Malokabad for DF. See number 1 above. M

Sample collected and found positive for V. cholera 31-Oct-10 AWD KPK D.I. Khan Kachi Paind Khan 61 M Ogawa. See number 2 above.

DHQ Alpurai, Man- M, 2 samples out of 3 were declared positive for DF by 3-Nov-10 VHF KPK Shangla doria Martung, Shafai, 38, 8, 5 M, F Kadona NIH. See number 1 above.

KTH, Navay Kale Vil- M, 4-Nov-10 VHF KPK Peshawar lage, Munda – Lower 17, 20 M Samples were negative for DF, see number 1 above. Dir

Rahim Yar Basti Bangla Kahiri Alert was reported, sample is sent to NIH. Active 2-Nov-10 AFP Punjab 4 F Khan Village surveillance under process

8, 80, M, Upon active survellance few cases were identified. 1-Nov-10 VHF Punjab Muzaffargarh Gul Wala Road Basera 25, 7, F, F, Sample collected but all found negative for DF. See 45 F, F number 1 above. Samples were negative for diphtheria, likely due to M, 2, 6, 7, prior antibiotic treatment. Contacts identified and 2-Nov-10 Diph Sindh Ghotki Ghota Hospital F, 10 M, F treated. Campaign to reach affected UC in planning stage.

Mea- Sample collected and sent to NIH, active surveil‐ 2-Nov-10 Sindh Ghotki TH Ghotki 10 F sles lance under process.

DTC-LUMHS Hydera- Sample collected and 1 out of 2 found positive for 4-Nov-10 AWD Sindh Hyderabad 1, 3 M, F bad V. cholera Ogawa. See number 2 above.

• Each alert below was responded within 24 hours.

Date of Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes alert

8-Nov-10 AWD Balochistan Jaffarabad CH Usta Muhammad 13 M Sample collected and sent to NIH, See number 2 above.

8-Nov-10 AWD Balochistan Jaffarabad Village Jhatpat 2 F Sample collected and sent to NIH, See number 2 above.

On investigation chronic cases of Hepatitis B and C were 9-Nov-10 AJS Balochistan Lasbela DHQ Lasbela ** ** found.

10-Nov-10 NNT Balochistan Naseerabad DHQ Naseerababd ** ** Theses cases are reported from 16 July to 23 Oct.

Sohabat pur (Saleem Khoso 11-Nov-10 VHF Jaffarabad 2 M Balochistan Village) Sample collected and sent to NIH. See number 1 above.

BHU Charbanda Sample collected and sent to NIH, active surveillance under 6-Nov-10 Measles KPK Mardan 2 M (Qadarshah Kaley) process

6-Nov-10 Diph KPK Charsadda Hisara Village 4 F Sample was negative for Diphtheria.

Lady Reading Hospital Sample collected and sent to NIH. Active surveillance under 10-Nov-10 Diph KPK Peshawar 8 M (Haseen Abad) process

DHQ Mardan, Rashakai Sample collected and sent to NIH, active surveillance under 11-Nov-10 Measles KPK Mardan Nowshera, Karkawand 7m, 16m M, M Mohallah process.

8-Nov-10 VHF Sindh Ghotki Raja Colony Dahraki 22 M Sample was negative for DF, see number 1 above.

8-Nov-10 NNT Sindh Ghotki Ghotki 15d, 8d, 17d F, M, F Patients are improving, active surveillance was done.

30m, 1, 2, 3, Kad Tent City, Karampur M, F, F, F, M, During past two months 10 deaths from Measles have been 11-Nov-10 Measles Dadu 5, 2, 3, 3, Sindh Village F, M, M, M, F 1.5, 1, reported.

DTC Hyderabad (Lajpat 11-Nov-10 AWD Hyderabad 12 M Sindh Road) Sample collected and sent to NIH, See number 2 above.

Bishti lashkar Khan Village, Khawand Bux Sudrani 5, 18m, 4, M, M, M, M, Alerts were received from different places and after active 11-Nov-10 Measles Ghotki Village, Near Almehran Sindh 9m, 3, 1, 5 M, M, F School Ghotki City, Sobho surveillance samples from suspected cases are sent to NIH. Chachar Village 4, 5, 5, 3, F, F, M, F, M, 18m, 18m, Sample collected and sent to NIH, active surveillance under 11-Nov-10 Measles Kashmore Kabil Khan Bhayo Village F, M, M, F, F, Sindh 54m, 4, 3, M process. 18m, 18m Table-6: List of confirmed Polio Cases from flood affected districts, week 45-2010

S. NO. Province Districts SEX AGE (m) Date onset of Paralysis WPV Type

1 Sindh Ghotki Male 18 24‐10‐2010 NSL1

• The above mentioned reports are reporting from health facilities to DEWS system on weekly basis, we are hereby using the same data providing transition to our weekly reporting system.

• Four alerts were received and investigated this week; 2 alerts were for diphtheria, and 2 were for Measles.

Diseases Wk-42 Wk-43 Wk-44 Wk-45

Skin Diseases 7,606 (6%) 6,019 (5%) 6,009 (5%) 4,287 (5%)

ARI (URI and LRI) 41,617 (30%) 40,474 (31%) 37,350 (33%) 33,657 (38%)

Acute Diarrhea 12,312 (10%) 9 929 (8%) 8,496 (7%) 7,173 (8%)

Bloody Diarrhea 1,452 (1%) 1,615 (1%) 1,100 (1%) 1,095 (1%)

Suspected Malaria 5,024 (4%) 4,376 (3%) 2,648 (2%) 2,228 (3%)

Total consultations 137,280 131,942 113,796 88,983 Province Punjab Figure-7: Trend of priority communicable diseases, province Punjab (3 August - 11 November 2010) • 11 districts reported data to DEWS from Punjab province

• 218 fixed health centers and 18 mobile medical outreach centers reported to DEWS

• 106,603 patient consultations were reported during this reporting period

• In Punjab, a higher proportion of suspected malaria was reported again this week (8%). Although a peak of malaria in October reflects seasonal trend of diseases, DEWS officers are collaborating with Malaria Control Program to investigate areas of increased malaria, providing rapid diagnostic test and appropriate medicines.

Diseases Wk-42 Wk-43 Wk-44 Wk-45

Skin Diseases 11,673 (9%) 11,204 (10%) 11,284 (9%) 10,231 (10%)

ARI (URI and LRI) 20,339 (20%) 21,323 (18%) 22,594 (18%) 21,299 (20%)

Acute Diarrhea 9,447 (9%) 9,196 (8%) 8,849 (7%) 7,409 (7%)

Bloody Diarrhea 19 30 26 20

Suspected Malaria 13,447 (13%) 12,959 (11%) 11,990 (10%) 8,794 (8%)

Total consultations 103,588 115,603 122,437 106,603

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]. 05 Epidemiological Bulletin: Flood Response in Pakistan Province Sindh Figure-9: Trend of priority communicable diseases, province Sindh (6 August - 11 November 2010) • This week 7 districts reported to DEWS from Province Sindh • 115 fixed health centers and 23 mobile medical outreach centers reported to DEWS • 33,406 patient consultations were reported during the reporting period of week 45, 5 - 11 November, 2010 • In Sindh, proportional morbidity of major health events remained the same when com- pared to last week. • Six alerts were received and responded this week; 3 for suspected Measles and 1 each for VHF, Neonatal Tetanus and AWD. • A Dengue surveillance and response cell has been established in Hyderabad to address in- creasing numbers of cases of Dengue Fever.

Diseases Wk-42 Wk-43 Wk-44 Wk-45

Skin Diseases 11,554 (15%) 9,985 (14%) 5,096 (15%) 3,552 (11%)

ARI (URI and LRI) 13,070 (17%) 12,216 (17%) 6,942 (20%) 8,825 (26%)

Acute Diarrhea 8,479 (11%) 6,129 (9%) 2,879 (8%) 1,762 (5%)

Bloody Diarrhea 2,664 (3%) 2,133 (3%) 1,118 (3%) 448 (1%)

Suspected Malaria 9,888 (13%) 8,755 (12%) 4,261 (12%) 2,964 (9%)

Total consultations 77,547 70403 35,022 33,406

Province Balochistan Figure-11: Trend of priority communicable diseases, province Balochistan (6 August - 11 November 2010) • In this week, 10 districts reported to DEWS from province Balochistan • 186 fixed health centers and 5 mobile medical outreach centers reported to DEWS • 45,209 patient consultations were reported during the reporting period of week 45, 5 - 11 November, 2010 • 5 alerts were received and responded this week. Two for AWD, and one each for Acute Jaun- dice Syndrome, Neonatal Tetanus and VHF. • Certain hot spots are experiencing higher than usual levels of suspected malaria cases. Malaria outbreaks in districts Naseerabad, Sibi, Zhob and Jhal Magsi are being addressed in collabo- ration with the Malaria Control Program.

Diseases Wk-42 Wk-43 Wk-44 Wk-45

Skin Diseases 2,296 (9%) 2,244 (9%) 3,531 (12%) 3,908 (9%)

ARI (URI and LRI) 4,834 (19%) 4,567 (19%) 5,696 (19%) 9,388 (21%)

Acute Diarrhea 3,079 (12%) 2,432 (10%) 2,699 (9%) 3,766 (8%)

Bloody Diarrhea 524 (2%) 528 (2%) 599 (2%) 1,134 (3%)

Suspected Malaria 3,794 (15%) 4,255 (18%) 5,690 (19%) 6,737 (15%)

Total consultations 25,670 23,713 29,669 45,209

Figure-13: AD trends, KPK, 2009 and 2010 Since July 29, 2010, approximately 8,668,227 pa‐ Percentage tient consultations have been reported to DEWS 20 from the flood affected provinces in Pakistan. 16 2009 2010 The major causes for seeking healthcare by the af‐ 12 fected communities continue to be diarrheal dis‐ eases, acute respiratory infections, skin diseases 8 and suspected malaria. 4

In KPK, proportional morbidity of AD continues to 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 decline to 8% this week (Please see Fig.13) Epi‐week

Focus on: why do we have a measles outbreak when we just had vaccination?

Measles is a highly infectious viral disease caused by a Morbillivirus and for which humans are the only reservoirs. Transmis‐ sion is primarily person‐to‐person via aerosolized droplets. Before the widespread availability of measles vaccine, virtually all children contracted the disease.

In a non‐immune person exposed to measles virus, after an incubation period of about 10 to 12 days (range 7‐18 days), pro‐ dromal symptoms of fever, malaise, cough, coryza (runny nose), and conjunctivitis appear. Within 2 ‐ 4 days of the prodromal symptoms, a rash made up of large, blotchy red spots (maculo‐papular rash) appears behind the ears and on the face accom‐ panied with a high fever. The rash spreads to the trunk and extremities and typically lasts 3‐7 days. Individuals with measles are infectious 2 ‐ 4 days before the rash through 4 days after rash onset.

The dates of onset of fever in most of the recent cases in Sindh were during the last part of October and early November. The mass campaign was also conducted during the same period (25 Oct to 05 Nov). Obviously these children were not pro‐ tected during exposure to the virus by the mass campaign dose which would take 2‐4 wks to produce immunity.

Most children experience uncomplicated measles. However, in about a third of the cases, measles is followed by at least one complication caused by disruption of epithelial surfaces and immunosuppression. These include pneumonia, ear and sinus infections, mouth ulcers, persistent diarrhea, upper airway obstruction from croup (laryngo‐tracheo‐bronchitis). Less com‐ mon complications include corneal drying that could progress to ulceration (keratomalacia) and blindness, protein energy mal‐ nutrition, convulsions and brain damage. Complications are more common in young children below 5 years of age, and severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A, or whose immune systems have been weakened by other diseases.

Unless managed early and aggressively, these complications may lead to death within the first month after the onset of rash. The case fatality from measles is estimated to be 3 – 5% in developing countries but may reach more than 10% in epidemics among populations with high levels of malnutrition and a lack of adequate health care. Vitamin A supplementation can reduce morbidity and mortality by 50%. Every child with measles should receive vitamin A.

Epidemics of measles occur when the number of susceptible individuals in a population reaches a critical threshold. Outbreaks may occur in pockets of low coverage, which are likely to occur in certain geographic areas, such as urban slums, remote rural areas or islands, and in certain population groups with habitually low vaccination coverage rates such as ethnic and racial mi‐ norities, nomadic peoples, persons with religious or philosophical objections to immunization. As immunization coverage in‐ creases, the size of epidemics decreases. In addition, the inter‐epidemic period lengthens, and the proportion of cases among older children increases. From WHO Afro Measles Guidelines, 2004, and WHO online Factsheet on Measles, 2010.

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.