Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

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Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 3, Issue 17, Wednesday 2 May 2012

Highlights Priority diseases under surveillance Epidemiological week no. 17 (22 to 28 April 2012) in DEWS

Acute (Upper) Respiratory Infection • In week 17, 2012, total 87 districts including 2 agencies provided surveillance data to the Pneumonia DEWS on weekly basis from around 1,958 health facilities. Data from mobile teams is reported Suspected Diphtheria through sponsoring BHU or RHC. Suspected Pertussis Acute Watery Diarrhoea Bloody diarrhoea • A total of 758,579 consultations were reported through DEWS of which 17% were acute Other Acute Diarrhoea respiratory infections (ARI); 9% were acute diarrhoea; 5% were suspected malaria; while 4% were Suspected Enteric/Typhoid Fever Skin disease. Suspected Malaria Suspected Meningitis Suspected Dengue fever • A total of 246 alerts reported while 25 outbreaks were identified in week 17, 2012: Alto‐ Suspected Viral Hemorrhagic Fever gether 130 alerts for Measles; 25 for Leishmaniasis; 18 each for AWD and Typhoid; 17 for Acute Pyrexia of Unknown Origin diarrhoea; 11 for NNT and tetanus; 9 for Pertussis; 8 for Bloody diarrhoea; 3 each for acute jaun‐ Suspected Measles Suspected Acute Viral Hepatitis dice syndrome and Scabies; 2 for DF; while 1 each for Malaria and ARI. Chronic Viral Hepatitis

Neonatal Tetanus • In this week no new polio cases was reported. As of 30 April 2012, the total number of polio Acute Flaccid Paralysis cases confirmed by the laboratory is 15 from 10 districts/towns/tribal agencies and areas. Scabies Cutaneous Leishmaniasis Others

Figure‐1: Weekly trend of Acute diarrhoea, Bloody diarrhoea, ARI and Suspected malaria in Pakistan, Week‐1, 2011 to week‐17, 2012.

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

Percentage 20 15 10 5 0 9 7 5 3 1 9 7 5 3 1

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

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

Table 1: Most common communicable diseases syndromes reported weekly

Disease Wk-10 Wk-11 Wk-12 Wk-13 Wk-14 Wk-15 Wk-16 Wk-17

Acute respiratory infection 155,186 (23%) 162,325 (23%) 145,261 (21%) 155,558 (20%) 128,653 (20%) 132,836 (19%) 131,146 (18%) 126,299 (17%)

Skin diseases 30,909 (4%) 31,713 (4%) 28,719 (4%) 31,638 (4%) 28,123 (4%) 28,245 (4%) 28,441 (4%) 30,647 (4%)

Acute diarrhoea 38,427 (6%) 40,950 (6%) 41,535 (6%) 51,227 (7%) 52,033 (8%) 60,539 (9%) 63,332 (9%) 68,364 (9%)

Bloody diarrhoea 2,874 (0.42%) 3,651 (0.51%) 2,890 (0.42%) 3,480 (0.45%) 2,977 (0.46%) 3,328 (0.47%) 3,563 (0.50%) 3,421 (0.45%)

Suspected malaria 29,599 (4%) 30,594 (4%) 29,521 (4%) 32,888 (4%) 28,298 (4%) 30,846 (4%) 31,573 (4%) 34,721 (5%)

Total consultation 688,813 717,186 681,475 772,042 647,695 711,300 718,289 758,579

• The above graph shows the weekly trend of ARI; Acute diarrhoea; Bloody diarrhoea and Suspected malaria as proportional morbidity (percentage of cases out of total consultations) reported to DEWS on weekly basis.

• The above table provides the total consultations for the last 8 weeks proportional morbidity of the leading five disease syndrome. Proportional morbidity of ARI is highest in Khyber Pakhtunkhwa, Sindh and Balochistan, while acute diarrhoea is highest in Khyber Pakhtunkhwa, FATA, Sindh and Balochistan (please see the graphs for every province in page 7 and 8).

10 cases of Measles were reported from DHQ Hospital. All the patients were timely re‐ sponded and presented with typical signs and symptoms. Vit A drops provided and health Village Nayabad, UC 16‐Apr Measles Balochistan Gwadar 2 6 1 1 education imparted. 10 children were assessed for vaccination, 6 Children found totally Gwadar‐N unvaccinated whereas 4 had received only one dose of Measles. DHMT was informed and requested to send outreach team for vaccination.

2 Pertussis cases were reported. On investigation; 13 more cases were identified with same signs and symptoms. Patient was given health education. Erythrocin and Cough syrup was Killi Samazai, UC Gawal 19‐Apr Pertussis Balochistan Killa Saifullah 7 3 4 1 given. Community awarenesss session was conducted. All patients found totally unvaccinated. Ismailzai Information shared with DHO and EPI representative and requested to send outreach team for vaccination.

One case and a death due to measles were reported from BHU Kambila. On active surveil‐ lance 13 cases including 2 deaths of suspected measles were identified in whom 6 seriously ill children were referred to the KTH Peshawar. The Agency Surgeon, FSMO and PPHI were Mashoom baba Tatara, Khyber informed.An investigation team including PPHI monitoring officer was formed for the affected 19‐Apr Measles FATA UC Kambila, Tehsil 7 0 6 0 Agency Mulagori area.Another death was occurred on the day the investigation team arrived there.Vitamin A given to the measles cases.Mass measles vaccination of 130 children were done.Health edu‐ cation imparted.Blood samples of two suspected cases taken and sent to NIH Islama‐ bad.Report shared with DOH and PPHI.

2 cases of suspected measles were reported from BHU. On active surveillance, 4 more sus‐ Khyber pected measles cases were found. All 6 cases found totally unvaccinated. 12 children were charnee near kalpani 20‐Apr Measles Pakhtunk‐ Buner 2 0 4 0 assesed in house cluster, 100% found vaccinated against pentavalent and measles 1 vaccine. 2 tehsil gagra hwa blood samples were taken. Information shared with EPI coordinator and outreach vaccination campaign will be planned in the locality.

Alert of suspected measles case was generated by BHU. Suspected case was given Vit A drops. Blood sample was taken and sent to NIH. Active surveillance was conducted in the area. 16 more cases were identified who had measles in past 1 month. During active surveillance and Khyber record analysis, 1132 children were assessed for vaccination status. 338 children were missing 17‐Apr Measles Pakhtunk‐ Haripur Afghan Refugee camp 6 7 5 3 2 hwa measles 1 vaccine and 173 children were missing measles 2 vaccine. Children were referred to nearest health facility for completion of vaccination. Health education session on prevention and spread was conducted for the affected families. CHWs were involved in active case find‐ ing. EDO Health and Save the children were informed about the outbreak.

Alert of suspected measles case was generated from Afghan Refugee camp 2. Suspected case was given Vit A. Blood sample was taken and sent to NIH. Active surveillance was conducted in the area. 28 more cases were identified who had developed measles in past 1 month. On Khyber active surveillance and record analysis, 698 children were assessed for vaccination status.83 18‐Apr Measles Pakhtunk‐ Haripur Afghan Refugee camp 2 7 10 5 7 children were missing measles 1 vaccine and 35 children missing measles 2 vaccine. CHWs hwa were involved in active case finding. EPI coordinator and save the children were informed about the outbreak. Missing children were referred to nearest health facility for completion of vaccination. Health education on prevention and spread was conducted for the affected families.

Seven suspected cases of measles were detected and responded, vitamin A drops given, one blood specimen collected and sent to NIH, on field investigation found 43% children fully 17‐Apr Measles Punjab D. G. Khan Mitha khoo uc Gadai 5 1 0 1 vaccinated. Health education session conducted. Provided IEC material. Outreach vaccination activity planned with the help of DOH. An alert of AWD was reported from hospital with severe dehydration, during active surveil‐ Village Guhram Khan lance 7 more cases were found, Water supply suspected as the source of disease, Aqua tabs, 18‐Apr AWD Sindh Dadu Gopang, near Pir Najeeb 0 5 2 1 Zinc tabs and ORS distributed, health and Hygiene session was conducted, EDOH, THO, DSC ullah and FP‐National program was informed, 1 Stool and 2 water samples were collected for lab testing. 6 cases of AWD were admitted in THQ, active search for more cases was done, Hand Pump Village Essani Khoso, near was the source of water, Aqua tabs, Zinc tabs supplied, IEC material and ORS distributed, 18‐Apr AWD Sindh Matiari Oil field, Palijani station, 0 1 0 5 taluka Matiari health sessions conducted, EDOH informed, 3 Stool and 4 water samples collected for lab testing. Suspected cases of AWD was reported from community, active surveillance done along with Village Ghulam Muham‐ PPHI & Merlin NGO and found five more cases of AWD in the village, open Dug well was the 20‐Apr AWD Sindh Thatta mad Khati, UC Karochan, 1 2 1 1 taluka Kharochan suspected source of water, Aqua tabs, Zinc tabs, ORS and IEC Material distributed, health education imparted, EDOH informed and 2 Water samples collected for quality testing. 1 confirmed case of CCHF was reported from NIBD, EDO representative accompanied during NIBD (National Institute investigation, case belongs to quetta, initially case was suspected for Malaria and anti Malar‐ 18‐Apr CCHF Sindh Karachi of Blood Disease), Gul‐ 0 1 0 0 ial treatment given.Later on CCHF diagnosed by lab test. Platelets count reduced to 10,000, shan‐e‐Iqbal Town patient attendent were sensitized regarding proper Hygiene, brief about the mode of trans‐ mission, advised to use insect repellents and information shared with SO DEWS Quetta.

An alert of suspected measles case was reported from BHU, during active surveillance 5 more cases of suspected measles were found, Vitamin (A) provided and Health Education imparted, Qambar Kot Ghulam Shah, UC 5 blood samples were taken for lab confirmation. Immunization status was assessed for 6 26‐Apr Measles Sindh 1 3 0 2 Shahdadkot Rawanti, taluka Kambar. children and only 2 (less than half) found vaccinated against measles 1 vaccine whereas none of the children received measles 2 vaccine. DHMT and EDOH was informed for implementa‐ tion of routine immunization in the locality

An alert of suspected Measles case was reported from the community, during active surveil‐ Tando Village Suleman Soomro, lance 8 more suspected cases were found, 9 children were assessed for routine immunization 26‐Apr Measles Sindh Muhammad UC Mula Katiar, taluka 4 1 2 2 and only 1 child were found vaccinated gainst measles 1 vaccine and none for measles 2 Khan Tando Muhammad Khan vaccine. Vitamin(A) given to all cases, health education imparted, EDOH informed and 1 Blood sample collected for lab confirmation.

Suspected case of Measles was notified from THQ Sujawal, active surveilliance was done in Village Allah Dad Solangi, the village and found 9 more cases of post Measles, Cluster of 15 houses were taken where 23‐Apr Measles Sindh Thatta UC Googani, taluka Shah 2 1 3 4 Bunder 23 children were assessed, routine coverage found below 70%, health education imparted, Vitamain (A) was given, blood sample collected and infromation share with DHO, THO & TSV.

Suspected case of Measles & one death was notified from community. On active surveillance Village Chatto Jamali, UC 5 more cases of Measles were found, Cluster of 15 houses were taken where 18 children 23‐Apr Measles Sindh Thatta Chouhar Jamali, taluka 4 0 3 0 Shah Bunder were assessed, routine coverage was below 50%, health education imparted, Vitamain (A) was given to the cases. Infromed DHO, THO & TSV.

An alert of suspected pertussis case was notified from a private clinic, during active surveil‐ lance, 9 more cases were foundin the locality. House to House cluster taken to assess the 24‐Apr Pertussis Sindh Ghotki Gahi Mangrio, UC Mithri 7 1 1 1 routine immunization status and none of the child found vaccinated, 14 days complete dose of erythromycin was provided to all patients and close contacts. informed EDOH & DSV for vaccination and conducted health promotion in the area.

An alert of suspected Pertussis cases were reported from community, on active search 13 Village Bahar Larik UC suspected cases were found,13 children were assessed for routine immunization and none of 24‐Apr Pertussis Sindh Khairpur 3 2 3 5 Noorpur Taluka Kingri the child found vaccinated. Health promotion activity conducted in the locality, information provided to Incharge BHU, DHMT and request for mop‐up the area.

Suspected case of Pertussis was informed by AWARE NGO team. On active search 65 more cases of Pertussis were found, No health facility located in the village, immunization status of Village Seenhara, UC children under 5 years of age were assessed and all children found totally unvaccinated, 23‐Apr Pertussis Sindh Tharparkar 8 18 11 28 Tardos, taluka Chachro health education imparted regarding importance of immunization. Erythromycin tabs and syrups , Cough syrups supplied. Health education material distributed, EDOH was informed and 5 Nasal Swabs were collected for lab confirmation.

Suspected 5 cases of pertussis were reported by Dr. Soomar Khoso, On active surveillance, 4 Village Haji Usman Lodo, more cases were found, vaccination status were checked for 9 children and only 9% children 24‐Apr Pertussis Sindh Thatta UC Gul Muhammad 4 0 4 1 Baran, taluka Jati found partially vaccinated with penta 1. Health education imparted, Erythromycin was given to cases and informed DHO,THO, TSV and 5 Throat samples were collected for testing.

Distribution of Wild Polio Virus cases Pakistan 2011 and 2012

As of 30 April 2012, the total number of polio cases confirmed by the labora‐ tory is 15 from 10 districts/towns/tribal agencies and areas.

Cases 2011 Cases 2012 Province P1 P3 P1 P3 P1+P3

Punjab 9 ‐ 1 ‐ ‐

Sindh 33 ‐ 2 ‐ ‐

Khyber Pakhtunkhwa 23 ‐ 4 ‐ ‐

FATA 57 2 4 1 1

Balochistan 73 ‐ 2 ‐ ‐

AJ&K ‐ ‐ ‐ ‐ ‐

Gilgit‐Baltistan 1 ‐ ‐ ‐ ‐

Islamabad ‐ ‐ ‐ ‐ ‐

Total 196 2 13 1 1

This weekly Epidemiological Bulletin is published jointly by the 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]. 04 Weekly Bulletin: DEWS, Pakistan, Week no. 17 (22 to 28 April 2012) Number of alerts by province, week 17, 2012 Province Sindh Cont’d Province Sindh Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 23‐Apr AWD Dadu Village Butra Gopang, taluka Dadu 1 1 1 0 26‐Apr Measles TM Khan Village Suleman Soomro 4 1 2 2 23‐Apr AWD Dadu Village Doodani Jamali, taluka Johi 0 0 0 1 23‐Apr Measles Thatta Village Ali Morai, UC Bujora 0 1 0 0 23‐Apr AWD Dadu Village Kaloo Khan Lund, taluka Dadu 0 1 0 0 23‐Apr Measles Thatta Village Allah Dad Solangi 2 1 3 4 23‐Apr AWD Dadu Village Meenhoon Khan Bhand 0 0 0 6 23‐Apr Measles Thatta Village Chatto Jamali 4 0 3 0 25‐Apr Measles Thatta Village Sof Jakharo taluka Thatta 1 0 1 0 26‐Apr AWD Dadu Village Dar Mangneja, taluka K.N Shah 1 0 4 1 26‐Apr Measles Thatta Water Pump Colony, UC Gharo 1 0 1 0 24‐Apr AWD Hyderabad Kacha Qila, taluka Hyderabad 1 1 1 1 28‐Apr Measles Thatta Shah Ibrahim, Ward # 3 0 0 2 0 25‐Apr AWD Hyderabad Khawaja colony, Kachi Abadi 0 0 0 1 27‐Apr Measles Umer Kot Akhay Ji Dhani, UC Gharibabad 2 0 0 0 25‐Apr AWD Hyderabad Rustum Malang Goth, Wadhu Wah 0 1 0 0 23‐Apr NNT Badin Village Dhano Kohli, CHAK #57 1 0 0 0 27‐Apr AWD Jamshoro Village Kamal Rashdani, UC Lakhat 0 1 0 1 23‐Apr NNT Q Shahdadkot Bero Khoso, UC Dostli 1 0 0 0 25‐Apr AWD Sanghar Village Dutro Shareef, UC Landhi 0 1 0 0 24‐Apr NNT Q Shahdadkot Badi Hakara, Behram 1 0 0 0 25‐Apr AWD T Allah Yar Village Ahmed Khan Lashari 0 0 0 1 27‐Apr NNT Q Shahdadkot Gopang Mohalla Baghoder 1 0 0 0 25‐Apr AWD T Allah Yar Village Deputy Abdul Haq 0 0 0 1 27‐Apr NNT Q Shahdadkot Village Magasi, near Shaikh Wah 1 0 0 0 24‐Apr AWD TM Khan Village Ali Muhammad 0 3 0 3 28‐Apr NNT Sukkur Village Sajjan Bharo, Alaf Kacho 0 0 1 0 26‐Apr AWD TM Khan Talpur colony 0 0 0 2 24‐Apr Pertussis Ghotki Gahi Mangrio, UC Mithri 7 1 1 1 26‐Apr AWD TM Khan Village Kamal Rashdani 0 1 0 1 26‐Apr Pertussis Ghotki Village Chhato Lund, UC Yaro Lund 1 1 0 0 23‐Apr AWD Tharparkar Village Amin ji Dhani, UC Rajoro 0 0 2 0 24‐Apr Pertussis Khairpur Village Bahar Larik UC Noorpur 3 2 3 5 24‐Apr Measles Badin Shahbaz colony, UC and taluka Badin 1 1 1 0 24‐Apr Pertussis Q Shahdadkot Jan Muhammad Banghar 1 0 2 0 25‐Apr Measles Badin Koat Foram, Kumbhar Muhalla 2 1 1 0 23‐Apr Pertussis Tharparkar Village Seenhara, UC Tardos 8 18 11 28 26‐Apr Measles Badin Chak #41, UC Ahmed Rajo 3 0 1 0 27‐Apr Pertussis Tharparkar Village Chaudhary colony 0 0 1 0 24‐Apr Pertussis Thatta Village Haji Usman Lodo 4 0 4 1 25‐Apr Measles Dadu Village Allah Wasayo Janweri 6 1 0 2 26‐Apr Scabies Ghotki Village Aliabad, UC Yaro Lund 3 12 5 5 25‐Apr Measles Dadu Village Rahim Ali Khoso 1 1 1 0 27‐Apr Scabies Sukkur Jamia Arabia Madarsah 0 65 0 0 24‐Apr Measles Ghotki Soomra Muhalla, Rahmoo wali 2 0 3 2 26‐Apr Typhoid Sukkur Bvillage Behram Jatoi 0 1 0 1 24‐Apr Measles Ghotki Village Abdullah Lakhan 1 0 1 0 25‐Apr Measles Ghotki Village Chibhar Kosh, UC Wasti Jeewan 1 0 0 2 Province Balochistan <5M >5M <5F >5F 26‐Apr Measles Ghotki Benazir colony, UC 3 1 0 0 0 Date Disease District Area 25‐Apr AJS Chagai Killi Kunar Kani, UC Chilgazi 1 1 0 1 26‐Apr Measles Ghotki Memon Muhalla, Ghota market 1 1 0 1 27‐Apr AWD Lasbela Sidique Goth,Parya Goth 0 3 0 10 26‐Apr Measles Ghotki Randhawa house, near Anaj Mandi 1 0 0 0 23‐Apr AWD Sibi BHU Sultan Kot 1 1 1 0 26‐Apr Measles Ghotki Village Chhato Lund, UC Yaro Lund 2 4 1 0 25‐Apr Leishmaniasis Jhal Magsi Village Gajan, UC Patri 1 1 1 0 23‐Apr Measles Hyderabad Latifabad # 5 taluka Latifabad 0 1 1 0 27‐Apr Leishmaniasis Kalat Village Jeeva, Tehsil Surab 0 1 0 0 23‐Apr Measles Hyderabad Latifabad Unit #12, near Kamal Autos 0 1 1 3 26‐Apr Leishmaniasis Killa Saifullah Village and UC Shna Khuwara 4 1 2 9 24‐Apr Measles Hyderabad Behind Civil hospital, taluka Hyderabad 0 0 0 1 27‐Apr Leishmaniasis Lasbela Village Lakhra, Tehsil Uthal. 0 2 0 1 26‐Apr Measles Hyderabad Allah Dad Chand Goth, Ooder cinema 0 0 1 0 25‐Apr Leishmaniasis Panjgur Mohalla Taar Office, UC Chitkan 0 1 0 0 26‐Apr Measles Hyderabad Mir Muhalla, near Jamia Masjid 0 0 0 1 27‐Apr Leishmaniasis Panjgur Mohalla Ball UC Washbood 0 1 0 0 27‐Apr Measles Hyderabad Mullah Ismail Goth, Islamin colony 2 0 0 1 25‐Apr Leishmaniasis Ziarat Village Chawatra, UC Ziarat 0 0 0 1 23‐Apr Measles Karachi Behind Abdullah Shah Ghazi Mazar 1 0 0 0 26‐Apr Measles Jaffarabad Village Nushki jadeed, Tehsil Gandakha 3 4 4 2 24‐Apr Measles Karachi Malokhair Muhalla, Village Rehri Goth 2 0 2 0 26‐Apr Measles Kech Village Sulband, UC Nodiz 2 0 0 0 24‐Apr Measles Karachi Musani 2 Muhalla, Village Rehri Goth 5 0 1 1 27‐Apr Measles Kech Village Kasak, UC Shahrak 0 1 1 0 25‐Apr Measles Karachi Street #1, Eidgah chowk 1 0 0 0 22‐Apr Measles Sibi RHC Lehri 0 1 0 0 27‐Apr Measles Karachi Street # 45, Delhi colony 1 1 1 1 24‐Apr NNT Chagai Killi Qasim Khan, UC Town Dalbandin 1 0 0 0 27‐Apr Measles Kashmore Mushtaq Bijrani, UC Karam Pur 1 0 2 3 26‐Apr Pertussis Killa Saifullah Village and UC Shna Khuwara 0 0 1 0 24‐Apr Measles Khairpur Mallah Muhallah, UC Ahmedpur 0 0 1 0 22‐Apr Typhoid Chagai Faisal Colony, UC sadder Dalbandin 0 2 0 1 26‐Apr Measles Khairpur Sheikh Mohalla, Rahooja Goth 1 0 2 0 22‐Apr Typhoid Kharan BHU Lijjay, UC Sarawan 0 2 0 2 27‐Apr Measles Khairpur Village Haji Hatim Ali Shambani 1 0 0 0 Province Gilgit Baltistan 23‐Apr Measles Larkana Village Sanhro Machi 0 0 1 0 Date Disease District Area <5M >5M <5F >5F 24‐Apr Measles Larkana Channa Muhalla, Akil road 0 1 0 0 23‐Apr Measles Skardu Village Hargeesa clifton road Skardu 1 0 0 0 26‐Apr Measles Larkana Near Brohi hotel, Khaliq colony 0 0 1 0 FATA 26‐Apr Measles Larkana Village Alam Khan Gopang 2 1 1 0 Date Disease Agency Area <5M >5M <5F >5F 27‐Apr Measles Larkana Meat Street, Nazar Muhalla 1 0 0 0 27‐Apr Leishmaniasis Khyber Village Ghakhi and Shagai Tana 1 1 0 0 27‐Apr Measles Larkana Near Khosa Imam Bargah 1 0 2 0 24‐Apr Measles Bajaur village Alijan, Tehsil Khar 1 0 0 0 27‐Apr Measles Larkana Village Ghulam Hussain Mugheri 0 0 2 0 24‐Apr Measles Bajaur village Maina, Tehsil Mamoond 1 0 0 0 24‐Apr Measles Mirpur Khas Village Khakoo Khan Maher 1 0 0 1 24‐Apr Measles Bajaur village sheikh kalay, Tehsil Khar 1 0 0 0 23‐Apr Measles N feroze Sochi Paro, near Edhi center 0 0 1 1 25‐Apr Measles Mohmand Shah jee korona 0 0 2 0 26‐Apr Measles Mohmand Mare Kale 0 0 1 0 24‐Apr Measles N feroze Village khair Muhammad Dasti 0 0 1 1 23‐Apr NNT Bajaur village Kotkai, Tehsil Salarzai 1 0 0 0 24‐Apr Measles N feroze Ward # 13, Old Station 0 0 8 3 25‐Apr NNT Bajaur village Ambar, Tehsil Ambar, Mohmand 1 0 0 0 26‐Apr Measles Q Shahdadkot Ali Sahabo, UC Wagan, taluka Warah 1 0 1 0 25‐Apr NNT Bajaur village garigal of Tehsil Mamoond 1 0 0 0 26‐Apr Measles Q Shahdadkot Kot Ghulam Shah, UC Rawanti 1 3 0 2 25‐Apr NNT Bajaur village sheikh kalay, Tehsil Khar 0 0 1 0 27‐Apr Measles Q Shahdadkot Sangha, UC Jean Abro 0 0 0 1 Azad Jammu and Kashmir 26‐Apr Measles Sanghar Doctors colony, Civil hospital 1 1 0 0 Date Disease District Area <5M >5M <5F >5F 23‐Apr Measles Shikarpur Village Daro, UC Amrote Sharif 0 1 0 0 25‐Apr Leishmaniasis Bagh RHC Seasar UC/Tehsil dhirkot 0 1 0 3 23‐Apr Measles Shikarpur Village Maroo Kakepota 0 0 1 0 25‐Apr Leishmaniasis Bagh vill khana mori Bagh UC Town Tehsil Bagh 0 1 0 0 24‐Apr Measles Shikarpur Village Qambar Wahan 3 0 0 0 27‐Apr Leishmaniasis Poonch Sheikh Zaid hosp Rawalakot 0 2 0 3 25‐Apr Measles Shikarpur Village M. Hayat Junejo 1 0 1 1 22‐Apr Measles Bagh vill Dhara Saliayan UC Saliyan Tehsil bagh 1 0 0 0 vill nakar Saliyan Maldiyalan UC saliyan 26‐Apr Measles Shikarpur Village Daud ji Wandh 1 1 0 0 26‐Apr Measles Bagh 1 0 0 0 Tehsil Bagh 24‐Apr Measles Sukkur GMC Teaching hospital and Kumbhar 0 1 0 0 vill Naka Kharick UC Town Tehsil Raw3ala‐ 24‐Apr Measles Poonch 1 4 0 4 28‐Apr Measles Sukkur Dadu Canal, UC Arain 0 0 1 0 kot This weekly Epidemiological Bulletin is published jointly by the 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 Weekly Bulletin: DEWS, Pakistan, Week no. 17 (22 to 28 April 2012) Province Khyber Pakhtunkhwa Province Punjab Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 25‐Apr AD Kohat Village Suleman Talab 0 0 0 0 23‐Apr AD Bhakkar BHU Sial, UC Sial, Tehsil Bhakkar. 13 8 9 12 23‐Apr Leishmaniasis Lakki Marwat Mohallah Boghanan 0 1 0 0 26‐Apr AD Bhakkar BHU Barkat Wala , UC Daggar Qureshi 24 9 26 13 25‐Apr Leishmaniasis Mardan Village Pir Ali, Kandao Baba & Janabad 0 15 8 23 27‐Apr AD Bhakkar BHU Katchi Shahani, UC Katchi 12 8 7 7 23‐Apr Leishmaniasis Nowshera Ghazi Abad, Dak Ismail Khel 0 3 0 1 23‐Apr Leishmaniasis Nowshera Halki Banda, Dak Ismail Khel 0 0 0 1 27‐Apr AD Bhakkar DHQ Hospital Bhakakr 76 47 28 28 23‐Apr Leishmaniasis Nowshera Shah Kot, Dak Ismail Khel 1 0 0 1 25‐Apr AD D. G. Khan UC Aaliwala 17 9 11 19 27‐Apr Leishmaniasis Nowshera Farangi Talab, Dak Ismail Khel 0 1 0 0 25‐Apr AD D. G. Khan UC Kot Chutta 71 130 87 63 27‐Apr Leishmaniasis Nowshera Hospital Korona, Dak Ismail Khel 0 0 1 0 24‐Apr AD Layyah BHU 136,UC Mandi Town 10 3 8 11 27‐Apr Leishmaniasis Nowshera Kotki Kalay, Dak Ismail khel 0 1 0 1 22‐Apr AD Mianwali RHC Kammar Machani 33 8 21 6 27‐Apr Leishmaniasis Nowshera Phase 6, Sector A, Block 3, Tent 52 0 1 0 0 23‐Apr AD Mianwali BHU Paki Shah Mardan 18 5 21 2 27‐Apr Leishmaniasis Nowshera Phase 6, Sector D, Block 2, Tent 32 1 0 0 0 22‐Apr AD Multan Matotali 12 8 11 13 27‐Apr Leishmaniasis Nowshera Shah Kot Bala, Saleh Khana 0 1 0 1 23‐Apr AD Multan Kotla chakar 19 10 7 22 28‐Apr Leishmaniasis Nowshera Lashkar Khel, Spin Khak 0 0 0 1 28‐Apr Leishmaniasis Nowshera Usman Khel, Inzari 0 0 0 1 26‐Apr AD Multan Basti Malook 7 11 6 8 23‐Apr Leishmaniasis Shangla Village Kabalgram 0 1 0 0 24‐Apr AD Muzaffargarh Basti Dhudi Wala, Moza Sh. Ali 13 53 19 72 27‐Apr Leishmaniasis Shangla village Martung, Puran 0 1 0 0 23‐Apr AD Rahim Yar Khan Khairpur Khadali 10 12 8 17 23‐Apr Measles Abbottabad Ochar, Upper Salhad 1 0 0 0 23‐Apr AD Rahim Yar Khan Sonak 11 19 14 26 24‐Apr Measles Bannu Koti Sadad 0 0 1 0 23‐Apr AD Rajanpur THQ Jampur, UC jampur Urban 271 82 191 49 27‐Apr Measles Battagram Village Jabree Phagora, UC Rajdhari, 1 0 0 0 24‐Apr AJS Mianwali DHQ Mianwali 2 1 1 1 24‐Apr Measles D. I. Khan City 2 1 0 0 0 25‐Apr AJS Rahim Yar Khan Trinda Sawaye Khan 0 3 0 1 24‐Apr Measles D. I. Khan Daraban, Tehsil Daraban 0 0 2 0 24‐Apr Measles D. I. Khan Mandhra 1 0 0 0 24‐Apr ARI Layyah BHU 136,UC Mandi Town 13 17 20 35 24‐Apr Measles D. I. Khan Pahar Pur Urban, Tehsil Pahar Pur 2 0 0 0 24‐Apr BD Bhakkar BHU Kohawar Kalan, UC Kohawar 1 2 2 0 24‐Apr Measles D. I. Khan Shaikh Yousaf 0 1 0 0 26‐Apr BD Bhakkar BHU Daggar Rehtas, UC Daggar Rehtas 0 3 1 0 24‐Apr Measles D. I. Khan Shor Kot 0 0 1 0 22‐Apr BD Mianwali RHC Kammar Machani 2 0 1 0 24‐Apr Measles D. I. Khan UC City 1 0 0 1 0 24‐Apr BD Rahim Yar Khan Pacca Laran 2 3 0 2 24‐Apr Measles D. I. Khan Wanda Rorri, Tehsil Kulachi 1 0 0 0 24‐Apr BD Rahim Yar Khan Shahbazpur Sharqi, Liaqatpur 1 2 0 0 27‐Apr Measles D. I. Khan Kachi Kot Garh, Tehsil Pahar Pur 0 1 0 0 25‐Apr BD Rajanpur RHC Dajal, UC Dajal, Tehsil Jampur 1 1 1 0 27‐Apr Measles D. I. Khan Opposite Nawab Adda 0 0 1 0 25‐Apr BD Rajanpur RHC mohammadpur 0 3 0 0 27‐Apr Measles D. I. Khan Shah Hassan Khel, Abdul Khail 0 0 1 0 27‐Apr Measles D. I. Khan Village Garah Bakhta 2 0 0 0 26‐Apr BD Rajanpur Moza Islampur, UC Bukhara 0 2 1 0 24‐Apr Measles D.I. Khan Mianwali (Pharpoor) 0 0 1 0 23‐Apr DHF Lahore Mughal Pura 0 0 0 1 27‐Apr Measles Hangu J‐ 07, IDP Camp Togh Sarai 1 0 0 0 23‐Apr DHF Lahore Ravi Town,Sadaqat Park Lahore 0 0 0 3 22‐Apr Measles Haripur Village Kotla, UC Muslimabad 1 0 3 1 23‐Apr Leishmaniasis Rahim Yar Khan Basti Meeran, Rajanpur Kalan 0 1 0 0 22‐Apr Measles Haripur Village Muslimabad, UC Muslimabad 0 2 1 1 23‐Apr Malaria Mianwali RHC Wan Bucharan 3 7 4 11 23‐Apr Measles Haripur Village Bagra, UC Bagra 1 1 0 0 23‐Apr Measles Bhakkar UC Yousaf Shah,Tehsil Bhakkar. 1 0 0 0 24‐Apr Measles Haripur Afghan Refugee Camp 15 1 1 0 0 24‐Apr Measles Bhakkar Tiba Hamid Shah, UC Angra 0 1 0 0 25‐Apr Measles Haripur Village Jab, UC Pind Kamal Khan 0 3 1 0 25‐Apr Measles Bhakkar Chak # 60/61 TDA UC Notak 0 1 0 0 26‐Apr Measles Haripur Police Chooki Muhallah, Haripur city 1 0 0 0 26‐Apr Measles Haripur Railway Station Muhallah,Haripur city 2 0 0 0 24‐Apr Measles D. G. Khan Chah Bhatti wala Drahma 1 0 0 0 27‐Apr Measles Haripur Talokar Road, Naee Abadi, Haripur city 0 1 0 0 24‐Apr Measles D. G. Khan Shehzad Colony uc Choratta 0 0 0 1 27‐Apr Measles Haripur Village Gandhian 0 0 1 0 26‐Apr Measles D. G. Khan Bank DG Canal uc Wadore 0 0 3 1 26‐Apr Measles Karak Banda Menzai, UC Banda Dawood Shah 1 0 0 0 23‐Apr Measles Lahore R.A Bazar 0 1 0 0 26‐Apr Measles Kohat Deri banda, UC Shahpur 0 1 0 0 24‐Apr Measles Lahore Barsinda road 0 1 0 0 26‐Apr Measles Kohat Near railway station, UC Khushal garh 1 0 0 0 25‐Apr Measles Lahore Gulberg Town 1 0 1 0 26‐Apr Measles Kohat UC Surgul 0 0 1 0 25‐Apr Measles Multan Pir Khursheed colony, chungi no. 8 0 0 1 0 25‐Apr Measles Mansehra Charach Behali 1 0 0 1 26‐Apr Measles Mansehra Kohistan Colony Near Dedra Chowk 1 0 1 1 25‐Apr Measles Muzaffargarh Basti Baat Wala, Moza & UC Jhuggi 0 0 1 1 24‐Apr Measles Mardan Village Jhanga Banda, UC Lund Khwar 0 1 2 1 25‐Apr Measles Muzaffargarh Mohallah Master Sharif Dogar 1 0 0 0 26‐Apr Measles Mardan Afghan Refugee Camo, Dargai 0 0 1 0 26‐Apr Measles Muzaffargarh Basti Gharib Abad Colony 0 0 0 1 26‐Apr Measles Mardan Village Hajiyan Kheila, UC Rashakai 0 0 1 0 26‐Apr Measles Muzaffargarh Basti Qaim Pur, Moza Dittan Wali 1 0 0 0 Tent: 5, Block: 1, Sector: F, Phase: 5, 23‐Apr Measles Nowshera 0 0 1 0 24‐Apr Measles Rajanpur Basti jamal Shah, Moza Wang 0 1 0 1 Jalozai IDP's Camp. C/O Merlin J‐3 24‐Apr Measles Rajanpur Basti Rakh Maarri 1 0 0 0 25‐Apr Measles Nowshera Miagano Kalay, Zando Banda 0 0 1 0 Tent: 1551, Block: 4, Phase: 3, Jalozai 26‐Apr Measles Rajanpur Moza Islampur, UC Bukhara 3 0 3 0 26‐Apr Measles Nowshera 1 0 0 0 IDP's Camp. C/O CAMP‐1 Health Post 27‐Apr Measles Rajanpur Dajal by‐pass road, UC Basti Rndan 0 1 0 0 Tent: 72, Block: 4, Sector: g, Phase: 5, 26‐Apr Measles Nowshera 0 1 0 0 25‐Apr Scabies Layyah BHU Shahuwala, UC Sahuwala 15 11 19 23 Jalozai IDP's Camp. C/Omerlin J‐3 Tent: 38, Block: 2, Sector: D, Phase:6, 26‐Apr Scabies Rahim Yar Khan Kot Haq Nawaz 3 12 1 9 27‐Apr Measles Nowshera 0 0 0 1 Jalozai IDP's Camp. C/O Merlin J‐3 26‐Apr Tetanus Lahore Nishter town 1 0 0 0 24‐Apr Measles Swabi BHU Yaqoobi 2 0 1 0 25‐Apr Typhoid Bhakkar BHU Chak No 73, UC Chak No 67/ML 1 2 0 2 25‐Apr Measles Swat Village and UC Kanjoo, Tehsil Kabal 0 1 0 0 25‐Apr Typhoid Bhakkar THQ Hospital Mankera, UC Mankera 1 5 1 10 25‐Apr Measles Swat Village and UC Shah Dherai 0 0 1 0 25‐Apr Measles Swat Village Asogay, UC Bar Aba khel 0 0 1 0 23‐Apr Typhoid Layyah BHU 300,UC Aulakh Thal Kalan 0 0 0 2 25‐Apr Measles Swat Village Sirsenai Shahi bagh 0 0 1 0 23‐Apr Typhoid Layyah BHU Jherkal, UC Samtia, Tehsil Karoor 0 5 0 4 25‐Apr Measles Swat Villege kabal babasham 0 0 1 0 23‐Apr Typhoid Layyah RHC Chowk Azam, UC Chowk Azam 0 1 0 1 26‐Apr Measles Swat Village Sher Palam, UC Pir Kale 1 0 0 0 22‐Apr Typhoid Mianwali RHC Kammar Machani 0 3 0 2 27‐Apr Measles Swat Village and UC Dureshkhela 1 0 0 0 23‐Apr Typhoid Muzaffargarh DHQ Muzaffargarh 0 2 1 0 27‐Apr Measles Swat Village Nokhera, UC Darmai 0 0 1 0 23‐Apr Typhoid Muzaffargarh RHC DD Panah, Kotaddu 1 0 0 1 25‐Apr NNT D. I. Khan Mohallah Khair Abad, Kirri Shamozai 1 0 0 0 23‐Apr Typhoid Muzaffargarh RHC Sinanwan, Kotaddu 1 1 0 1 24‐Apr NNT Lakki Marwat Nasir Khel Siraye Naurang 1 0 0 0 24‐Apr Typhoid Muzaffargarh RHC Khangarh, Tehsil MZG 0 1 1 1 26‐Apr Pertussis Swabi BMC Swabi, Zaida 1 0 0 2 26‐Apr Pertussis Swabi Private Clinic, TandKohi 1 0 1 3 24‐Apr Typhoid Muzaffargarh Thatha Qureshi, Tehsil MZG 1 0 0 1 23‐Apr Typhoid Nowshera Mohallah: Mari Khel, Jalozai Village 0 0 0 1 25‐Apr Typhoid Muzaffargarh BHU Utra Sandhila 1 0 0 1 26‐Apr Typhoid Nowshera G‐1, Phase‐3 0 0 0 1 25‐Apr Typhoid Rahim Yar Khan Trinda Sawaye Khan 0 4 0 3 This weekly Epidemiological Bulletin is published jointly by the 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]. 06 Weekly Bulletin: DEWS, Pakistan, Week no. 17 (22 to 28 April 2012) Table‐1: Leading causes of seeking health care in districts, Wk‐31, 2010 to Figure‐2: Number of consultations by age and gender, week 17, 2012 Wk 17, 2012, compiled from weekly reports Number of Diseases 250000 Consultations Acute respiratory infection 15,440,170 (23%) 200000 cases

of Skin diseases 6,466,570 (10%) 150000

Acute diarrhoea 5,986,366 (9%) 100000 number

Bloody diarrhoea 516,717 (<1%) 50000

Suspected malaria 3,994,701 (6%) 0 < 1 yr 1‐4 yr 5‐14 yr 15‐50 yr 50 + yr Unexplained fever 2,536,003 (4%) Male 26625 61104 76947 117361 53150 Female 25694 58753 82458 194151 62336 Total consultations 67,795,248 Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response 2010 2011 2012 (up till week 17) Total Disease A O A O A O A O Acute watery diarrhoea 209 85 1350 543 127 10 1686 638 Acute jaundice syndrome 5 2 51 17 52 5 108 24 Bloody diarrhoea 10 1 98 20 52 4 160 25 Dengue fever 81 32 785 111 28 2 894 145 Measles 48 6 1710 91 1496 108 3254 205 Pertussis 1 0 287 81 212 75 500 156 NNT + tetanus 5 0 399 0 234 0 638 0 Malaria 12 7 131 88 25 9 168 104 Leishmaniasis 1 0 298 33 339 32 638 65 Others 75 11 643 69 540 48 1258 128 Total 447 144 5752 1053 3105 293 9304 1490 Province Khyber Pakhtunkhwa: Figure-3: Trend of priority communicable diseases, province KPK • 509 health facilities from 18 districts of Khyber 50 Pakhtunkhwa reported to DEWS on weekly basis with AD BD ARI S. Malaria a total of 139,017 patients consultations in week 17, 45 2012. 40 35 • 69 alerts were reported in week 17; Altogether 49 for 30 Measles; 13 for Leishmaniasis; 2 each for NNT, Per- 25 Percentage tussis and Typhoid; while 1 for Acute diarrhoea. 20 15 • 2 outbreaks, 1 each for Leishmaniasis and Pertussis 10 were identified and appropriate measure were taken. 5 0 1 3 5 7 9 1 3 5 7 9

15 17 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 11 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 Province Sindh: Figure-4: Trend of priority communicable diseases, province Sindh • 530 health facilities from 23 districts in Sindh reported on weekly basis to DEWS with a total of 279,052 patient 50 AD BD ARI S. Malaria consultations in week 17, 2012. 45 40 • 76 alerts were reported; Altogether 49 for Measles; 16 35 for AWD; 6 for Pertussis; 3 for NNT; while 1 each for 30 25 Typhoid and Scabies. Percentage 20 15 • 18 outbreaks, 11 for Measles; 4 for Pertussis; while 3 for 10 AWD were identified and appropriate measures were 5 taken. 0 1 3 5 7 9 1 3 5 7 9

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

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

15 17 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 11 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 Province Balochistan: Figure-6: Trend of priority communicable diseases, province Balochistan • 444 health facilities from 22 districts in Balochistan 50 reported to DEWS, with a total of 66,843 patient con- AD BD ARI S. Malaria 45 sultations. 40 • 18 alerts were reported in week 18 from Balochistan; 35 Altogether 7 for Leishmaniasis; 4 for Measles; 2 each 30 for AWD and Typhoid; while 1 each for AJS, NNT and 25

Pertussis. Percentage 20

• 3 outbreaks, 1 each for AWD, Leishmaniasis and Mea- 10

sles were identified and appropriate measures were 5

taken. 0 2 4 6 8 2 4 6 8

16 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 10 12 14

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 Province Gilgit Baltistan:

Figure-7: Trend of priority communicable diseases, Gilgit Baltistan

• 28 health facilities from 4 districts in Gilgit Baltistan 50 AD BD ARI S. Malaria reported to DEWS in week 17, with a total of 13,955 45 patient consultations. 40 35 • Less number of report were received because of ongo- 30 ing unstable situation in Gilgit Baltistan. 25 20

Percentage 15 1 alert for Measles was received and appropriate meas- • 10 ures were taken. 5

0 1 2 3 4 5 6 7 8 9

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 10 11 12 13 14 15 16 17 48 49 50 51 52

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 wk wk wk wk wk wk wk wk wk wk State of Azad Jammu and Kashmir: FATA: • 140 health facilities from 10 districts reported to DEWS in this • 38 health facilities from 2 agencies reported from FATA in week with a total of 29,069 patient consultations. this week, with a total of 11,025 patient consultations.

• 6 alerts, 3 each for Leishmaniasis and Measles were received • 10 alerts, 5 for Measles; 4 for NNT; while 1 for Leishmaniasis and appropriated measures were taken. were received and appropriate measures were taken.

50 50 AD BD ARI S. Malaria AD BD ARI S. Malaria 40 40

30 30

20 20 Percentage Percentage 10 10

0 0 6 8 2 4 6 8

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 10 12 14 16

10 12 14 16 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

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

Cholera is an acute enteric infection caused by the ingestion of bacterium Vibrio cholera present in faecally contaminated water or food. Primarily linked to insufficient access to safe water and proper sanitation, its impact can be even more dramatic in areas where basic environmental infrastructures are dis‐ rupted or have been destroyed. Countries facing complex emergencies are particularly vulnerable to cholera outbreaks. Massive displacement of IDPs or refugees to overcrowded settings, where the provision of potable water and sanitation is challenging, constitutes also a risk factor. Every year, there are an estimated 3–5 million cholera cases and 100,000–120,000 deaths due to cholera worldwide.

Cholera is characterized in its most severe form by a sudden onset of acute watery diarrhea that can lead to death by severe dehydration. The extremely short incubation period ‐ two hours to five days ‐ enhances the potentially explosive pattern of outbreaks, as the number of cases can rise very quickly. About 75% of people infected with cholera do not develop any symptoms. However, the pathogens stay in their feces for 7 to 14 days and are shed back into the environ‐ ment, possibly infecting other individuals. Cholera is an extremely virulent disease that affects both children and adults. Unlike other diarrheal diseases, it can kill healthy adults within hours. Individuals with lower immunity, such as # of Lab‐confirmed Province # of outbreaks # of suspected cases # of deaths malnourished children or people living with HIV, are at greater risk of death cases if infected by cholera. Sindh 213 2463 183 111 Cholera is endemic in Pakistan. In 2010, the Ministry of Health in Pakistan reported laboratory confirmation of 99 cases of Vibrio cholera. These cases Khyber Pakhtunkhwa 189 4594 198 40 have been reported sporadically from a wide geographical area in the flood‐ Punjab 73 389 75 24 affected provinces of Sindh, Punjab and KPK. In 2011, total of 541 out‐ breaks, 11,811 suspected cases out of which 519 were confirmed cases and Baluchistan 30 2427 28 21 218 deaths with suspected Cholera had also been reported. WHO‐DEWS FATA 8 197 9 2 team, department of health and health partners jointly responded to these GB 8 92 10 1 outbreaks. Table shows the distribution of outbreaks by Province in 2011. Although in 2012 no confirmed outbreaks of cholera have been reported so AJK 20 1649 16 19 far but with the start of the diarrhoea season the risk of Acute Watery Diar‐ Total 541 11811 519 218 rhoea (AWD) outbreaks has also increased now.

Risk factors for Acute Watery Diarrhoea: Lack of safe water, inadequate quantity and quality of water, poor personal hygiene, poor washing facilities, insufficient soap for washing hands, Poor sanita‐ tion, inadequate cooking facilities, Overcrowding, population movement/displacement.

Key steps for prevention and control: Ensuring adequate safe drinking water supply and proper sanitation are the most important means of protection against severe diarrhoeal diseases including cholera epidemics.

Safe drinking water: In areas where the infrastructure for provision of safe drinking water does not exists simple inexpensive measures can be used to make water safe for drinking at household level as follows. Boiling: Bringing water to a vigorous, rolling boil and keep it boiling for one minute will kill Vibrio cholera O1 and most other organisms that cause diarrhoea. Chlorination at household: First prepare stock solution by mixing 33 gm of bleaching powder in one litre of water and store it in a brown glass bottle. Then put 3 drops (0.6 ml) of stock solution in one litre of water or 30 drops (6 ml) in 10 litres of water or 60 ml in 100 litres. Do not cover the container for first 30 minutes after adding stock solution in it and wait 30 minutes before drinking or using the water. Alternatively, water disinfection tablets (eg. Aquatabs) can be added to the water ac‐ cording to package instructions. Solar water disinfection: Another small‐scale and cost‐effective immediate technique is solar water disinfection (SODIS) by which transparent plastic bottles filled with water are placed horizontally on a flat surface and exposed to solar light for about 5 hours in order to let the ultraviolet light in solar irradiation kill the pathogens. The effect of solar irradiation can be enhanced by painting the bottom half of the bottle black or placing them on a black background. (Note: In case of Cholera outbreak Chlorination is the only option to make the water safe for consumption)

Hand‐washing Studies of diarrhoea show that washing hands with soap and water (where soap is not available one may use ash) reduces the incidence of diarrhoea by up to 35%. Hands must be washed: After defecation; After any direct or indirect contact with stools; Before preparing and distributing food; Before eating; Before feeding children.

Sanitation Improvements in water supply and environmental sanitation will reduce the incidence of diarrhoeal diseases in the long run. Even where sanitation is poor, simple measures help ensure the safe disposal of stools and must be followed – particularly in the case of out‐ Key messages: breaks of diarrhoeal diseases: No defecation on the open ground – cover stool with soil Cholera is transmitted through contaminated water or food. (or use trench latrines that are regularly covered); No Prevention and preparedness of cholera require a coordinated multidisciplinary approach defecation near a water supply/source; Disposal of chil‐ Cholera can rapidly lead to severe dehydration and death if left untreated dren’s stools in toilets or latrines or buried in the Once Vibrio cholera is confirmed, the WHO clinical case definition is sufficient to diagnosis and ground; Washing hands with soap (or ash) after any management of cases. Laboratory testing is required only for antimicrobial sensitivity testing contact with stools; Build and use latrines – a pit latrine and for confirming the end of an outbreak. 2 metres deep with an opening of 1 metre by 1 metre Provision of safe water, proper sanitation, and food safety are critical for preventing occurrence can be used by a family of 5 persons for a period of 2 to of cholera 4 years. Latrines must be sited downhill and away from Health education aims at communities adopting preventive behavior for averting contamination sources of drinking‐water (at least 30 metres), wash ORS can successfully treat 80% of cholera cases daily and regularly disinfected with cresol or bleaching Appropriate antibiotics can reduce the duration of Vibrio Cholera bacterium in the patient stool powder.