Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 2, Issue 43, Monday 31 October, 2011

Highlights Priority diseases

under surveillance Epidemiological week no. 43 (21 to 27 October, 2011) in DEWS

• 81 districts and 2 agencies provided surveillance data to the DEWS this week from Acute Flaccid Paralysis (AFP)

2,514 health facilities. Data from mobile teams is reported through sponsoring BHU or Acute Jaundice Syndrome (AJS) RHC. Acute Respiratory Infections (Upper and Lower) (ARI) • A total of 802,810 consultations were reported through DEWS of which 192,059 (24%) were acute respiratory infections (ARI); 69,127 (9%) were Skin disease; 62,127 Acute Watery Diarrhoea (AWD)/ Suspected Cholera (8%) were acute diarrhoea; and 58,508 (7%) were suspected Malaria. Acute Bloody Diarrhoea (BD)

• A total of 140 alerts with 11 outbreaks were reported in week‐43, 2011: Altogether Other Acute Diarrhoeas (AD) 33 alerts were for Dengue Fever, 33 for AWD, 28 for Measles, 17 for Neonatal tetanus Suspected Viral Hemorrhagic and Tetanus, 10 for Leishmaniasis, 6 each for Malaria and Pertussis, 1 Bloody diarrhoea, Fever (VHF) while 6 for other non‐communicable diseases. Suspected Malaria (Mal)

• National Polio Eradication Initiative reported 4 new polio cases, 1 each from Sindh Suspected Measles (MS)

(Thatta), FATA (Waziristan North), Balochistan (Pishin) and Khyber Pakhtunkhwa Suspected Meningitis (MG) st (Swabi). As of 31 October, 2011, Pakistan has reported a total of 136 polio cases (134 Others type‐1 and 2 type‐3) from 42 districts/towns/tribal agencies/areas. Please see map on page 6.

Figure‐1: Weekly trend of leading priority diseases in Pakistan, 29 July 2010 to 27 October 2011 (Epi week 31, 2010 to week 43, 2011)

35 AD BD ARI S. Malaria 30

20 Percentage 15

0 1 3 5 7 9

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

‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ 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

Disease Wk-36 Wk-37 Wk-38 Wk-39 Wk-40 Wk-41 Wk-42 Wk-43

Acute respiratory infection 158,580 (18%) 175,906 (19%) 193,771 (19%) 205,597 (21%) 209,436 (21%) 221,144 (22%) 210,475 (24%) 192,059 (24%)

Skin diseases 104,676 (12%) 107,435 (12%) 107,243 (11%) 105,912 (11%) 95,842 (9%) 93,937 (9%) 80,944 (9%) 69,127 (9%)

Acute diarrhoea 96,128 (11%) 109,523 (12%) 110,835 (11%) 105,295 (11%) 97,007 (10%) 92,214 (9%) 73,343 (8%) 62,127 (8%)

Bloody diarrhoea 7,387 (0.85%) 7,920 (0.85%) 8,676 (0.86%) 9,393 (0.94%) 8,075 (0.80%) 8,016 (0.78%) 6,007 (0.68%) 5,389 (.67%)

Suspected malaria 58,753 (7%) 64,766 (7%) 78,109 (8%) 83,684 (8%) 82,802 (8%) 85,698 (8%) 68,059 (8%) 58,508 (7%)

Total consultation 864,693 931,318 1,005,251 995,450 1,014,266 1,023,163 886,224 802,810

Since July 29, 2010, approximately 50,324,518 patient consultations have been reported to the DEWS from all provinces, FATA and AJ&K. While we still receive reports on about 1,000,000 consultations per week, there is a drop in timely reporting due to challenges in accessibility caused by floods, security and infrastructure. The above graph shows the weekly trend of four major diseases as percentage of cases out of total consultations reported to DEWS. From last 6 weeks (38 to 43, 2011) acute diarrhoea cases have been decreased (From 12% to 8%), while at the same time cases of ARI have been increased (From 18% to 24%). Sus‐ pected Malaria cases have also shown seasonal increase from week 35 especially from districts in Sindh and Balochistan.

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]. 01 Epidemiological Bulletin: DEWS, Pakistan, Week no. 43 (21 to 27 October, 2011) Current week's Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken Alert for suspected Malaria, 23 cases were reported. 21 samples were taken and 17 verified positive 27‐Oct Malaria Balochistan Jhal Magsi BHU Barija 3 8 5 7 (PF=5,PV=8,and Mix=4); SPR=81%, while FR = 53%. RDTs were distributed and DHO was informed. Alert for CCHF, one death of a suspected CCHF case was reported from village Khaido, district Haripur. The patient had initially presented with fever and body aches. Lab investigations revealed thrombocytopenia. Blood sample was taken and sent to NIH which came back positive for CCHF. A joint team of WHO and Dept 27‐Oct CCHF KPK Haripur Village Khidoo 0 1 0 0 of health visited the area. Epidemiological and environmental assessments were carried out. A session on CCHF spread and prevention was conducted in the community. EDO Health was informed. Residual spray in the area was also carried out.

AWD alert, suspected case found in Hospital and investigated during active surveillance 5 more cases were 25‐Oct AWD Sindh Badin Ward # 05, UC Talhar 2 2 0 2 found, health education provided. Aqua tabs, Zinc tabs, ORS and Hygiene kits were distributed. EDO‐H informed, 1 stool and 2 water sample taken.

AWD alert, suspected case admitted in hospital with Dehydration, during active surveillance found 5 more Malik Shah Town, UC Nago‐ 27‐Oct AWD Sindh Jamshoro 3 2 0 1 cases, water supply was the source, health education imparted, Aqua tabs, Zinc tabs, ORS, Jerry cans and line IEC material distributed, EDO‐H informed, 1 stool and 2 water samples were taken.

AWD alert, suspected case found in Hospital during active surveillance 6 more cases were found in the Village Fazil Noohani, Digri village, health education imparted to house hold, Doctors and Paramedic briefed on case definition and 27‐Oct AWD Sindh Mirpur Khas 1 3 1 2 City reporting. Aqua tabs, Zinc Tabs, ORS and hygiene kits were distributed. Water sample was found contami‐ nated.

AWD alert, suspected case with deaths reported from IDP camp, during active surveillance found 21 more 26‐Oct AWD Sindh Sanghar IDP camp near Village Berwari 2 11 2 7 cases. Hand pump was the source of water, health education provided, Aqua tabs, Zinc tabs, ORS, Jerry cans and hygiene kits were distributed. EDO‐H and DSM informed, 1 stool and 2 water samples were taken.

AWD alert, during active surveillance 7 more cases found with severe dehydration, health education im‐ Village Rajo Lashari, UC 24‐Oct AWD Sindh T. Allah Yar 2 3 1 1 parted. Aqua tabs, Zinc tabs, ORS, Jerry cans and hygiene kits were distributed. EDO‐H informed, 1 stool and Dhingano Bozdar 2 water samples were taken.

Village Loolja, UC Kandi Alert for Malaria, 20 cases were investigated, 11 confirmed by RDT, SPR=55%, health education was im‐ 22‐Oct Malaria Sindh Dadu 0 0 0 0 chukki parted. TMA/TMO, EDO‐H and DOH were informed and requested for fumigation.

Alert for Malaria, 30 cases were investigated, 49 RDT conducted out of them 30 were confirmed, SPR=61%, 23‐Oct Malaria Sindh Tharparkar Tent Village, Nohato Road 1 18 1 10 health education imparted. Bed nets were provided to the patients; EDO‐H, Malaria Focal Person were informed.

Alert for probable Pertussis, 14 suspected cases were found during the monitoring of polio campaign at village Allah Wasayo Chachar, UC Qadirpur. House to house search was carried out, routine immunization 25‐Oct Pertussis Sindh Ghotki Village Allah Wasayo 7 2 4 1 status was found to be zero. Health education imparted in the village and informed EDOH and DSV and requested for vaccination in the village.

Alert for Pertussis, 5 suspected cases were found during the monitoring of polio campaign at village Khuda Bux Marnas, UC Bago Daho. House to house case searching done, routine immunization status was found 26‐Oct Pertussis Sindh Ghotki Village Khuda Bux Marnas 2 1 1 1 to be zero. Health education imparted in the village and informed EDOH and DSV and requested for vaccina‐ tion in the village.

Current week's Alerts: Province Khyber Pakhtunkhwa Current week's Alerts: Province Balochistan Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 27‐Oct AWD Battagram Village Shingli Bala, UC Gijjbori 0 1 0 0 26‐Oct DHF Quetta Fatima Jinnah Chest Hospital 0 2 0 0 25‐Oct BD Kohat Village Garhi Mawaz Khan 0 2 0 6 27‐Oct CCHF Haripur Village Khidoo, Haripur 0 1 0 0 26‐Oct Leishmaniasis Awaran wadi UC camp Jhaoo 1 0 0 0

21‐Oct DHF D. I. Khan Gur Wali, Kirri Shamozai, Tehsil Paroa, 0 1 0 0 21‐Oct Leishmaniasis Jhal Magsi Balina kotra UC Khari CD Kotra 1 0 0 0 26‐Oct DHF D. I. Khan P.O. Kot Jai, Tehsil Pahar Pur 0 1 0 0 25‐Oct Leishmaniasis Jhal Magsi DHQ Hospital‐Basti Kamal Shah UC Gandawah 1 0 0 0 24‐Oct DHF Haripur Haripur city 0 1 0 0 25‐Oct DHF Haripur Saidan Kharan, Haripur 0 1 0 0 24‐Oct Leishmaniasis Kalat Khail UC Kalat Saddar Tehsil Kalat 0 1 0 0 21‐Oct DHF Lower Dir Village & UC Khungi Sha, Tehsil Timar‐ 0 1 0 0 27‐Oct Leishmaniasis Khuzdar Tehsil Khuzdar and Nall 0 2 0 0 22‐Oct DHF Lower Dir Village & UC Rabat, Tehsil Timargara 0 1 0 0 27‐Oct DHF Shangla Mohallah Ali Khel , Village Choga 0 1 0 0 25‐Oct Leishmaniasis Panjgur UC Washbood, Mohalla Qazi Abad 0 1 0 0

23‐Oct Diphtheria Kohistan Village Dhaan (Thapan), UC Ranolia 2 1 0 0 27‐Oct Leishmaniasis Quetta Hazara town, Brewery road 0 0 0 1 27‐Oct Leishmaniasis Tank Dabarra 1 0 0 0 27‐Oct Malaria Jhal Magsi BHU Barija 3 8 5 7 21‐Oct Measles D. I. Khan Arra, Tehsil & District D I Khan 1 0 0 0 21‐Oct Measles D. I. Khan Kokar, Tehsil & District D I Khan 0 0 1 0 25‐Oct Malaria Nasirabad BHU Mir Hassan, Tehsil Chutair 25 70 10 50 Kot Jai, Tehsil Pahar Pur, District D I 21‐Oct Measles D. I. Khan 0 0 1 0 Khan 27‐Oct Measles Awaran Bigari Zeelag UC Korak Jhaoo 1 0 0 0 25‐Oct Measles Lower Dir Village Barghando, UC & Tehsil Lal Qilla 0 0 0 1 Village Meergam Payeen, UC Gall & Lal 25‐Oct Measles Chagai RHC Chagai Village 1 0 2 0 25‐Oct Measles Lower Dir 0 0 1 0 Qilla 26‐Oct Measles Kalat Langhari UC Iskalkoo Tehsil Kalat 1 3 1 1 26‐Oct Measles Lower Dir Village Khan Abad, UC Kotkay, Tehsil 1 1 0 1 26‐Oct Measles Khuzdar Zehri abad UC Feroz Abad Tehsil Khuzdar 1 0 0 0 27‐Oct Measles Malakand Haybatgram 2 1 2 2 25‐Oct Measles Mardan Mohallah Chachi, Khwaja Ganj Bazar 1 0 0 0 27‐Oct Measles Khuzdar Nawa UC Baleena Kattan Tehsil Khuzdar 5 0 2 0 Mohallah Faujiabad, UC Dagaai Sikan‐ 25‐Oct Measles Mardan 1 0 0 0 dari 27‐Oct Measles Khuzdar Zangi Abad UC Zereena Kattan Tehsil Khuzdar 1 0 0 0 21‐Oct Measles Swabi BMC Swabi, Shagai Maneri 1 0 2 0 25‐Oct NNT Bolan Village mitiri, tehsil Dhadar 1 0 0 0 22‐Oct Measles Swat Village and UC Udigram near 0 0 1 0 JannatAbad, ChesanKuch, KirriHaider 25‐Oct Pertussis Chagai RHC Chagai Village 3 0 0 0 25‐Oct Measles Tank 1 2 0 1 and UmerAdda 27‐Oct NNT Swabi IDH Peshawar 0 0 2 0 24‐Oct Typhoid Chagai gorgage girdi jungle 0 2 1 4

25‐Oct AWD Badin Village Ahmed Rajo, Golarchi road 0 1 0 0 27‐Oct AWD D. G. Khan Y block D.G.Khan city 0 1 0 0 25‐Oct AWD Badin Ward # 05, UC Talhar, Taluka Talhar 2 2 0 2 DHQ Hospital Bhakkar (Bharmi Nawab, 23‐Oct DHF Bhakkar 0 3 0 0 26‐Oct AWD Hyderabad Gujrati Para, Tando Yousuf 0 1 0 0 Muslim Kot) 27‐Oct AWD Jamshoro Malik Shah Town, UC Nagoline 3 2 0 1 26‐Oct DHF D. G. Khan Nishter Hospital Multan (DG Khan) 0 2 0 0 24‐Oct AWD Mirpur Khas FAP camp, Eidgah Primary school 1 1 0 1 24‐Oct AWD Mirpur Khas Village Ahmedabad, UC Araro Burguri 0 1 0 0 24‐Oct DHF Jhang Nishter Hospital Multan (Jhang) 0 2 0 1 24‐Oct AWD Mirpur Khas Village Patayoon Mohalla, UC Turk Ali Mari 0 1 0 1 27‐Oct DHF Khanewal Nishter Hospital Multan (Khanewal) 0 23 0 2 24‐Oct AWD Mirpur Khas Village Haji Muhammad Ali Halepotto 0 0 0 1 24‐Oct AWD Mirpur Khas Village Mir Anwar Talpur, neear Jara water 0 1 0 0 21‐Oct DHF Layyah Chak No. 160/TDA Layyah 0 1 0 0 25‐Oct AWD Mirpur Khas Village Manhori, UC Girhore Shareef 0 0 1 0 DHQ Layyah; Sarwar Abad Darya Khan/ 25‐Oct AWD Mirpur Khas Village Naban Shar, Sanghar road, 1 0 0 0 21‐Oct DHF Layyah 0 2 0 0 bhakkar 27‐Oct AWD Mirpur Khas Railway Quarters, near Railway station 1 1 0 1 27‐Oct DHF Mianwali Hernoli Tehsil Piplan 0 1 0 0 27‐Oct AWD Mirpur Khas Village Fazil Noohani, Digri City 1 3 1 2 27‐Oct AWD Mirpur Khas Village Sobho Khan Laghari, UC Kangoro 0 0 1 0 27‐Oct DHF Mianwali Bani Afghan, Isakhel 0 0 0 2 27‐Oct AWD N Feroze Village Kamal Dero, UC Kamal Dero 2 1 0 1 26‐Oct AWD Sanghar IDP camp near Village Berwari 2 11 2 7 27‐Oct DHF Multan Nishter Hospital Multan (Multan) 0 8 0 1 27‐Oct AWD Sukkur Gopang Mohalla, New pind 0 1 0 0 23‐Oct DHF Muzaffargarh Nishter Hospital Multan (Muzaffargarh) 0 4 0 0 21‐Oct AWD T. Allah Yar Akram Colony, UC3 0 1 0 0

22‐Oct AWD T. Allah Yar Village Piyaro Land 2 1 0 0 26‐Oct DHF Muzaffargarh Chak Number 137 & UC Shah Jamal 0 1 0 1 22‐Oct AWD T. Allah Yar Village Sarang Hakro, UC Shaikh Musa 1 2 1 0 24‐Oct AWD T. Allah Yar Village Rajo Lashari, UC Dhingano Bozdar 2 3 1 1 25‐Oct DHF Pakpattan Nishter Hospital Multan (Pakpattan) 0 8 0 0

26‐Oct AWD T. Allah Yar Village Gul Mohd Lashari, UC Dhingano 0 1 0 0 Rahim Yar Jinnah Park St, No 10; Ittahad Colony 21‐Oct DHF 0 5 0 0 21‐Oct AWD TM Khan Village Dadoon, UC Jinan Soomro 1 0 2 0 Khan Gulshan ‐i‐Usman Rahim Yar Basti Masurain, Mouza Ghot Juda Chak 21‐Oct AWD TM Khan Village Rashidani, UC‐3 0 0 1 0 22‐Oct DHF 0 1 0 2 Khan 165/P 22‐Oct AWD Tharparkar Village Doongari, UC Nagarparkar 0 1 0 1 Rahim Yar Fatehpur Punjabina, Golor Maso Khan, 23‐Oct DHF 0 2 0 1 25‐Oct AWD Thatta Village Kala Kot, UC Domani 0 1 0 0 Khan Chak No 50 /P 26‐Oct AWD Thatta Village Ghulam Hussain Lakhetio 1 1 0 0 Rahim Yar 25‐Oct DHF Ranger H/Q, Sunni Pul Chak No 83/P 0 2 0 0 27‐Oct AWD Thatta Village Jongi Peryer, UC Darya Khan Soho 0 1 0 1 Khan Rahim Yar 27‐Oct DHF Khairpur Village Mudd, UC Mudd 0 1 0 0 26‐Oct DHF Chak No 124 Bagho Bahar 0 1 0 0 Khan 21‐Oct DHF Sukkur Village Nehal Khan Khoso 0 0 0 1 Rahim Yar Muhalla Fasialabad, Near Fire Birgrade 27‐Oct DHF 0 1 0 0 25‐Oct DHF Sukkur Village Rahooja, site area Sukkur 0 1 0 0 Khan Station, Sadiqabad 27‐Oct DHF Sukkur Village Garho Goth, UC Kandhra 1 0 0 0 25‐Oct DHF Sahiwal Nishter Hospital Multan (Sahiwal) 0 8 0 0 22‐Oct Malaria Badin Village Taj Mohammad Shah 1 3 0 5

21‐Oct Malaria Dadu Village Sodo Solangi, UC Allahabad 6 3 11 2 24‐Oct DHF Vehari Nishter Hospital Multan (Vehari) 0 1 0 1 22‐Oct Malaria Dadu Village Loolja, UC Kandi chukki 0 0 0 0 Leishmani‐ Rahim Yar Basti Khair Mohammad Khosa, UC Chandia, 27‐Oct 0 1 0 0 23‐Oct Malaria Tharparkar Tent Village, near Village Sandino Khaskheli 1 18 1 10 asis Khan Tehsil Khanpur 25‐Oct Measles Ghotki Village Changlani, UC Bereri 0 0 1 0 Basti Joiya Wala, Moza Ruken Wali, UC 21‐Oct Measles Muzaffargarh 1 0 0 0 Binda Ishaq 27‐Oct Measles Jacobabad Garhi Khairo City 2 0 1 0 Basti Sawan Wala, Moza Allah Abad Sharqi, 22‐Oct Measles Jamshoro Ameer complex, UC Nagoline 0 1 0 0 26‐Oct Measles Rajanpur 2 0 1 0 UC Allah Abad 26‐Oct Measles Jamshoro Khaskheli Mohalla, UC Nagoline 0 1 0 0 Basti Khameesa Abad, Moza Allah Abad 26‐Oct Measles Rajanpur 1 0 0 1 27‐Oct Measles Karachi Street # 5, Manzoor Colony 1 0 0 0 Gharbi, UC Allah Abad 22‐Oct Meningitis Benazirabad Dado Jhandi, UC 7 1 0 0 0 Mohalla Lashaarian, Near Alipur Bazar, UC 26‐Oct Measles Rajanpur 0 0 1 0 Jampur Urban 26‐Oct NNT Ghotki Village Haji Muhammad Sadique Lashari 1 0 0 0 26‐Oct NNT Karachi Neonatal ICU, NICH 0 0 1 0 26‐Oct NNT D. G. Khan Chabree bala UC Chabree 0 0 1 0 26‐Oct NNT Karachi Juma Goth, Malir # 5 1 0 0 0 27‐Oct NNT D. G. Khan Basti Malah UC Kot Qaisrani Taunsa 1 0 0 0 26‐Oct NNT Kashmore Village Wali Mohammad Kosh 1 0 0 0 22‐Oct NNT Larkana Rasool abad Muhalla 1 0 0 0 27‐Oct Pertussis D. G. Khan Dab Jhan Nee Baghalchor UC Mubarkee 1 0 0 0 22‐Oct NNT Larkana Village chakro 0 0 1 0 Qambar Basti Maywa Dareshak, UC Fateh Pur, 22‐Oct NNT Village wadi drib 1 0 0 0 27‐Oct Pertussis Rajanpur 2 0 0 0 Shahdadkot Tehsil Rajanpur Moza Fateh Pur, UC fateh Pur, Tehsil 24‐Oct NNT Qambar Village Kheo mugheri, UC Behram 1 0 0 0 27‐Oct Pertussis Rajanpur 0 0 1 1 Rajanpur 27‐Oct NNT Qambar Village Raban Gadhi, Taluka Nasirabad 1 0 0 0 24‐Oct NNT Shikarpur Village Daud ji Waandh, 1 0 0 0 26‐Oct Tetanus D. G. Khan Samina village UC Samina 1 0 0 0 27‐Oct NNT TM Khan Village Bakar Nizamani 1 0 0 0 Current week's Alerts: AJK; FATA; GB and ICT 25‐Oct Pertussis Ghotki Village Allah Wasayo 7 2 4 1 Date Disease District Area <5M >5M <5F >5F South Waziristan 26‐Oct Pertussis Ghotki Village Khuda Bux Marnas 2 1 1 1 21‐Oct DHF D I Khan (Sheerana, Wana) 0 1 0 0 Agency 25‐Oct PUO Tharparkar Village Waqar Colony Noukot 0 1 0 0 village tohid abad, UC Arang, Tehsil 25‐Oct Measles Bajaur Agency 1 0 0 0 21‐Oct Scabies Badin Village Mitho Junejo, UC Haji Sawan 1 4 1 1 Utmankhel 25‐Oct Tetanus Sukkur New pind 0 1 0 0 23‐Oct Leishmani‐ Diamir DHQ Hospital Chilas 1 0 0 0

3500 2 7 3 Acute Respiratory Infection 11,210,361 (22%) 8 6 7 7 7 6 8 13 6

3000 6 6 8 8 Skin Diseases 5,413,322 (11%) 8 8 8 11 2500 11 8 11 8 11

2000 8 Acute Diarrhoea 4,802,069 (10%) 12 411 400 375 331 11 215 361 3375 3363 3354 192 1500 3329 26 3259 3259 3251 3250 3234 3215 153 3196 3156 3142 3120 3109 26 3058 3022 3021 2982 128 2935 2909 2785 105 2752 2745 2716 2671 46 2648

Bloody Diarrhoea 2595 81 2564

425,825 (1%) 2547

2532 2522 2514 2466 2450 58 2404 2349 1000 2322 2262 2255 2251 2199 2022 2021 1797 1680 1488 1463

500 1289 1215 1167 1158 1143 1130 999 1111 1113

Suspected Malaria 967 949 1073 3,095,925 (6%) 1067 879

854 0 3 5 7 Unexplained Fever 9

1,929,266 (4%) 11 33 35 37 39 41 43 45 47 49 51 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 ‐

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 Total Consultations 50,324,518 Wk Epi‐week Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response Post Flood 2010 2011 (up till wk 42) Current Week (43) Total Disease A O A O A O A O Acute Watery Diarrhoea 209 85 1186 520 33 5 1428 610 Acute Jaundice Syndrome 5 2 42 14 ‐ ‐ 47 16 Bloody Diarrhoea 10 1 85 15 1 ‐ 96 16 Dengue Fever 81 32 700 111 33 ‐ 814 143 Measles 48 6 1432 88 28 ‐ 1508 94 Pertussis 1 ‐ 229 57 6 2 236 59 NNT + Tetanus 5 ‐ 262 ‐ 17 ‐ 284 ‐ Malaria 12 7 93 62 6 3 111 72 Leishmaniasis 1 ‐ 185 27 10 ‐ 196 27 Others 75 11 489 55 6 1 570 67 Total 447 144 4703 949 140 11 5290 1104 Province Khyber Pakhtunkhwa: Figure-3: Trend of priority communicable diseases, province KPK • This week 658 health facilities from 19 districts reported to

DEWS with a total of 135,005 patients consultations. 50

45 • The proportional morbidity of AD is showing gradual de- 40 cline during the last 6 weeks after a consistent higher pro- 35 portion (16%) from week 35, 2011. 30 25

• 25 alerts were reported in this week, 12 were for Measles; 7 Percentage 20 15 for DHF, while 1 each for AWD, BD, CCHF, Diphtheria, 10 Leishmaniasis and Neonatal tetanus. 5

0 1 3 5 7 9

• 1 outbreak for CCHF was received and responded. 31 33 35 37 39 41 43 45 47 49 51 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43

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 AD BD ARI S. Malaria

Province Sindh: Figure-4: Trend of priority communicable diseases, province Sindh • This week 750 health centers from 22 districts reported to DEWS with a total of 329,253 patient consultations. 50

45 • In Sindh, AD cases reported were 27,855 (8%), proportional 40 morbidity lower by 1% as compared with last week. 35 30 25 60 alerts were reported from Sindh in this week: 30 were for • 20 Percentage AWD; 12 for Neonatal tetanus and tetanus; 5 for Measles, 4 15 each for DHF and Malaria, 2 for Pertussis, while 1 each for 10 Meningitis, Scabies and Unexplained fever. 5 0 1 3 5 7 9

31 33 35 37 39 41 43 45 47 49 51 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 9 outbreaks 5 for AWD and 2 each for Malaria and Pertussis 43

• 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 were received and responded. wk AD BD ARI S. Malaria

20 • 33 alerts were reported in this week from Punjab; 20 were Percentage 15 for DHF; 4 for Measles, 3 for Neonatal tetanus and tetanus; 10 3 for Pertussis, 2 for AWD; while 1 Leishmaniasis. 5 0 1 3 5 7 9

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

• No outbreak for any disease was received this week. 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 • In this week, 15 districts reported to DEWS from Balochistan province. 392 health centers reported a 50 AD BD ARI S. Malaria total of 61,992 patient consultations. 45 40 • AD reported in 5,764 (9%) of the total consultations, 35 same proportional morbidity as compared with the 30 last week. 25

• 19 alerts were reported in this week from Balochis- Percentage 20 tan, 7 for Leishmaniasis; 6 for Measles; 2 for Malaria; 15 while 1 each for DHF, Neonatal tetanus, Pertussis 10 5

and Typhoid. 0 1 3 5 7 9

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

• 1 outbreak for malaria was reported and responded 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 this week. wk Province Gilgit Baltistan:

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

45 • In this week, 79 health centers from 7 districts in AD BD ARI S. Malaria Gilgit Baltistan sent weekly report with a total of 40 20,616 patient consultations. 35 30 • ARI cases reported were 5,055 (25%), while Acute 25

Diarrhoea were 1,893 (9%). Percentage 20 15 • 1 alert for Leishmaniasis received and responded this 10 week. 5 0 14 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

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:

• In this week, reports were received from 112 health facilities from • This week 43 health facilities in 2 agencies reported from FATA, 10 districts with a total of 28,322 patient consultations. with a total of 6,327 patient consultations. • ARI cases reported were 5,832 (21%), while Acute diarrhoea re- • ARI cases reported were 1,459 (23%), while Acute diarrhoea was ported 965 (3%) cases. reported 532 cases (8%) • No alert for any disease was received this week. • Two alerts 1 each for DHF and Measles were received and responded this week.

45 AD BD ARI S. Malaria 40 AD BD ARI S. Malaria 40 35 30 30 25 20 20 15 Percentage Percentage 10 10 5 0 0 9 8 7 6

13 14 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 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 43 10 42 41 40 39

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 wk wk wk wk wk wk wk wk wk

Distribution of Wild Polio Virus cases Pakistan 2010 and 2011 Year 2010: The total number of polio cases reported in 2010 is 144 including 120 type‐1 cases and 24 type‐3 from 40 infected districts/towns/agencies.

Year 2011: As of 31 October, 2011, the total number of polio cases con‐ firmed by the laboratory is 136 (134=type‐1, and 2=type3) from 42 districts.

Cases 2010 Cases 2011 Province P1 P3 P1 P3 Punjab 6 1 2 - Sindh 26 1 28 - Khyber Pakhtunkhwa 19 5 12 - FATA 63 11 36 2 Balochistan 6 6 55 - AJK - - - - Gilgit‐Baltistan - - 1 - Islamabad - - - - Total 120 24 134 2 Focus on: Dengue fever, November 2011 Pakistan has been facing an epidemic of Dengue Fever causing to date 16,580 confirmed cases and 257 deaths reported in La‐ hore, and nearly 5000 cases and 60 deaths reported from the rest of the country.

While all the evidence has not been confirmed, expert entomologists believe that early rains and warmer weather in Lahore gave Aedes mosquito population a head start this year, Reported Dengue Fever: Suspected, Confirmed and Death Cases, explaining why Dengue Fever cases started to be re‐ Pakistan 2006 to 28 Oct 2011 ported in August, two months before the usual trans‐ 20,000

mission season. Expert clinicians believe that the virus 21,590 also was a new serotype for the Lahorians, explaining why more cases were hospitalized and more patients 15,000 died of severe Dengue Hemorrhagic Fever than in the past five years. 10,000

11,024

WHO Pakistan has provided and is continuing to pro‐ 5,000

vide technical assistance, standard guidelines, and ca‐

316 15,901 1,931 1,226 2,469 1,085 480,054 2,792 1,940 pacity building in planning and implementation in all 4,961 41 40 2304 18 17 13 ‐ three areas of prevention and control of Dengue Fever 2006 2007 2008 2009 2010 2011 – Vector Control, Case Management, and Community Suspected cases Lab confirmed cases Deaths Awareness ‐ to all three provinces with Dengue cases – Punjab, Sindh, and Khyber Pakhtunkhwa.

Vector Control

WHO vector control specialist has provided technical advice and guidelines to the Provincial Health Departments to initiate the implementation of the following: • Notification of provincial level task force for dengue control in the province. • Constitution of district level dengue control groups • Procurement of insecticides (adulticides and larvicides) from WHOPES prequalified manufacturers along with concrete plans for vector control targeting both adult mosquitoes and the larvae; • Training of field staff in the use of equipments and application of insecticides. • Prioritization of major breeding sites in and around houses and open spaces and tire yards and cemeteries.

Clinical Case Management

• From 20 October – 3 November 2011, WHO fielded a mission by experts in Dengue case management from the WHO Collaboration Centre in Thailand. They conducted a series of workshops in Sindh, Punjab, and Islamabad Capital Territory for the training of

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 Epidemiological Bulletin: DEWS, Pakistan, Week no. 43 (21 to 27 October, 2011) nurses and doctors in treatment of hospitalized cases of dengue fever. Their recommendations include: • Establishment of fever counters in all hospitals with trained staff round the clock. • Using low wbc and low platelets as one criteria for admission. • Providing clear patient education about warning signs if patient is sent home. • Careful monitoring of admitted patients with vital signs, Hematocrit and measuring urine output every six hours. • Using calculated amount of fluids over 48 hours; no use of prophylactic platelet transfusions.

Following evidence‐based guidelines on clinical case management of patients including management of acidosis, hypocalce‐ mia, bleeding, and blood sugar fluctuations.

Community Awareness

Community awareness helps the control of dengue fever in two ways – the community can remove vector breeding sites and prevent mosquito bites, and the patients can be brought to the hospital at the right time when the community knows the warning signs. WHO adapted a globally tested Teachers’ Resource Manual on Dengue for use in Pakistan, translated it from English to Urdu and printed 10,000 copies for use in Pakistan schools to train school teachers to mobilize students in elimination of Aedes breeding sites from houses and workplaces. Three hundred teachers have been trained in using this resource in Karachi, and 33,000 students have been mobilized to eliminate mosquito breeding sites in and around their homes. WHO and CDA col‐ laborated in training 60 teacher trainers on 2 November 2011 in Islamabad.