Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 3, Issue 27, Wednesday 27 June 2012

Highlights Figure‐1: 86 districts reported to DEWS in week 25, 2012. Epidemiological week no. 25 (17 - 23 June 2012)

• Measles: 173 alerts investigated, responding to 27 outbreaks involving 418 measles cases.

• CCHF: In 2012, total of 21 confirmed cases have been reported throughout the country. Most of the cases (12) directly reported from Balochistan, 4 each KPK and Sindh and 1 from Punjab.

• 2 AWD outbreaks identified in 2 districts of Sindh and responded few confirmed cases in localities.

• Acute diarrhoea: Trend of acute diarrhoea is stable in all provinces. Districts in Sindh and Khy‐ ber Pakhtunkhwa are investigating alerts for acute watery diarrhoea/suspected cholera.

• No new polio case was reported; As of 25 June Priority diseases 2012, Pakistan has reported a total of 22 polio Cumulative number of selected health events reported in under surveillance Epi‐week 1 ‐ 25 (1 Jan ‐ 23 June 2012) cases (19 type‐1, 2 type‐3 and 1 mixture type‐1 in DEWS

and 3) from 13 districts/tribal agencies. Pneumonia Disease # of Cases Percentage Acute Watery Diarrhoea Bloody diarrhoea Acute diarrhoea 1,269,435 8% • 86 districts have reported in week 25, 2012, Other Acute Diarrhoea Suspected Enteric/Typhoid Fever Bloody diarrhoea 80,391 0.48% Please see map. 2,260 health facilities have Suspected Malaria shared weekly data to the Disease Early Warning Suspected Meningitis ARI 3,320,196 20% System (DEWS) in this week Suspected Dengue fever Suspected Viral Hemorrhagic Fever Suspected Measles S. Malaria 755,999 5% Suspected Diphtheria • 812,072 patients’ consultations were reported in Suspected Pertussis Skin Diseases 736,469 4% week 25 compared to 833,414 consultations Suspected Acute Viral Hepatitis Neonatal Tetanus Unexplained fever 581,072 3% reported on week 24, 2012. Acute Flaccid Paralysis Scabies Total (All consultations) 16,721,988 Cutaneous Leishmaniasis Others Major health events reported during the Epi‐week ‐ 25 (17 ‐ 23 June 2012) Figure‐2: Weekly trend of Acute diarrhoea in Pakistan Week‐1, 2011 to week‐25, 2012. Disease # of Cases Percentage 20 Acute diarrhoea 75,793 9% 2011 2012 15 Bloody diarrhoea 4,127 0.51%

ARI 118,507 15% 10 S. Malaria 45,515 6% Percentage 5 Skin Diseases 36,707 5%

0 Unexplained fever 29,687 4% 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epi‐week Total (All consultations) 812,072

• The graph (Figure‐1) shows the comparison of weekly trend of Acute diarrhoea as proportional morbidity (percentage of cases out of total consultations) reported to DEWS each week in year 2011 and 2012.

• The overall weekly trend of acute diarrhoea remained stable during the last 4 week, however in KP the weekly propor‐

tional morbidity of AD shows an upward trend in all the provinces.

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 Weekly Bulletin: DEWS, Pakistan, Week no. 25 (17 to 23 June 2012) Current week's (25/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken Muslim Bagh town 12 suspected cases of Leishmaniasis were reported. Patients were investigated and found lesions on Leishma‐ 21‐Jun Balochistan Killa Saifullah area, Tehsil 0 6 0 6 face, nose, arms and legs. No travel history have seen in these patient. Treatment as per WHO protocol niasis Muslim Bagh was given.

Leishma‐ Village Kolak, UC 6 suspected cases of Leishmaniasis were reported. Patients have history of disease since one year but no 19‐Jun Balochistan Pishin 0 0 0 6 niasis Oramzai improvement after treatment. Treatment has provided to the patients.

Mungli, UC Par‐ 21 cases of malaria were reported and tested for confirmation.11 found positive (SPR=52%) of P.F=2 19‐Jun Malaria Balochistan Awaran war, Tehsil Mash‐ 2 6 5 8 (FR=55%), P. V=5, Mix=4. Anti malarial treatment provided. Information shared with DHO and requested kai for bed nets and fogging in the locality. BHU Padag, Killi 30 cases of suspected malaria were reported. 30 slides were tested where 19 verified positive (SPR=63%) 19‐Jun Malaria Balochistan Chagai Mohammad Jhan 3 5 10 12 of pf=8 (FR=42%),pv=11. RDTs and antimalarial medicines were provided. Bed nets not available in the Amuri, UC Padag district. 17 cases for suspected malaria were reported. 12 slides were tested using RDTs and all verified positive Goth Mohammd 18‐Jun Malaria Balochistan Jaffarabad 3 5 3 6 (SPR 100%). Antimalarial drug provided for treatment. Bed nets and insecticides not available in the Amin Kanadrani district. Suspected cases of malaria were reported from village. 21 slides tested out of which 14 were found Village Khichi, UC 22‐Jun Malaria Balochistan Jhal Magsi 4 12 3 16 positive (SPR=67%) of pf=7 (FR=48%), pv=4, Mix=3. Information shared with DHMT and requested to take Barija necessary action. ACTs supplied for proper treatment of the patients.

DHQ Hospital, 60 cases of Malaria were reported. 25 slides tested where 13 were positive (SPR=52%) pf=7 (FR=54%), 18‐Jun Malaria Balochistan Lasbela 12 9 15 24 Tehsil Uthal pv=6. Patients were treated with antimalarial drugs. Information shared with DHO for necessary action.

2 suspected cases of measles were reported. During field investigation 4 more suspected cases were Jamadar Ayoob found. 23 children were assessed for routine immunization out of which 3 (13%) were not vaccinated 19‐Jun Measles Balochistan Kech 1 0 3 2 ward, UC Absar against any antigen. Health education session conducted regarding importance of routine immunization. Information shared with DHO. 2 suspected cases of measles were reported through community. During field investigation 3 more Suthkalbazaar, UC suspected cases were found.Vit A drops were given to the cases and health education imparted in the 20‐Jun Measles Balochistan Kech 2 0 3 0 Koshkalat community regarding routine immunization. 58 children were assessed for routine immunization out of which 5 were found totally unvaccinated against measles. Information shared with DHO. An alert of suspected measles was reported. On field investigation 12 more suspected cases were found. Baleena Rodeni, Vit A drops were given to the cases. Cases were assessed for the routine immunization but none of child 17‐Jun Measles Balochistan Khuzdar UC and Tehsil 6 2 1 4 found vaccinated against measles. Information shared with DHMT and requested for intensified out‐ Surab reach activity in the locality. Health education imparted regarding the routine immunization. 2 blood samples were taken for confirmation. Alert reported through LHW. investigation was done. Patients were presented with typical signs & symp‐ toms and had no immunization history. Vit A provided to all suspects. One blood sample was collected Sat Marlla, UC and sent to NIH. community was told about routine immunization importance and requested take their 18‐Jun Measles Balochistan Khuzdar Zereena Kattan, 1 2 3 1 Tehsil Khuzdar children to nearby EPI centre for routine immunization. Information shared with DHO and EPI team. 9 children less then 5 years were checked, 2 confirmed through EPI card while others partially immunized. Measles one dose coverage was 37.5% while second dose was zero. 6 suspected cases of measles were reported. Vit A drops provided. None of the case were found vacci‐ Killi Alozai, UC nated against measles. Immunization status of the community was not satisfactory because outreach 20‐Jun Measles Balochistan Killa Saifullah Akhterzai, Tehsil 2 0 3 1 Killa Saifullah activity has not been done due to compromised security in the area. DHO was informed about the situa‐ tion. An alert of measles were reported. During field investigation, 4 more suspected cases were found. Vit A Mohalla Shapatan, 22‐Jun Measles Balochistan Panjgur 4 0 1 0 drops were given to the cases. Health education imparted. 5 children were assessed for routine immuni‐ UC Chitkan zation out of which 4 (80%) were found vaccinated against measles. 4 suspected cases and 1 death due to measles were reported. All the cases were found unvaccinated. Vit Killi samkhail, UC A drops provided and health education imparted. 35 children were checked for routine immunization 18‐Jun Measles Balochistan Pishin 4 1 0 0 Saranan and all of them were found unvaccinated against measles. Vaccination done on spot by the support of EPI team. An outbreak of measles was reported from HF. Vit A drops were provided and health education was Village killi Baran‐ imparted in the community. During house to house survey, 73 children were assessed for routine immu‐ 21‐Jun Measles Balochistan Pishin 8 3 0 0 zai, UC Gulistan. nization and none of them were found vaccinated against measles. Vaccinated these children on spot by the support of EPI team. An alert of suspected measles were reported. On active search 4 more suspected cases were found. None of the case were found vaccinated against measles. Vit A drops provided to all cases. Blood sample 17‐Jun Measles Balochistan Ziarat Mana, UC Zindra 1 3 1 0 was collected and sent to NIH for lab confirmation. Health education imparted. 9 children were assessed for routine immunization where 2 children found completely vaccinated while rest of them were par‐ tially vaccinated. 3 children were found vaccinated with Measles 1 (37%). An alert of suspected measles was reported. On active search 6 more suspected cases were found. Cases were found unvaccinated. Vitamin A drops were given to the cases. Health education imparted. Matter 19‐Jun Measles Balochistan Ziarat Pasara, UC Sinjawi 3 1 2 1 was discussed with DHMT and EPI inchrage. 65 children <5 years were assessed for routine immunization out of which 40 were found totally unvaccinated. Follow up planned. An alert of suspected Pertussis was reported. During field investigation 7 suspected cases were found. Killi Zangi Abad, 22‐Jun Pertussis Balochistan Nushki 3 4 0 0 Erythromycin tabs and syrups provided to the cases and contacts. Health education imparted. Informed UC Ahmed Waal DHO 4 suspected cases of measles were reported. On active search 5 more suspected cases were found. Blood samples were collected and sent to NIH for lab confirmation. Vit A drops provided and health Village Serai‐Haji Bajaur education imparted. 39 children were assessed for routine immunization out of which 32 (82%)were 20‐Jun Measles FATA lawang, Tehsil 3 1 3 2 Agency Khar found unvaccinated against measles,17 (43%) for BCG & Penta‐1 to 3 whereas rest of the children were found totally unvaccinated. 150 children were vaccinated against measles. Agency Surgeon and epidemic response team were informed about the situation and necessary actions were taken.

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]. 02 Weekly Bulletin: DEWS, Pakistan, Week no. 25 (17 to 23 June 2012) Cont’d current week's (25/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken An outbreak of 6 suspected cases of measles was found on active surveillance. Vit A drops provided and health education Moh‐ imparted. During field investigation, 95 children were assessed for routine immunization out of which 81 (85%) were found 21‐Jun Measles FATA mand Daro bazar‐Anmbar 2 0 1 3 unvaccinated against measles. Agency Surgeon & EPI Coordinator informed, 84 children were vaccinated against Measles after Agency the intensified outreach vaccination activity in the area.

Khyber 6 suspected cases of measles from the same family were found on active surveillance visit to hospital. Vit A drops provided. Abbotta‐ Murkalan, Nelay p, 20‐Jun Measles Pakhtunk‐ 1 1 2 2 During field investigation 10 children were assessed for routine immunization out of which 3 were found totally unvaccinated. bad Mangalar hwa Vaccination was done on the spot by the support of EPI. Khyber An alert of suspected measles was reported. On active search 4 more suspected cases were found. Vitamin A drops were given Village Qasim, UC 18‐Jun Measles Pakhtunk‐ Mardan 0 3 2 0 to the cases.17 children were assessed for routine immunization but none of the patient were found vaccinated against mea‐ Toru, Tehsil Mardan hwa sles. Health education session conducted, EDO‐H Focal person & EPI Coordinator were informed.

3 deaths due to suspected measles were reported. During active surveillance 4 more suspected cases were found. Vitamin A Khyber drops provided. The whole of the village has been left unvaccinated for the past 09yrs; reason being life threats from the local 18‐Jun Measles Pakhtunk‐ Shangla Mol Sar UC Butyal 3 1 1 2 community to EPI technician. DEWS‐Team along with DOH gathered the elders and managed to vaccinate 62 children for hwa Measles 01. Blood samples were taken from 02 children and sent to NIH for further analysis. Follow up planned.

Khyber An alert of suspected measles was reported. During field investigation 9 more suspected cases were found in the same locality. Private Clinic, Bacha 18‐Jun Measles Pakhtunk‐ Swabi 5 1 4 1 EPI Cards were not available with the cases and parents were not able to recall about the vaccination. Vit.A drops provided, Saib Banda, Dand hwa health education imparted, EDO H and EPI coordinator Informed. Intensified outreach vaccination activity planned. Village Haji Sher An alert of AWD was reported. On active search 6 more cases were found, Hand pump was the source of water. Aqua tabs, Zinc Tando 22‐Jun AWD Sindh Muhammad, taluka 1 3 1 2 tabs and ORS were distributed, health education imparted, EDOH informed, 1 Stool and 2 water samples collected for lab Allahyar Chambar confirmation. Peerzada Muhalla, 3 AWD cases were reported from Muhalla Peerzada, Farash Goth, active search for more case was carried out, Aqua tabs, 12‐Jun AWD Sindh Sukkur Farash goth, UC 0 2 0 1 Jerry cans, Life straw filters and IEC Material distributed, health education imparted, DHMT informed, 1 stool sample found Arain positive for Cholera, 3 water sample also collected result awaited. Hashim Wakeel An alert of suspected measles was reported. During active surveillance 5 more suspected cases were found, Vitamin (A) drops 18‐Jun Measles Sindh Dadu Muhalla, taluka K.N 1 4 1 0 were provided, health education imparted. 7 children were assessed for routine immunization where 4(64%) were found Shah vaccinated for measles1 and 3 (57%) for measles 2. THO and EDOH informed. 2 Blood samples collected for lab testing.

AWD case was reported with severe dehydration, vomiting and Fever, during field investigation 1 more AWD case was found, Gulshan‐e‐Munir 20‐Jun AWD Sindh Dadu 0 1 0 1 Aqua tabs, Zinc tabs and ORS distributed, health education imparted, EDOH, THO and DSC informed, 1 Stool sample was colony, city Dadu collected and found positive for Cholera, 2 water sample also collected result awaited.

An alert of suspected measles was reported, On active search 5 more suspected cases were found. Vitamin (A) drops were Bhittai Muhalla, city given to the cases, health education imparted. Routine immunization status were assessed for 6 children where 4(63%) found 19‐Jun Measles Sindh Dadu 3 1 2 0 and taluka Mehar vaccinated with measles1 and 3(56%) with measles 2. 3 Blood samples were collected for lab confirmation. THO and EDOH informed. Outreach vaccination activity planned.

An alert of suspected measles was reported. During field investigation 4 more suspected cases were found. Vitamin (A) drops Village Alam Khan provided, health education imparted. Routine immunization status were assessed for 7 children where measles1= 3(47%) and 21‐Jun Measles Sindh Dadu Jatoi, UC Murada‐ 2 3 0 0 Measles2= 2(29%).EDOH, THO and DSC informed and request outreach vaccination activity in the area. 2 Blood samples col‐ bad, taluka Dadu lected for lab confirmation.

Village Dato khan 11 suspected cases of Measles were detected on active surveillance visit. Vitamin (A) drops provided, health education im‐ 22‐Jun Measles Sindh Dadu Rodhani, UC Chinni, 2 3 4 2 parted. Vaccination status were assessed for 11 children where Measles1= 4(33%), Measles2=2 (21%). EDOH, THO and DSC taluka Johi informed. 2 Blood samples collected for lab testing.

An alert of suspected measles was notified. During field investigation 4 more suspected cases were found, vitamin (A) drops Village Huzoor Bux Kash‐ provided, health education imparted. Vaccination status of 12 children were assessed where 3(24%) children had BCG scar and 21‐Jun Measles Sindh kosh, UC Gheehal 1 0 3 1 more rest of the children were found totally unvaccinated, information shared with DHMT. 4 Blood samples collected for lab confir‐ pur mation.

An alert of suspected Measles was cross notified from Sukkur. During field investigation 18 more suspected cases were found, Village Dau, UC vitamin (A) drops provided, 5 blood samples collected for lab confirmation,18 children were assessed for their routine immuni‐ 19‐Jun Measles Sindh Khairpur Therhi, taluka 10 1 7 0 zation where none of the child was found vaccinated against measles, information shared with DHMT. Outreach vaccination Khairpur activity planned.

An alert of suspected measles was notified. During field investigation total 5 suspected cases including 1 death due to measles Village Ghulam complications were found. Vitamin (A) drops provided to the cases, 2 blood samples collected and sent to NIH for lab confirma‐ 21‐Jun Measles Sindh Khairpur Muhammad Khushk, 3 1 1 0 tion. 10 children were assessed for routine immunization where none of the child found vaccinated against measles. Informa‐ UC Nizamani tion shared with DHMT and outreach vaccination activity planned.

An alert of suspected measles was reported. During field investigation 4 more suspected cases were found, Vitamin (A) drops Qambar Fateh Mohammad provided, health education imparted. Vaccination status of 10 children were assessed where BCG=3(30%), Penta1=3(30%), 20‐Jun Measles Sindh Shahdad‐Supro , UC Dostli , 3 0 1 1 Penta2=2(20%), Penta3=1(10%), Measles1=1(10%), Measles2=(0%), DHMT informed and request for outreach vaccination kot Taulka Kambar activity in the area. 3 Blood samples were collected for lab confirmation.

An alert of suspected Measles was cross notified from Larkana. During field investigation total 9 suspected cases were found, 6 Village sher dil Shikar‐ blood samples were collected for lab confirmation, Vitamin (A) drops were given to the cases, health education imparted about 20‐Jun Measles Sindh khakhrani, UC 6 0 3 0 pur the importance of routine immunization. 25 children were assessed for routine immunization where BCG=6(24%) and no waryaso history for other antigens. Information shared with DHMT .

An alert of suspected measles was notified. During field investigation 6 more suspected post measles cases were found. Cluster Village Ali Muham‐ of 30 houses were taken where 21 children were assessed for routine immunization but none of the child were found vacci‐ 22‐Jun Measles Sindh Thatta mad Mirbahar, UC 0 5 1 1 nated. Health education imparted, Vitamin (A) drops provided, 4 blood samples collected for lab confirmation. Informed DHO, Kalri THO & TSV. Outreach vaccination activity planned.

An alert of suspected Pertussis was reported. During field investigation total 9 suspected cases were found. Health education Naushah Village Latif Arain, imparted. Erythromycin tabs and syrups provided to the cases and contacts, 12 children were assessed for routine immuniza‐ 22‐Jun Pertussis Sindh 0 0 6 3 ro feroze UC DK Mari tion where BCG= 9(75%), penta1=7(58%), penta‐2=6(50%),penta‐3=5(41%), Measles‐1=3(25%),Measles‐2=(0%). Information shared with DHMT.

An alert of suspected Pertussis was reported. During field investigation 5 more suspected cases were found. 03 Nasopharyn‐ Village Roshanabad, geal swabs were collected for lab confirmation, Erythromycin tabs and syrups provided to the cases and contacts. Health 20‐Jun Pertussis Sindh Sukkur UC patini, taluka 3 1 1 1 education imparted. 15 children were assessed for routine immunization where 12 (80%)children were found vaccinated Rohri against BCG, while no information provided by parents regarding Pentavalent vaccine. Information shared with DHMT.

Village Burkhio, UC An alert of suspected Pertussis was reported. During field investigation total 7 suspected cases were found, Erythromycin tabs Thar‐ 20‐Jun Pertussis Sindh Mithrio Charan, 5 0 1 1 and Syps were given to the cases and contacts, health education imparted, vaccination status were assessed but none of the parkar taluka Chachro child were found vaccinated, EDOH informed. 2 Nasopharyngeal swabs were collected for lab confirmation.

50 250000

200000 40 AWD

CCHF 150000 cases

DF of

# alerts 100000

of Leishmaniasis

# 20 Malaria 50000 Measles 10 Pertussis 0 < 1 yr 1‐4 yr 5‐14 yr 15‐50 yr 50 + yr Male 25124 65859 83478 128679 57381 0 Female 24711 62741 86901 210793 66405 Wk‐22 Wk‐23 Wk‐24 Wk‐25 Province Khyber Pakhtunkhwa: 456 health facilities from 18 districts of Khyber Pakhtunkhwa reported to DEWS with a total of 130,529 patients consultations reported in week 25, 2012. Total 70 alerts were received while 4 outbreaks were identified and appropriate measures were taken. Altogether 52 alerts for Measles; 14 each for Leishma‐ niasis; while 1 each for AWD, AFP, Pertussis and Typhoid. Acute diarrhoea shows a slightly upward trend in KP.

Figure-5: Trend of acute diarrhoea diseases, province KPK Figure-6: Number of alerts received and responded week 22 - 25, 2012, province KPK

20 50 AWD 40 15 CCHF DF 30

10 ale rts

Leishmaniasis of 20 # Percentage Malaria 5 10 Measles 2011 2012 Pertussis 0 0 13579111315171921232527293133353739414345474951 Wk‐22 Wk‐23 Wk‐24 Wk‐25 Province Sindh: 738 health facilities from 23 districts in province Sindh were reported to DEWS with a total of 357,815 patients consultations in week 25, 2012. Total 93 alerts received while 14 outbreaks were identified and appropriate measure were taken. Altogether 60 alerts for Measles; 16 for AWD; 6 for Typhoid; 4 for Pertussis; 3 for NNt; 2 for AFp; while 1 each for AJS and Scabies. The AD shows a steady trend in Sindh.

Figure-7: Trend of trend of acute diarrhoea, province Sindh Figure-8: Number of alerts received and responded week 22 - 25, 2012, province Sindh

20 50 2011 2012 40 15 AWD 30

10 ale rts Malaria

# 20 Percentage Measles 5 10 Pertussis

0 1 3 5 7 9 111315171921232527293133353739414345474951 0 Epi‐week Wk‐22 Wk‐23 Wk‐24 Wk‐25 Province Punjab: 402 health facilities from 8 districts in province Punjab reported to DEWS with a total of 194,456 patients consultations in week 25, 2012. Total 54 alerts were received and appropriate measures were taken. Altogether 30 alerts for Measles; 9 for Acute diarrhoea; 5 for Typhoid; 4 for AWD; while 1 each for AFP, AJS, ARI, Bloody diarrhoea, Leishmaniasis and Scabies. A slightly decline noted in the proportion of AD consultation in Punjab during the last few week.

Figure-9: Trend of acute diarrhoea, province Punjab Figure-10: Number of alerts received and responded week 22 - 25, 2012, province Punjab

20 50 2011 2012 40 15 AWD

30 DF 10 alerts Leishmaniasis of

20 #

Percentage 5 Malaria 10 Measles 0 1 3 5 7 9 111315171921232527293133353739414345474951 0 Epi‐week Wk‐22 Wk‐23 Wk‐24 Wk‐25

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. 25 (17 to 23 June 2012) Province Balochistan: 490 health facilities from 23 districts in province Balochistan reported to DEWS with a total of 78,219 patients consultations in week 25, 2012. Total 49 alerts reported while 19 outbreaks were identified and appropriate measures were taken in week 25, 2012. Altogether 26 alerts for Measles; 7 each for Leishmaniasis and Malaria; 2 each for CCHF and Typhoid; while 1 each for Acute diarrhoea, AFP, AWD, Pertussis and Scabies..

Figure-11: Trend of acute diarrhoea, province Balochistan Figure-12: Number of alerts received and responded week 22 - 25, 2012, province Ba-

20 50 2011 2012 AWD 40 15 CCHF 30 10 Leishmaniasis alerts

Percentage

of 20 Malaria

5 # Measles 10 Pertussis 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 0 Epi‐week Wk‐22 Wk‐23 Wk‐24 Wk‐25 Province Gilgit Baltistan: 30 health facilities from 4 districts in Gilgit Baltistan reported to DEWS with a total of 13,080 patients consultations in week 25, 2012. No alerts were reported in week 25, 2012. AD showing upward trend.

Figure-13: Trend of acute diarrhoea, province Gilgit Baltistan Figure-14: Number of alerts received and responded week 22 - 25, 2012, Gilgit Baltistan

35 50 2011 2012 30 40 Leishmaniasis 25 Measles 20 30 15 Pertussis laerts 20 of

10 # Percentage 5 10 0 13579111315171921232527293133353739414345474951 0 Epi‐week Wk‐22 Wk‐23 Wk‐24 Wk‐25 FATA: 53 health facilities from 3 agencies in FATA reported to DEWS with a total of 15,066 patients consultations in week 25, 2012. Total 5 alerts for Measles were reported in week 25, 2012 and appropriated measures were taken.

Figure-15: Trend of acute diarrhoea, FATA Figure-16: Number of alerts received and responded week 22 - 25, 2012, FATA

20 50 2011 2012 40 15 Leishmaniasis

30 Measles alerts

10 of

# 20

Percentage 5 10

0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 0 Epi‐week Wk‐22 Wk‐23 Wk‐24 Wk‐25 State of Azad Jammu and Kashmir: 78 health facilities from 6 districts in AJ&K reported to DEWS with a total of 18,410 patients consultations in week 25, 2012. No alerts reported in week 25, 2012.

Figure-17: Trend of acute diarrhoea, AJ&K Figure-18: Number of alerts received and responded week 24 - 25, 2012, AJ&K

20 50 2011 2012 40 15 Leishmaniasis

30 Measles 10 alerts

20 Percentage # 5 10

0 13579111315171921232527293133353739414345474951 0 Epi‐week Wk‐22 Wk‐23 Wk‐24 Wk‐25

Bloody diarrhoea 98 20 74 5 1 0 75 5

Dengue fever 785 111 53 2 0 0 53 2

Measles 1708 110 2707 248 173 27 2880 275

Pertussis 287 81 269 109 6 4 275 113 NNT + tetanus 399 0 273 3 0 276 0 Malaria 131 88 66 40 7 5 73 45 Leishmaniasis 298 33 463 39 22 2 485 41 Others 645 69 765 61 35 0 800 61 Total 5752 1072 4947 528 271 39 5218 567

Distribution of Wild Polio Virus cases Pakistan 2011 and 2012

• In week 24, 2012 no new type‐1 polio case was reported.

• As of 25th June 2012, Pakistan has reported a total of 22 polio cases (19 type‐1, 2 type‐3 & 1 mixture type‐1 & 3) from 13 districts/tribal agencies.

Cases 2011 Cases 2012 Province P1 P3 P1 P3 P1+P3 Punjab 9 ‐ 2 ‐ ‐ Sindh 33 ‐ 3 ‐ ‐ Khyber Pakhtunkhwa 23 ‐ 4 ‐ ‐ FATA 57 2 8 2 1 Balochistan 73 ‐ 2 ‐ ‐ AJ&K ‐ ‐ ‐ ‐ ‐ Gilgit‐Baltistan 1 ‐ ‐ ‐ ‐ Islamabad ‐ ‐ ‐ ‐ ‐ Total 196 2 19 2 1

Follow up of CCHF, Measles and Dengue

CCHF: CCHF is a serious viral hemorrhagic fever with up to 50% case fatality rate, caused by an RNA virus of family Bunyaviridae, genus Nairovirus, carried by Hyalomma species of ticks. Human beings become infected by tick bites or crushing the ticks, which are usually found on sheep, cattle, goats or camels, and their slaughtered skins. They may also be exposed to the virus in blood or tissues of a viremic animal during its slaughter and butchering; or by contact with infected blood or secretions of acute human cases in home or hospital setting.

In Pakistan, the first known CCHF outbreak occurred Number of CCHF cases (week 1 to 25, 2012), Pakistan during January 1976 at Rawalpindi General Hospital (RGH) 10 among a surgical team. After above scenario, outbreaks were Cases Positive Deaths 8 reported mostly from Balochistan province during 1978, 1987, 1994, 1995 and 1999 involving 4 to 9 cases per year. 6

4 In 2012, total of 28 suspected cases have been re‐ Numbers ported throughout the country with 21 confirmed to date and 2

6 deaths; (CFR is 30%). 17 cases have been reported from 0 12345678910111213141516171819202122232425 Balochistan; 4 each from KP and Sindh and 3 from Punjab. Epi‐week Chart at right illustrates current situation of CCHF cases in 2012.

Approximately all the cases have contact history with animal trading/handling, tick bite, contact with patient, tannery worker, butcher/animals slaughtering, a traditional practice of wearing fresh animal skin (posti) to treatment ailment. These animals and their skins have continuous movement!intra Pakistan and between neighboring countries (Afghanistan and Iran).

Measles: As of 23 June 2012, more measles cases and deaths have been reported in Pakistan than in 12 months last year. Table 1 updates the situation of measles in 2012 up to 23 June; and table 2 illustrates about the alerts and outbreaks in week 25 (17‐ 23 June, 2012).

Table‐1 2012 (Week 1 ‐ 25) Table‐2 Epi ‐ week 25, 2012 Province # of Alerts # of Outbreaks # of Cases # of Deaths Province # of Alerts # of Outbreaks # of Cases # of Deaths

AJ&K 71 4 115 0 AJ&K 0 0 0 0 Balochistan 239 59 1052 9 Balochistan 26 11 113 1

FATA 103 17 299 4 FATA 5 2 20 0

Gilgit Baltistan 14 0 15 0 Gilgit Baltistan 0 0 0 0

ICT 10 2 38 0 ICT 0 0 0 0

Khyber Pakhtunk‐ Khyber Pakhtunk‐ 1164 60 2116 29 52 4 96 5 hwa hwa Punjab 400 21 691 13 Punjab 30 0 30 1

Sindh 879 112 2204 38 Sindh 60 10 159 2 Total 2880 275 6530 93 Total 173 27 418 9

As it is shown in the above table that majority of the measles cases have been reported from Sindh and Khyber Pakhtunkhwa provinces. Both of these provinces have announced the EPI facilities will be providing measles vaccine twice a week for all children under age 5.

Dengue:

Weekly trend of positive dengue cases, week 1 to 25, 2012 The chart at right show the weekly number of con‐ 10 Punjab Sindh firmed Dengue cases reported by surveillance focal 8 8 8 points from the Departments of Health in Sindh and 7 7 Punjab in 2012. Total number of confirmed dengue 6 6 6 6 cases to date in 2012 is 67 in Sindh and 72 in Punjab. 5 5 5 55 cases 4 4 4 4 4 of

# 4 Month of peak incidence in 2010 was November 3 33 3 333 while peak incidence in 2011 was in September and 2 2 2 2 2 2 2 October. 1 1 11 1 1 11 1 111 1 0000 0 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Epi week

Malaria slide positivity rate, Week 25, 2012 Malaria: 60

50 The chart at right shows the malaria slide positivity rate and Falciparum rate reported in week 40 25, 2012. Total number of malaria cases tested in 30

week 25, 2012 is 18995, out of which 4030 were Percentage 20 found positive. 10

0 Balochistan Sindh KP FATA Punjab GB AJK ICT SPR 22.33 21.97 25.55 24.85 12.64 0 0 0 F. R 51.23 24.17 16.9 0.69 5.78 0 0 0