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Home , Bagh District, Muzaffarabad, Muzaffarabad District

Epidemiological Week No. 49 (2-8 Dec 2006) 14 Dec 06/ Vol. 55/ DEWS 2006-49

Reporting Units...... 2 Total number of consultations ...... 2 DEWS Data, Epidemiological Week N0 49 2006...... 3 DEWS Data, Monthly Summary (Epidemiological Weeks N0 46-49) ...... 4 Acute Watery Diarrhoea ...... 5 Bloody Diarrhoea...... 6 Acute Jaundice Syndrome...... 6 Malaria ...... 7 Measles ...... 7 Acute Respiratory Infection ...... 8 Other Reportable Diseases and Conditions ...... 8 Outbreak Alert and Response ...... 9 Number of reported cases and deaths per District, AJK

...... 10 in Winter Number of reported cases and deaths per District, Picture by Shahzad Alam Khan NWFP ...... 11

ƒ In the past month (Epidemiological ƒ In week 49, there were 2 deaths weeks 46-49 inclusive), 143,111 health reported from acute Watery diarrhoea events under surveillance were reported One from and one including 82 deaths from district. ƒ Seven suspected cases of meningitis ƒ This week, there were 292 reporting reported this week, all cases were from units contributing to the report. Muzaffarabad district

ƒ In week 49, Total 66,429 consultations ƒ In this week 49, Malaria cases were were reported, with 15 deaths increased by 28% (from 636 to 455 cases).

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

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

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

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

The WMMR is published by the World Health Organization (WHO), Health Emergency Operation Centre, House #6, Street #20, F-7/2, , Pakistan For More Information, please contact: Dorcas Taylor, Epidemiologist, WHO/EHA/Pakistan; [email protected] or Dr. Birjees Mazher Kazi, Chief, Public Health Laboratories Division, NIH MOH; [email protected] or WHO Webpage: http://www.whopak.org/disaster WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

Reporting Units

The number of sites able to report decreased by 30 this week and the reporting timeliness of the DEWS systems has also decreased at the current Epidemiological week compared with week 48. See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 11 Nov - 8 Dec 2006. Reporting Health Facilities Area Population 11-17 Nov 18-24 Nov 25Nov-1Dec 2-8 Dec Week 46 Week 47 Week 48 Week 49 Muzaffarabad 894,364 98 73 82 80 Bagh 452,532 44 46 46 44 633,712 64 66 66 67 Mansehra / 1,154,804 65 66 67 58 / Shangla 592,256 42 40 42 43 Total 3,727,668 313(96%) 322(99%) 303(93%) 292(90%)

Total number of consultations

In week 49, there was a decrease in the number of reporting sites, AND number of consultations also decreased to 66,642. The highest number of consultations by district was in Muzaffarabad, with 19,231 and the lowest was in Battagram, at 5,623. The weather in week 49 was cold and rainy or snowy throughout most of the affected districts, which may have contributed to the decline in consultations.

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

250 150000

200

100000 150

100 50000

50

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

Week

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 – 8 Dec 2006.

2 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

DEWS Data, Epidemiological Week No. 49, 2006

Between 1-8 Dec 2006, 66,429 consultations were reported through DEWS. Overall, 28% (18,652) were due to acute respiratory infections (ARI), 6% (3,793) due to acute watery diarrhoea (AWD), 7% (4,510) due to fever of unknown origin (FUO), and 5% (3,073) due to injuries (INJ). ARI accounted for 36% and 25% of consultations in the less than 5 years old and 5 or more years old respectively. All other reportable conditions each represented less than 1% of the total consultations in week 48.

AWD AWD AWD 4% ARI 6% 10% ARI 25% 28% ARI 36%

FUO OTH* 7% FUO 43% OTH* OTH* 57% 7% FUO 53% INJ INJ INJ 7% 5% 5% 3% ≥ 5yrs (n=48,197) < 5yrs (n=18,232) All Ages (n=66,429) Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 1-8 Dec 2006. *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

DEWS Data, Epidemiological Week No. 49, 2006: Consultations by age

ARI has been increasing steadily, but the rate of ARI by facility varies. The highest average rate is seen in Muzaffarabad, at 47% in children under five. For patients five and over, the highest rate is also in Muzaffarabad, at 34%. Maximum proportions of consultations for ARI range from 100 to 0% of consultations, though for patients five years and over, no facility had 100% of consultations for ARI. See figure 3.

Average Proportion of Consultations in Reporting Sites that are for ARI, by Age Group and District s

100.0 90.0 80.0 70.0 60.0 Average <5 50.0 40.0 Average >=5 30.0 20.0

reporting sites reporting 10.0 0.0 BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH Average proportionAverage of consultations for ARI, acros

District

Figure 3: Average proportion of consultations for ARI, with minimum and maximum value bars, by age group and district, Earthquake Affected Areas, Pakistan 1 – 8 December 2006

3 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

DEWS Data, Monthly Summary (Epidemiological Weeks No. 46-49)

In the past four weeks, between 11 Nov to 8 Dec 2006 (Epidemiological weeks 46-49 inclusive), 143,311 consultations for health conditions under surveillance were reported, out of a total 324,829 consultations. 26% (83,443) of consultations were due to acute respiratory infection (ARI), 6% (19,225) acute watery diarrhoea (AWD), 7% (21,300) unexplained fever (FUO) and 5% (15,484) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 11 Nov- 8 Dec 2006. Week WEEK 46 WEEK 47 WEEK 48 WEEK 49 TOTAL CFR% Event C D C D C D C D C D AWD 4999 2 5322 1 5111 0 3793 2 19225 5 0.026 BD 314 0 363 1 389 0 282 0 1348 1 0.067 AFP 1 0 1 0 0 0 1 0 3 0 0.000 MAL 510 0 519 0 636 0 455 0 2120 0 0.000 ARI 19795 3 21199 5 23797 5 18652 0 83443 13 0.016 MES 3 0 6 0 6 0 2 0 17 0 0.000 MEN 7 1 4 0 5 0 7 0 23 1 0.000 JAU 42 0 34 2 45 1 26 0 147 3 0.000 TET 0 0 0 0 0 0 1 0 1 0 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 5455 0 5685 0 5650 0 4510 0 21300 0 0.000 INJ 3903 0 4501 0 4007 0 3073 0 15484 0 0.000 OTH 46561 20 49077 12 50240 14 35640 13 181518 59 0.033 TOTAL 81590 26 86711 21 89886 20 66442 15 324629 82 RU 313 322 303 292

C – Cases, D – Deaths, AWD - Acute Diarrhoea, BD - Bloody Diarrhoea, AFP - Acute Flaccid Paralysis, MAL – Malaria, ARI - Acute Respiratory Infection, MES – Measles, Men - Meningitis, JAU - Acute Jaundice Syndrome, TET - Neonatal Tetanus, AHF Acute Hemorrhagic Fever, FUO –Unexplained fever, INJ – Injuries, OTH – Others, RU – Reporting Units. Please note data from late reporting in previous weeks has been updated. During the same reporting period 93,788 consultations were reported in the less than 5 years old group, (29% of the total consultations), of which 31% (28,787) were due to ARI, 9% (8,685) due to AWD, 6% (5,932) due to FUO and 3% (3,190) were reported as injuries (INJ). Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 11 Nov-8 Dec 2006. Week WEEK 46 WEEK 47 WEEK 48 WEEK 49 TOTAL CFR% Event C D C D C D C D C D AWD 2190 2 2369 1 2331 0 1795 2 8685 5 0.058 BD 93 0 117 1 135 0 100 0 445 1 0.225 AFP 1 0 1 0 0 0 1 0 3 0 0.000 MAL 89 0 55 0 104 0 73 0 321 0 0.000 ARI 6914 3 7186 5 8218 2 6469 0 28787 10 0.035 MES 3 0 2 0 6 0 1 0 12 0 0.000 MEN 1 0 1 0 1 0 2 0 5 0 0.000 JAU 9 0 5 1 13 0 5 0 32 1 0.000 TET 0 0 0 0 0 0 0 0 0 0 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 1402 0 1694 0 1571 0 1265 0 5932 0 0.000 INJ 820 0 949 0 818 0 603 0 3190 0 0.000 OTH 9418 5 9218 2 19722 3 7918 6 46276 16 0.035 TOTAL 20940 10 21597 10 32919 5 18232 8 93688 33 RU 313 322 303 292

4 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

In the current week, there was a decrease in the number of cases of AWD with 5,111 last week and 3,793 this week. In the current week, ARI decreased in the total number of cases as compared with the previous week, (23,797 last week and 18,652 this week). The weekly proportion of ARI and AWD is shown in figure 4.

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

Week

Figure 4. Weekly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 5 November 2005 – 8 December 2006.

Acute Watery Diarrhoea

In week 49 there were 3,793 cases of AWD reported, with two associated deaths, in patients under 5 in Mansehra and Muzaffarabad. The rate of AWD differs by district, with Battagram showing the highest rate in week 49, and Bagh the lowest. See Figure 5.

10.0 8.0 6.0 4.0 2.0

consultations 0.0 BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH AWD AWD as a percent of all

District

Figure 5: AWD as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 1 – 8 December 2006

5 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

Bloody Diarrhoea

I week 49, there were 282 cases of bloody diarrhoea reported. There were no associated deaths. The rate of bloody diarrhea varies by district. In week 49, Battagram had the highest rate of bloody diarrhea, while Poonch had the lowest in patients under five, and Bagh in patients five years and older. Muzaffarabad had a rate that differed considerably between the younger and older age groups, whereas other districts had similar rates for both patients under an over five in week 49. See figure 6

1.40 1.20 1.00 0.80 <5 0.60 >=5 0.40 0.20 0.00 BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH of all consultations Bloody diarrhea as a percent

District

Figure 6: Bloody diarrhoea cases as a percent of all consultations, by district and age group, Earthquake Affected Areas, Pakistan, 1 – 8 December 2006

Acute Jaundice Syndrome

In week 49 there were 26 cases of suspected hepatitis, a decrease of 42% over week 48. There were no associated deaths. Though the number of consultations has decreased, both Battagram and Mansehra districts have seen an increase in their overall rate of suspected hepatitis. See figure 7.

0.25

0.20 BAGH 0.15 BATTAGRAM MA NSERA 0.10 MUZAFFARABAD POONCH 0.05 Suspected hepatitisSuspected a as

percent of all consultations 0.00 2006-46 2006-47 2006-48 2006-49 Week

Figure 7: Trend in suspected hepatitis as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 11 November - 8 December, 2006

6 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

Malaria

In week 49, there were 455 malaria cases reported, a decrease of 28%. There were no associated deaths. Though there are differences in numbers of reporting sites and populations, no one district would be considered a dominant source of malaria cases. Bagh and Battagram have the lowest number of cases, at 14 and 13% respectively, and Muzaffarabad has the highest number of cases, at 27%. See figure 8.

1750, 14% 2550, 21%

BAGH 1544, 13% BATTAGRAM MANSERA MUZAFFARABAD 3206, 27% POONCH 3074, 25%

Figure 8: Malaria cases by district, Earthquake Affected Areas, Pakistan, 15 October 2005 – 8 December, 2006

Measles

There were 2 cases of measles reported in week 49, both in Battagram. Though measles are a disease of significant concern, it is still a relatively rare condition. Battagram has had the highest rate of measles since reporting began, at slightly more than one half of one percent of all consultations. The lowest rate has been in Poonch, at only 2 cases of measles per thousand consultations. See figure 9.

0.060 0.050 0.040 0.030 0.020 0.010 0.000 BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH consultations Measles as a percent of all

District

Figure 9: Measles as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 15 October 2005 – 8 December 2006. 7 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

Acute Respiratory Infection

In week 49, there were 18,652 consultations for ARI, a decrease of 22%. There were no associated deaths. Though the absolute number of consultations for ARI has decreased, the rate of ARI has increased in all districts. The greatest increase was in Muzaffarabad, and the lowest in Bagh. See figure 10

35.0 30.0 25.0 BAGH BATTAGRAM 20.0 MA NSERA 15.0 MUZAFFARABAD

consultations 10.0 POONCH 5.0 ARI as a percent as ARI of all 0.0 2006-46 2006-47 2006-48 2006-49 Week

Figure 10: Trend in ARI as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 11 November - 8 December, 2006

Other Reportable Diseases and Conditions

There were 7 cases of suspected meningitis in week 49, all in Muzaffarabad. There was one case of acute flaccid paralysis in Mansehra. There was one case of tetanus, in Battagram. There were no cases of hemorrhagic fever. There were 4,510 cases of fever of unknown origin, and 3,073 injuries.

Mansehra has had over half of the reported acute flaccid paralysis cases. Overall, there have been 65 cases of acute flaccid paralysis since reporting began. See figure 11.

6 5 POONCH 4 MUZAFFARABAD 3 MA NSERA BATTAGRAM 2 BAGH 1

0 2005-42 2005-44 2005-46 2005-48 2005-50 2005-52 2006-02 2006-04 2006-06 2006-08 2006-10 2006-12 2006-14 2006-16 2006-18 2006-20 2006-22 2006-24 2006-26 2006-28 2006-30 2006-32 2006-34 2006-36 2006-38 2006-40 2006-42 2006-44 2006-46 2006-48 Acute flaccid paralysis cases

Week

Figure 11: Acute flaccid paralysis cases, by district, Earthquake Affected Areas, Pakistan, 15 October 2005 – 8 December 2006

8 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

Outbreak Alert and Response1

Acute Jaundice: 13 cases of suspected hepatitis were reported from BHU Bangoin (6), RHC Paniola (6), and RHC (1). The alert was reported on 2nd December and investigated on 4th December. On investigation, the six cases at Bangoin and Paniola were found to be the same people, who sought help at both facilities. These patients ranged in age from 3 to 12 years (1 below five, 5 over five), and were all from the same family. The first patient affected developed symptoms on 18th November, and others thereafter. They all used the same source of water, but had recently changed their water source from a spring to a nearby bore. Blood samples from two patients and water samples from both the spring and the bore were taken for confirmation.

Acute Flaccid Paralysis: Mansehra One case of acute flaccid paralysis in a 3 year old boy was reported from Guldheri, . The child was brought to DHQ Hospital on November 28th. He was completely vaccinated against polio. Stool samples were taken for confirmation.

1 Outbreak Investigation and response of Suspected Viral Hepatitis, Malaria, and Bloody Diarrhoea and Watery Diarrhoea would only take place when a cluster of cases is identified or there is an increase in the incidence of the disease. (Note: Single death due to Diarrhoea and single case of reported severe dehydration among >5 years would be investigated) 9 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55/ DEWS 2006 -49

Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, , Earthquake Affected Areas, Pakistan, 11 Nov - 8 Dec 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 46 416 0 27 0 0 0 21 0 2937 0 0 0 0 0 5 0 0 0 0 0 161 0 610 0 10846 3 47 470 0 46 0 0 0 23 0 2692 0 0 0 0 0 3 0 0 0 0 0 240 0 605 0 8336 4 48 589 0 40 0 0 0 42 0 4002 0 0 0 0 0 1 0 0 0 0 0 199 0 750 0 13080 5 49 452 0 29 0 0 0 7 0 2966 0 0 0 0 0 0 0 0 0 0 0 253 0 631 0 9440 0 Total 1923 0 142 0 0 0 93 0 12597 0 0 0 0 0 9 0 0 0 0 0 853 0 2596 0 41702 12

Table 7. Number of reported cases and deaths, Poonch District, Earthquake Affected Areas, Pakistan, 11 Nov - 8 Dec 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 46 1070 0 13 0 0 0 196 0 3396 0 1 0 0 0 0 0 0 0 0 0 1601 0 646 0 5854 4 47 1414 0 30 0 0 0 257 0 3946 1 0 0 0 0 3 1 0 0 0 0 2111 0 726 0 7654 3 48 1405 0 23 0 0 0 336 0 4360 1 0 0 0 0 13 0 0 0 0 0 2140 0 718 0 7301 0 49 990 0 21 0 0 0 209 0 3507 0 0 0 0 0 2 0 0 0 0 0 1728 0 539 0 5332 2 Total 4879 0 87 0 0 0 998 0 15209 2 1 0 0 0 18 1 0 0 0 0 7580 0 2629 0 26141 9

Table 8. Number of reported cases and deaths, Muzaffarabad District, Earthquake Affected Areas, Pakistan, 11 Nov - 8 Dec 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 46 1921 1 172 0 0 0 169 0 7372 1 0 0 7 1 12 0 0 0 0 0 1483 0 1910 0 14026 8 47 1906 0 188 0 1 0 168 0 8077 0 4 0 3 0 13 0 0 0 0 0 1562 0 2409 0 15051 5 48 1678 0 186 0 0 0 151 0 8112 1 0 0 5 0 17 1 0 0 0 0 1679 0 1794 0 13129 5 49 1279 1 115 0 0 0 176 0 6399 0 0 0 7 0 9 0 0 0 0 0 1448 0 1298 0 8500 5 Total 6784 2 661 0 1 0 664 0 29960 2 4 0 22 1 51 1 0 0 0 0 6172 0 7411 0 50706 23

10 WMMR Weekly Morbidity and Mortality Report Pakistan 14 Dec 2006 / Vol. 55 DEWS 2006 -49

Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 11 Nov - 8 Dec 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 46 514 0 49 0 0 0 41 0 1681 0 2 0 0 0 12 0 0 0 0 0 479 0 251 0 2964 1 47 595 0 47 0 0 0 26 0 1792 0 2 0 0 0 9 0 0 0 0 0 587 0 204 0 3683 0 48 500 0 74 0 0 0 42 0 2235 0 6 0 0 0 6 0 0 0 0 0 475 0 253 0 3552 0 49 517 0 71 0 0 0 31 0 1848 0 2 0 0 0 8 0 1 0 0 0 397 0 222 0 2531 1 Total 2126 0 241 0 0 0 140 0 7556 0 12 0 0 0 35 0 1 0 0 0 1938 0 930 0 12730 2

Table 10. Number of reported cases and deaths, *, Earthquake Affected Areas, Pakistan, 11 Nov - 8 Dec 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 46 1078 1 53 0 1 0 83 0 4409 2 0 0 0 0 13 0 0 0 0 0 1731 0 486 0 12871 4 47 937 1 52 1 1 0 45 0 4692 4 0 0 1 0 6 1 0 0 0 0 1185 0 547 0 14353 0 48 939 0 66 0 0 0 65 0 5088 3 0 0 0 0 8 0 0 0 0 0 1157 0 492 0 13178 4 49 555 1 46 0 1 0 32 0 3932 0 0 0 0 0 7 0 0 0 0 0 684 0 383 0 9825 5 Total 3509 3 217 1 3 0 225 0 18121 9 0 0 1 0 34 1 0 0 0 0 4757 0 1908 0 50227 13

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