Epidemiological Week No. 30 (21 – 27 July) August 1/ Vol. 88/ DEWS 2007-30

Rawalakot: DEWS training Pictured by: Mohammad Ali Reporting Units...... 2 Total number of consultations ...... 2 DEWS Data, Epidemiological Week No. 30, 2007...... 3 DEWS Data, Monthly Summary (Epidemiological Weeks No. 27-30)...... 4 Acute Watery Diarrhoea ...... 5 Acute Jaundice Syndrome...... 6 Malaria ...... 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 Number of reported cases and deaths per District, NWFP ...... 11

ƒ The number of bloody diarrhoea cases ƒ One alert of suspected measles was decreased by 6% from week 29 reported from DHQ hospital Bagh. (W29=601 & W30=568) ƒ One suspected case of meningitis ƒ Malaria cases increased by 26% from reported from DHQ hospital Bagh. week 29 (W29=706 & W30=893) ƒ Five cases of suspected acute watery ƒ Acute watery diarrhoea cases increased diarrhoea reported from BHU Mallot, by 3% from week 29 (W29=12,416 & District Bagh. W30=12,770)

The Weekly Morbidity and Mortality Report (WMMR) is published by the Ministry of Health of Pakistan (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, National Park Road, Chak Shehzad, Islamabad, 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 1 August 2007 / Vol. 88/ DEWS 2007-30

Reporting Units

The number of reporting sites able to report this week was 298; the reporting timeliness of the DEWS system has decreased by 3% compared with the previous week (epidemiological week 29). See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 30June to 27July 2007. Reporting Health Facilities 30June- 7-13 July 14-20 July 21-27 July Area Population 6July Week-27 Week-28 Week-29 Week-30 Bagh 452,532 41 40 42 40 Battagram 592,256 29 29 28 28 Mansehra 1,154,804 70 65 71 72 Muzaffarabad 894,364 90 82 86 82 Poonch 633,712 69 68 74 69 Total 3,727,668 299(89%) 284(85%) 301(90%) 291(87%)

Total number of consultations

In week 30, there was a 3% decrease in the number of reporting sites, but the number of consultations increased from 94,085 to 96,673. The highest number of consultations was from Muzaffarabad, with 33,607, and the lowest from Battagram district, at 5,333. The weekly trend of reporting units participating in the DEWS and the number of consultations is shown in figure 1.

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

150000 250

200 100000 150

100 50000

50

0 0 W42 W46 W50 W2 W6 W10 W14 W18 W22 W26 W30 W34 W38 W42 W46 W50 W02 W06 W10 W14 W18 W22 W26 W30

Week

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 - 27 July 2007.

2 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

DEWS Data, Epidemiological Week No. 30, 2007

During the last week (21 to 27 July, 2007), 96,673 consultations were reported through DEWS. Acute Respiratory Infections (ARI) accounted for 20% (18,938) of consultations, which was 3 percentage points higher than the rate seen in the same week last year. Acute Watery Diarrhoea (AWD) was 13% (12,770) of consultations, 8% (7,284) were due to Fever of Unknown Origin (FUO) and less than 1% (272) due to Injuries (INJ). The rate of AWD in patients under five years was less than one percentage point higher in week 30 of 2007 compared to the same week last year. In patients aged five and above, AWD was 11% of consultations, which was almost the same rate reported in the same week last year. All other reportable conditions each represented less than 1% of the total consultations in week 30. AWD ARI AWD ARI 11% 18% 13% 20% AWD ARI 21% 26% FUO 7% FUO INJ 8% <1% INJ FUO <1% 8%

INJ OTH* OTH* OTH* <1% 61% 58% 43%

< 5yrs (n=19,060) ≥ 5yrs (n=77,613) All Ages (n=96,673)

Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 21 to 27 July 2007. *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

DEWS Data, Epidemiological Week No. 30, 2007: Consultations by age The rate of AWD in patients five years and older was almost the same in last four weeks in 2007 compared with the same weeks in 2006. However, the rate in patients less than five years is 2 to 4 percent higher in week 27 and 28 but almost same in week 29 and 30 of 2007 compared with the same weeks last year. See figure 3.

25

20

15

10

5 AWD as percentage of all consultation 0 Weeks 27 28 29 30 2006 <5 yrs 2006 >=5 yrs 2007 <5 yrs 2007 >=5 yrs

Figure 3: AWD as a percent of all consultations, by age group, Earthquake Affected Areas, Pakistan, 1 -28 July 2006 to 30 June - 27 July 2007

3 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

DEWS Data, Monthly Summary (Epidemiological Weeks No. 27-30)

During the period, 30 June to 27 July, 2007 (Epidemiological weeks 27 to 30 inclusive), 153,659 consultations relating to health conditions under surveillance were reported, out of the total of 375,554 consultations. 19% (69,753) of consultations were due to acute respiratory infection (ARI), 13% (50,020) acute watery diarrhoea (AWD), 7% (26,624) unexplained fever (FUO) and 1% (1,983) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 30June – 27 July 2007. Week WEEK 27 WEEK 28 WEEK 29 WEEK 30 TOTAL Event C D C D C D C D C D CFR% AWD 11967 1 12867 1 12416 1 12770 3 50020 6 0.012 BD 618 0 464 0 601 0 568 0 2251 0 0.000 AFP 1 0 0 0 0 0 0 0 1 0 0.000 MAL 699 0 588 0 706 0 893 0 2886 0 0.000 ARI 16377 1 17210 2 17228 3 18938 3 69753 9 0.013 MES 9 0 8 0 9 0 4 0 30 0 0.000 MEN 1 0 1 1 1 0 2 1 5 2 40.000 JAU 26 0 37 0 22 0 21 0 106 0 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 6572 0 6303 0 6465 0 7284 0 26624 0 0.000 INJ 1152 1 313 1 246 0 272 0 1983 2 0.101 OTH 56520 16 53063 10 56391 10 55921 13 221895 49 0.022 TOTAL 93942 19 90854 15 94085 14 96673 20 375554 68 RU 299 284 301 291

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, 69,692 consultations were reported in children less than 5 years of age, (19% of the total consultations), of which ARI was 26% (18,206), AWD 22% (15,471), FUO 7% (4,765) and INJ was less than 1% (333). Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 30June – 27July 2007. Week WEEK 27 WEEK 28 WEEK 29 WEEK 30 TOTAL Event C D C D C D C D C D CFR% AWD 4083 1 3840 1 3581 1 3967 2 15471 5 0.032 BD 185 0 128 0 163 0 144 0 620 0 0.000 AFP 1 0 0 0 0 0 0 0 1 0 0.000 MAL 120 0 85 0 96 0 127 0 428 0 0.000 ARI 4783 1 4371 2 4143 3 4909 3 18206 9 0.049 MES 4 0 3 0 5 0 4 0 16 0 0.000 MEN 0 0 0 0 0 0 1 0 1 0 0.000 JAU 3 0 6 0 3 0 4 0 16 0 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 1071 0 991 0 1097 0 1606 0 4765 0 0.000 INJ 201 0 43 0 39 0 50 0 333 0 0.000 OTH 7191 4 6752 4 7644 2 8248 2 29835 12 0.040 TOTAL 17642 6 16219 7 16771 6 19060 7 69692 26 RU 299 284 301 291 4 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

There was a 3% increase in the number of AWD cases from 12,416 to 12,770 since last week, and also ARI increased from 17,228 to 18,938 since last week. It appears that the rates of ARI and AWD will not converge in 2007 the way they did in 2006. The weekly proportion of ARI and AWD is shown in figure 4.

% Consultation ARI and AWD percent of total consultations 40

35 ARI AWD 30

25

20

15

10

5

0 W45 W49 W1 W5 W9 W13 W17 W21 W25 W29 W33 W37 W41 W45 W49 W01 W05 W09 W13 W17 W21 W25 W29

Week

Figure 4. Weekly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 15 October 2005 – 27 July 2007.

Acute Watery Diarrhoea

During week 30, there were 12,770 cases of AWD reported which is less than 1 percentage point lower than the same week last year. There were two deaths in patients less than five years of age, one reported from Bagh and one from Muzaffarabad district, while a third death was reported in a patient over five years of age from Muzaffarabad district. The percentage of AWD by district in 2007 is very similar to that of 2006 in Bagh, while other districts show a difference of 2 to 7 percentage points from one year to the next. See figure 5.

AWD Wk27 to Wk30, 2006 AWD Wk27 to Wk30, 2007

POONCH BAGH BAGH 14 % 17 % 14 % POONCH 24%

MANSERA MANSERA 17% 15 %

Figure 5: Trend in AWD as a percent of all consultations, 2006 and 2007, Earthquake Affected Areas, Pakistan, 1 -28 July 2006 to 30 June - 27 July 2007

5 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

Bloody Diarrhoea

During week 30, there were 568 suspected cases of bloody diarrhoea reported, which was 5% lower than week 29. There were no associated deaths reported from any district. The percentage of BD in 2007 has been lower than that seen in 2006 for the last four weeks. See figure 6. 1.60 2006 2007 1.40

1.20

1.00

0.80

consultations 0.60

0.40

Bloody diarrhoea as percent of all 0.20

0.00 27 28 Weeks 29 30

Figure 6: Trend in bloody diarrhoea as percentage of all consultations, 2006 and 2007, Earthquake Affected Areas, Pakistan, 1 -28 July 2006 to 30 June - 27 July 2007

Acute Jaundice Syndrome

In week 30, there were 21 cases of suspected hepatitis reported. There were no associated deaths reported from any district. In 2006 the number of cases of hepatitis in patients five years and older was considerably higher than that seen in 2007, while the number of cases in patients under five in week 30 is very close to that seen in 2006. See figure 7. 90 80

70

60 50 40

30

20 10 AJS number of cases by age group age by cases of number AJS 0 Weeks 27 28 29 30 2006 <5 yrs 2007 <5 yrs 2006 ≥ 5yrs 2007 ≥ 5yrs

Figure 7: Trend in suspected hepatitis cases per reporting site, Earthquake Affected Areas, Pakistan, 1-28 July 2006 to 30 June to 27 July, 2007.

6 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

Malaria

In week 30, there were 893 suspected cases of malaria reported, 21% higher than last week, out of which 766 suspected cases were in patients over five years of age and 127 in patients less than five years of age. There were no associated deaths reported. In the last three weeks, there has been a steady increase in the rate of malaria in both age groups. See figure 8. 1.20

1.00

0.80

0.60 age group

0.40

0.20 Malaria as percent of all consultation by by consultation all of as percent Malaria

0.00 Weeks 27 28 29 30 2006 <5 yrs 2007 <5 yrs 2006 ≥ 5yrs 2007 ≥ 5yrs

Figure 8: Trend in malaria as a percent of all consultations within age group, Earthquake Affected Areas, Pakistan, 1-28 July 2006 to 30 June to 27 July, 2007.

Measles

There were 4 suspected cases of measles under five years of age reported in week 30. There were no associated deaths reported. There have been significantly fewer cases of measles in both age groups in 2007 than in 2006. See Figure 9.

25

20

15

10

Measles number of cases 5

0 Weeks 27 28 29 30 2006 <5 yrs 2007 <5 yrs 2006 ≥ 5yrs 2007 ≥ 5yrs

Figure 9: Trend in measles cases as a percent of all consultations, Earthquake Affected Areas, Pakistan, 1 -28 July 2006 to 30 June – 27 July, 2007

7 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

Acute Respiratory Infection

In week 30, there were 18,938 consultations for ARI reported through the DEWS system. There were three deaths in patient under five years of age was reported two from Muzaffarabad and one death reported from Mansehra district. The rate of ARI is in 2007 has been consistently higher in the last four weeks than seen in 2006. See Figure 10. 20 2006 2007 20 19 19 18 18 17 17 16 16

ARI as percent of all consultation all of as percent ARI 15 15 27 28 29 30 Weeks

Figure 10: ARI as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 1 – 28 July 2006 to 30 June - 27 July 2007

Other Reportable Diseases and Conditions

There were two cases of suspected meningitis reported one over five years of age from Muzaffarabad and one less than five years from Bagh district in week 30. There were 7,284 cases of Fever of Unknown Origin (FUO) and 272 cases of injuries in week 30. There were no cases of tetanus and acute hemorrhagic fever reported from any district. See figure 11.

20 2006 2007 18 16 14 12 10 8 6

Meningitis number of cases of number Meningitis 4 2 0 27 28 29 30 Weeks

Figure 11: Total number of meningitis consultations, Earthquake Affected Areas, Pakistan, 1-28 July 2006 to 30June- 27 July 2007 8 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88/ DEWS 2007-30

Outbreak Alert and Response1

Bagh Measles On 23 of July 2007, DHQ Bagh reported one suspected case of measles from village Kharal Abbassian. The patient was a one and half years old female resident of Kharal Abbassian. The patient was not completely immunized for all EPI diseases. A blood sample was taken and sent to NIH, Islamabad for further laboratory confirmation. During active surveillance of the village no more cases were identified. Parents were advised to isolate the baby till she fully recovers and to get her immunized after full recovery.

Meningitis On 23 of July 2007, DHQ Bagh reported an alert of suspected meningitis. The patient was a 4 months old female resident of Dharray, Tehsil Bag. She was admitted with 3 days history of high grade fever, not feeding, altered consciousness and generalized seizures. On examination both upper and lower limbs were stiff, fontanel was bulging, both pupils were non reactive to light with right one dilated. On active surveillance no similar case was found in the family and the locality.

Acute watery diarrhoea On 25th of July 2007, BHU Mallot reported 5 cases of AWD from village Channat. 2 stool samples were taken and sent to NIH, Islamabad for laboratory confirmation. During active surveillance no further cases were found. The water source of the area tested and found contaminated. Extensive hygiene education was provided to the community. Health working partners were informed for containment of the outbreak. WHO surveillance team revisited the area on 27th July to assess the situation.

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 1 August 2007 / Vol. 88/ DEWS 2007-30

Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, Bagh District*, Earthquake Affected Areas, Pakistan, 30 June -27 July 2007. 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 27 1308 1 31 0 1 0 75 0 2137 0 2 0 0 0 3 0 0 0 0 0 259 0 0 0 11355 3 28 1220 0 38 0 0 0 0 0 2160 0 0 0 0 0 1 0 0 0 0 0 277 0 0 0 10471 4 29 1470 0 43 0 0 0 120 0 2513 0 1 0 0 0 2 0 0 0 0 0 339 0 0 0 10464 2 30 1270 1 35 0 0 0 108 0 1974 0 2 0 1 0 0 0 0 0 0 0 310 0 0 0 11555 2 Total 5268 2 147 0 1 0 303 0 8784 0 5 0 1 0 6 0 0 0 0 0 1185 0 0 0 43845 11

Table 7. Number of reported cases and deaths, Poonch District*, Earthquake Affected Areas, Pakistan, 30 June -27 July 2007. 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 27 2355 0 60 0 0 0 363 0 3055 0 7 0 0 0 1 0 0 0 0 0 2399 0 106 0 7281 5 28 3086 0 43 0 0 0 336 0 3540 0 7 0 0 0 2 0 0 0 0 0 2140 0 0 0 7778 0 29 3278 0 70 0 0 0 389 0 3800 0 1 0 0 0 3 0 0 0 0 0 2192 0 0 0 8778 5 30 3243 0 44 0 0 0 448 0 3903 0 0 0 0 0 3 0 0 0 0 0 2297 0 6 0 9297 1 Total 11962 0 217 0 0 0 1536 0 14298 0 15 0 0 0 9 0 0 0 0 0 9028 0 112 0 33134 11

Table 8. Number of reported cases and deaths, Muzaffarabad District*, Earthquake Affected Areas, Pakistan, 30 June -27 July 2007. 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 27 5359 0 417 0 0 0 189 0 6815 0 0 0 1 0 0 0 0 0 0 0 2233 0 1046 0 19188 3 28 5096 0 259 0 0 0 129 0 6719 0 0 0 1 1 9 0 0 0 0 0 2236 0 313 1 17739 0 29 4362 1 366 0 0 0 136 0 5932 1 0 0 1 0 5 0 0 0 0 0 1918 0 246 0 18912 2 30 4623 2 345 0 0 0 217 0 7925 2 0 0 1 1 5 0 0 0 0 0 3002 0 266 0 17223 8 Total 19440 3 1387 0 0 0 671 0 27391 3 0 0 4 2 19 0 0 0 0 0 9389 0 1871 1 73062 13

10 WMMR Weekly Morbidity and Mortality Report Pakistan 1 August 2007 / Vol. 88 DEWS 2007 -30

Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District*, Earthquake Affected Areas, Pakistan, 30 June -27 July 2007. 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 27 960 0 90 0 0 0 37 0 1108 0 0 0 0 0 17 0 0 0 0 0 436 0 0 0 4200 1 28 953 0 73 0 0 0 24 0 925 0 0 0 0 0 13 0 0 0 0 0 438 0 0 0 2736 0 29 812 0 82 0 0 0 21 0 912 0 0 0 0 0 5 0 0 0 0 0 446 0 0 0 2759 0 30 926 0 107 0 0 0 51 0 992 0 1 0 0 0 8 0 0 0 0 0 417 0 0 0 2831 0 Total 3651 0 352 0 0 0 133 0 3937 0 1 0 0 0 43 0 0 0 0 0 1737 0 0 0 12526 1

Table 10. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 30 June -27 July 2007. 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 27 1985 0 20 0 0 0 35 0 3262 1 0 0 0 0 5 0 0 0 0 0 1245 0 0 0 14496 3 28 2512 1 51 0 0 0 31 0 3866 2 1 0 0 0 12 0 0 0 0 0 1212 0 0 0 14339 4 29 2494 0 40 0 0 0 40 0 4077 2 1 0 0 0 7 0 0 0 0 0 1570 0 0 0 15478 1 30 2708 0 37 0 0 0 69 0 4144 1 1 0 0 0 5 0 0 0 0 0 1258 0 0 0 15015 2 Total 9699 1 148 0 0 0 175 0 15349 6 3 0 0 0 29 0 0 0 0 0 5285 0 0 0 59328 10

11