Districts Battagram and Neelum Reported Higher Proportion of Consultations for Acute Diarrhoea Compared to Other Districts

Epidemiological Week No. 23 (31 May -6 June 08) June 23/ Vol. 133/ DEWS 2008-23

Muzaffarabad: WHO team assessing the health situation in Khun Bandi affected by landslide Picture credit: Dr. Mazhar Iqbal Reporting Units ...... 2 Total number of consultations...... 2 DEWS Data, Epidemiological Week No. 23, 2008 ...... 3 DEWS Data, (Epidemiological Weeks No.20 – 23, 2008):...... 4 Acute Diarrhoea and suspected Cholera: ...... 5 Acute Respiratory Tract Infections: ...... 7 Upper and Lower Respiratory Tract Infection:...... 7 Other Conditions under Surveillance: ...... 8 Outbreak Alert and Response...... 8 Number of reported cases and deaths per District, AJK ...... 9 Number of reported cases and deaths per District, NWFP ... 10

In week 23, total 71,601 consultations Districts Battagram and Neelum were reported from 277 reporting reported higher proportion of units consultations for Acute Diarrhoea compared to other districts

ARI remains the leading cause of Two alerts were received and consultation this week and the weekly investigated accordingly trend is on decline None of the alerts was found to be an Acute Diarrhoea reported in 10% of all outbreak consultations almost same as was reported last week.

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 Shahzad, Islamabad, Pakistan. For More Information, please contact: Dr. Rayana Bouhaka, Manager Operations, 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 23 June 2008 / Vol. 133/ DEWS 2008-23

Reporting Units

During week 23, 2008, total 277 (83%) weekly reports were received from the DEWS reporting sites on the due time. Compared to last week the DEWS reporting have decreased by 3% this week (86% and 83% respectively). The total number of reporting sites in the Earthquake affected districts remains 335 as of week 23, 2008. Table 1, summarizes reporting by each earthquake affected district for the last 4 weeks.

Table1. Heath Facilities by district, reported from Earthquake Affected Areas, Pakistan, 31May -6 June 2008. Reporting Health Facilities 31May-6June 10-16 May 08 17-23 May 08 24-30 May 08 Area Population 08 Week-20 Week-21 Week-22 Week-23 Bagh 452,532 35 36 36 33 Battagram 592,256 36 38 32 30 Mansehra 1,154,804 59 65 65 62 Muzaffarabad 770,000 70 76 73 70 Neelum 184,000 17 18 19 19 Poonch 633,712 64 61 63 63 Total 3,727,668 281(84%) 294(88%) 288(86%) 277(83%)

Total number of consultations

During week 23, Total 71,601 patient consultations were reported, a decrease by 3% compared to last week. Similar to the prior weeks, the district Muzaffarabad reports the highest proportion (35%) and Neelum reports the lowest proportion (5%) of the total consultation reported from all the Earthquake affected districts. Neelum is the smallest district with the least number of DEWS reporting sites among all the districts in the earthquake area. Figure 1 depicts the pattern of weekly reporting units participating in the DEWS and the total number of weekly consultations reported from week 1, 2007 to week 23, 2008

Figure1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, Week 1, 2007 – week 23 2008. # of Units Weekly pattern of reporting consultations # of Cns. 350 120000 Reporting Unit Consultations 300 100000 250 80000 200 60000 150 40000 100

50 20000

0 0 W03 W05 W07 W09 W11 W13 W15 W17 W19 W21 W23 W25 W27 W29 W31 W33 W35 W37 W39 W41 W43 W45 W47 W49 W51 W03 W05 W07 W09 W11 W13 W15 W17 W19 W21 W23

W01/07 Ep i- w e e k W01/08

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DEWS Data, Epidemiological Week No. 23, 2008

During the Epidemiological week 23 (31 May – 6 June, 2008), total 71,601 consultations were reported through DEWS. The distribution of consultations by age groups indicate that 19% are children less than 5 years of age, 20% are children 5-14 years of age, 42%, the majority, are adults 15-45 years of age, and 19% are adults above 45 years age. Of the total consultations reported for week 23, 53% were from female patients. The proportion for Upper Respiratory Tract Infection was 16%, Unexplained Fever 10%, Acute Diarrhoea 10%, Lower Respiratory Tract Infection 4% and Scabies 5% in all age groups and both sexes. Out of the total 71,601 reported consultation, in all ages and both sexes, 55% (39,036) accounted for health problems other than the diseases reported above. See (Figure 2).

Figure 2.Distribution of reported consultations by disease/health event and age groups, 31 May to 6 June 2008, Earthquake Affected Areas, Pakistan

Distribution of consultations by age Distribution of consultations by disease 45 AD 10% LRTI 40 URTI 42% 4% 35 16% 30 25 UF 20 10%

consultations 19% 20% Percentage of 15 19% 10 SCB 5 5% 0 <5 5-14 15-44 ≥45 OTH 55% Age-group

*OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

Comparison of consultation by sex shows that in female patients, health events other than the five common communicable diseases are reported higher than males (57% and 51% respectively). In males, the proportion for Acute Diarrhoea LRTI and URTI is higher than for females. The proportion of consultations for UF, and Scabies is same both in males and females (Figure 3)

Figure 3.Distribution of reported consultations by disease/health event and age groups, 31 May to 6 June 2008, Earthquake Affected Areas, Pakistan Distribution of consultations (Male) Distribution of consultations (Female) AD URTI AD LRTI 9% 11% LRTI 4% URTI 15% 5% 17%

UF 10% UF 10% SCB 5% SCB 5% OTH OTH 57% 51%

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Disease Distribution by Age:

Acute Upper Respiratory Tract Infections (URTI) is the highest reported disease in all age groups during week 23. In children less than five years of age Upper Respiratory Tract Infection was reported in 23% of the consultations, followed by Acute Diarrhoea (AD) 18%, Unexplained Fever 10%, Lower Respiratory Tract Infection (LRTI) 6%, Scabies 4% and other health problems 39%. In children 5 to 15 years of age Upper Respiratory Tract Infection was reported in 19% of the consultations followed by Acute Diarrhoea 11%, Unexplained Fever (UF) 11%, Scabies 6%, Lower Respiratory Tract Infection 5% and other health problems 47%. In both the adult age groups (15-45 years and above 45 years) the proportion of the other health problems (51% and 57%) is higher than reported for children, followed by URTI 17% and 15% in the respective age groups. The proportion of the remaining reported communicable diseases in adults is lower than reported in children but with slight differences between the two adult age groups. Figure 4 presents the comparisons of the reported consultation by age groups.

Figure4. Proportion of primary causes for all reported cases by age groups, 31 May – 6 June 2008, Earthquake Affected Areas, Pakistan,

SCB AD SCB AD MAL 4% 18% MAL LRTI 4% 6% <1% <1% 3% LRTI 6% URTI SCB AD MAL OTH SCB AD MAL 13% 5% 7% M<1%LRTI 39% 6% 11% <1% LRTI 5% 5% UF URTI URTI OTH 8% URTI 13% 23% 64% UF 19% 10% OTH UF OTH 57% < 5yrs (n=13,904) 47% ≥15 - ≤44yrs (n=29,836) 12% UF 11% 5 - <15yrs (n=14,212) ≥ 45yrs (n=13,649)

*OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

DEWS Data, (Epidemiological Weeks No.20 – 23, 2008):

During the period 10 May to 6 June, 2008 (Epidemiological weeks 20 to 23, 2008 both inclusive), total 298,935 consultations were reported in the Earthquake affected areas. The proportion of the five common diseases under surveillance was, 46% (138,551) of the total consultations reported during this period. This proportion remains almost consistent for the last four weeks. During this period 17% (52,118) of consultations were due to Upper Respiratory Tract Infection (URTI), 9% (27,824) Unexplained Fever (UF), 9% (27,444) Acute Diarrhoea (AD), 5% (14,257) Lower Respiratory Tract Infection (LRTI), and 5% (13,958) due to Scabies (SCB). Acute Jaundice Syndrome was reported in 70 consultations and Bloody Diarrhoea was reported in 1388 consultation during this period.

A total of 69 deaths were reported during this period. Most (90%) of the total reported deaths were due to health events other than the diseases under weekly surveillance. Five deaths due to Acute Diarrhoea all under five years age were reported in last four weeks, one from Mansehra and four deaths from Poonch District with a total AD case fatality of 0.018%. Two deaths were reported due to Lower Respiratory Tract Infection during the last four week period and the total case fatality for LRTI stands at 0.014%. No deaths were reported from any other disease under weekly surveillance during this four week period.

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Table 2. Weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, Week 20 - 23, 2008. Week WEEK 20 WEEK 21 WEEK 22 WEEK 23 TOTAL CFR% Event C D C D C D C D C D AD 6232 1 7132 1 7227 1 6853 2 27444 5 0.018 AFP 2 0 2 0 2 0 0 0 6 0 0.000 AJS 21 0 21 0 19 0 9 0 70 0 0.000 BD 366 0 352 0 313 0 310 0 1341 0 0.000 LRTI 3817 0 3708 1 3596 0 3136 1 14257 2 0.014 MAL 364 0 420 0 354 0 392 0 1530 0 0.000 MG 0 0 0 0 0 0 0 0 0 0 0.000 MS 3 0 0 0 0 0 0 0 3 0 0.000 OTH 39743 18 43072 16 38533 11 39036 17 160384 62 0.039 SCB 3517 0 3744 0 3429 0 3268 0 13958 0 0.000 UF 7053 0 6989 0 6758 0 7024 0 27824 0 0.000 URTI 13613 0 13598 0 13334 0 11573 0 52118 0 0.000 Total Cons. 74731 19 79038 18 73565 12 71601 20 298935 69 RU 281 294 288 277

Acute Diarrhoea and suspected Cholera: During week 23, 2008, Acute Diarrhoea was reported in 6,853 patients accounting for 10% of the total consultation in all age groups. In children less than 5 years of age Acute Diarrhoea was reported in 18% of the total consultations with no change in percentages compared to week 22. In children 5 to 14 years of age, 11% of the consultations were for AD. In the adult age groups, 15- 45 years and above 45 years of age, AD consultations were reported as 6% and 7% respectively, out of the total consultations. From week 16 onwards, the proportion of Acute Diarrhoea weekly consultations are increasing gradually presenting the usual seasonal pattern of the disease in the area. In week 23 the proportion of AD has slightly dropped compared to week 22. Comparison of the weekly trend of AD from week 1 to 23 depicts a similar pattern for the last three years (Fig 6). There were no cases of suspected cholera reported from any district; however, there were two deaths due to acute diarrhoea reported each from Poonch and Mansehra district.

Figure 5: Trend in Acute diarrhoea as a percent of all consultations, weekly comparison by years, Earthquake Affected Areas, Pakistan, Weekly comparison of acute diarrhoea (Year 05, 06, 07 and 08) 18 16 14 12 10 8 6 consultations

Percentage of all 4 2 0 1 3 5 7 9 111315171921232527293133353739414345474951 Ep i- w e e k 2005 2006 2007 2008

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In general there is an increasing trend of Acute Diarrhoea in all districts depicted for the last few weeks. When compared the trends of Acute Diarrhoea by district from Week 1 to 23, 2008, Battagram and Neelum report the highest proportion of AD throughout the period and presents a fluctuating pattern of cases. However, there is neither the indication of case clustering nor does the situation look like an epidemic reported from any part of the districts. As the disease pattern indicates the seasonal increase in the Diarrhoeal diseases the health cluster partners in the districts have already started measures and activities on prevention and control of diarrhoea diseases and are vigilantly monitoring the AD situation in their respective districts. (Fig 6)

Figure 6: Trend in Acute diarrhoea as a percent of all consultations, comparison by districts weeks 1-23, 2008, Earthquake Affected Areas, Pakistan Weekly trend of acute diarrhoea by district 14

consultations 4 Percentage of all all of Percentage

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Epi-week BAGH BATTAGRAM MA NSEHRA MUZAFFARABAD NEELUM POONCH

Bloody Diarrhoea: During week 23 of 2008, total 310 cases of Bloody Diarrhoea were reported from all the districts, which is slightly lower than the total BD consultation reported during the previous week. The overall proportion of reported Bloody Diarrhoea is very small for all the weekly consultations with a little weekly fluctuation. When compared the weekly trend of the BD by districts, District Muzaffarabad, Neelum and Battagram report slightly higher proportion compared to other three districts with a weekly fluctuating pattern of the disease. The WHO team along with DoH and Health Partners have conducted a thorough assessment of the BD situation in the districts and preventive measures have been initiated. The probable reason for the relatively higher proportion in these three districts is the consumption of contaminated water and poor hygienic practices (Figure 7).

Figure 7: Trend in weekly Bloody diarrhoea as a percent of all consultations, comparison by district, Earthquake Affected Areas, Pakistan, Weekly trend of bloody diarrhoea by district 2.00 1.80 1.60 1.40 1.20 1.00 0.80

consultations 0.60 Percentage of all all of Percentage 0.40 0.20 0.00 1234567891011121314151617181920212223 Epi-week BAGH BATTA GRA M MA NSEHRA MUZAFFARABAD NEELUM POONCH

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Acute Respiratory Tract Infections:

During week 23, 2008, total 14,709 consultations for ARI (both Upper and Lower Respiratory Tract Infection) were reported. ARI accounts for 21% of the total consultations reported for the week (URTI 16% and LRTI 5%) and are still the leading cause of consultations for all age groups, among all the diseases under surveillance. For the current week in children less than 5 years of age URTI was reported in 23% and LRTI in 6% of consultations. In 5 to 14 year age groups URTI was reported in 19% and LRTI in 5% of consultations. In 15 to 45 year age group URTI was reported for 13% and LRTI for 3% of consultations. In the age group above 45 years URTI was reported for 13% and LRTI for 5% of consultations. Proportion of ARI in male patients was reported higher compared to females. The weekly trend of ARI for the same weeks (from week 1 to 23) from the last three years displays a similar trend to that of 2008. The overall ARI trend, from weeks 10 to 18 remain consistent with a little weekly fluctuation in the earthquake affected districts. However, the proportion of ARI from weeks 12 to 23 in 2008 remains slightly higher than the same period in 2006 and 2007 (Fig 8). During week 23, 2008 there were 3136 consultations for Lower Respiratory Tract Infection and one death was reported from Mansehra district.

Figure 8: Comparison of ARI weekly trends of year 2005, 2006, 2007 and 2008, Earthquake affected districts Pakistan Weekly ARI trend, comparison by year 05, 06, 07 and 08 40 35 30 25 20 15

consultations 10 Percentage of all 5 0 1 4 7 101316192225283134374043464952 Epi-week 2005 2006 2007 2008

Upper and Lower Respiratory Tract Infection:

During week 23, 2008, there were 5% (3,136) of consultations for Acute Lower Respiratory Tract Infections and 16% (11,573) of cases of Upper Respiratory tract Infections reported in all age groups through the DEWS system. There is an overall declining trend in both Upper and Lower Respiratory Tract Infection from week 16, 2008 onwards. The proportion of consultation for ARII remained almost consistent from week 10 to 15. From week 16 onwards proportion of consultations for ARI has further declined (Figure 10).

Figure 10: Weekly Proportion of URTI and LRTI as percentage of all consultations, (week 1 – 23, 2008) Earthquake Affected Areas, Pakistan Weekly proportion of ARI, (week 1-23, 2008) 30 LRTI URTI 25

10 consultations Percentage of all 5

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Epi-week

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Malaria: In week 23, 2008, there were 392 suspected cases of malaria reported. District Poonch is reporting the highest number of suspected malaria case compared to the other districts. In comparison to last week, the proportion of suspected malaria cases has increase in the districts of Poonch, and Battagram and there has been a decrease in cases in the district of Bagh (Fig 9). There were no associated deaths due to suspected malaria reported from any district. Compared to the same weeks from the last two years, the percentage of malaria in 2008 is lower.

Figure 9: Weekly trends in Suspected Malaria as percentage of all consultations, comparison by district, Earthquake Affected Areas, Pakistan, weeks 1-23, 2008 Weekly trend of Malaria by district 1.80 1.60 1.40 1.20 1.00 0.80 0.60 consultations

Percentage of all 0.40 0.20 0.00 1234567891011121314151617181920212223 Epi-week BAGH BATTAGRAM MA NSEHRA MUZAFFARABAD POONCH

Other Conditions under Surveillance:

During this week, 39,036 (55%) consultations out of the total 71,601 consultation, in all ages and both sexes were for health problems other than reportable disease under weekly surveillance. There were 9 cases of Acute Jaundice Syndrome and no cases of suspected AFP reported from any district and there were no cases of suspected Measles, Meningitis, suspected Hemorrhagic Fever, and Neonatal Tetanus reported from any district for week 23, 2008.

Outbreak Alert and Response1

During week 23, 2008, in total 2 alert was identified/ reported and were responded accordingly.

Muzaffarabad:

District Muzaffarabad reported 2 alerts during week 23 and were responded

AIMS Hospital Muzaffarabad reported two suspected cases of meningitis. WHO surveillance team investigated the cases 1. The first case is a 15 month old male child from Athmuqam. Admitted on 2 June 2008, this was only a provisional diagnosis and the patient then turned out to be epileptic.

2. The second case was also a false report of suspected meningitis.

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) 8 WMMR Weekly Morbidity and Mortality Report Pakistan 23 June 2008 / Vol. 133/ DEWS 2008-23

Number of reported cases and deaths per District, AJK

Table 3. Number of reported cases and deaths, Bagh District*, Earthquake Affected Areas, Pakistan, 31May -6 June 2008.

AD SC BD AFP LRTI URTI MAL MS MG AHF SCB UF AJS 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 C D 20 489 0 0 0 18 0 0 0 165 0 1392 0 56 0 0 0 0 0 0 0 282 0 131 0 4 0 6932 1 21 644 0 0 0 14 0 0 0 127 0 1611 0 55 0 0 0 0 0 0 0 268 0 249 0 4 0 6034 1 22 657 0 0 0 18 0 0 0 115 0 1405 0 76 0 0 0 0 0 0 0 253 0 242 0 1 0 5747 0 23 444 0 0 0 22 0 0 0 32 0 907 0 28 0 0 0 0 0 0 0 173 0 131 0 0 0 3921 1 Total 2234 0 0 0 72 0 0 0 439 0 5315 0 215 0 0 0 0 0 0 0 976 0 753 0 9 0 22634 3

Table 4. Number of reported cases and deaths, Poonch District*, Earthquake Affected Areas, Pakistan, 31May -6 June 2008.

AD SC BD AFP LRTI URTI MAL MS MG AHF SCB UF AJS 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 C D 20 880 1 0 0 22 0 0 0 829 0 1879 0 154 0 0 0 0 0 0 0 405 0 1214 0 0 0 4514 0 21 921 0 0 0 12 0 1 0 792 0 1943 0 141 0 0 0 0 0 0 0 470 0 1065 0 0 0 4956 2 22 931 0 0 0 13 0 0 0 871 0 1807 0 140 0 0 0 0 0 0 0 421 0 1235 0 0 0 4430 5 23 930 1 0 0 17 0 0 0 732 0 1538 0 146 0 0 0 0 0 0 0 458 0 1104 0 0 0 4695 1 Total 3662 2 0 0 64 0 1 0 3224 0 7167 0 581 0 0 0 0 0 0 0 1754 0 4618 0 0 0 18595 8

Table 5. Number of reported cases and deaths, Muzaffarabad District*, Earthquake Affected Areas, Pakistan, 31May -6 June 2008.

AD SC BD AFP LRTI URTI MAL MS MG AHF SCB UF AJS 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 C D 20 2201 0 0 0 156 0 0 0 2149 0 5236 0 112 0 0 0 0 0 0 0 1377 0 3750 0 7 0 9752 12 21 2368 0 0 0 125 0 0 0 1942 1 5085 0 129 0 0 0 0 0 0 0 1289 0 3565 0 0 0 10677 6 22 2513 0 0 0 98 0 0 0 1637 0 4902 0 40 0 0 0 0 0 0 0 1327 0 3402 0 2 0 10689 0 23 2554 0 0 0 124 0 0 0 1766 0 4937 0 102 0 0 0 0 0 0 0 1269 0 3452 0 0 0 10616 0 Total 9636 0 0 0 503 0 0 0 7494 1 20160 0 383 0 0 0 0 0 0 0 5262 0 14169 0 9 0 41734 18

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Number of reported cases and deaths per District, NWFP

Table 6. Number of reported cases and deaths, Battagram District*, Earthquake Affected Areas, Pakistan, 31May -6 June 2008.

AD SC BD AFP LRTI URTI MAL MS MG AHF SCB UF AJS 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 C D 20 1079 0 0 0 82 0 0 0 155 0 1720 0 29 0 0 0 0 0 0 0 542 0 816 0 1 0 5641 0 21 1233 0 0 0 110 0 0 0 130 0 1638 0 83 0 0 0 0 0 0 0 479 0 878 0 9 0 5579 1 22 1217 0 0 0 116 0 0 0 160 0 2115 0 81 0 0 0 0 0 0 0 487 0 646 0 11 0 4999 0 23 1095 0 0 0 94 0 0 0 94 0 1502 0 106 0 0 0 0 0 0 0 472 0 975 0 8 0 5119 0 Total 4624 0 0 0 402 0 0 0 539 0 6975 0 299 0 0 0 0 0 0 0 1980 0 3315 0 29 0 21338 1

Table 7. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 31May -6 June 2008.

AD SC BD AFP LRTI URTI MAL MS MG AHF SCB UF AJS 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 C D 20 1287 0 0 0 60 0 2 0 262 0 2871 0 5 0 3 0 0 0 0 0 790 0 1118 0 7 0 11605 0 21 1526 1 0 0 52 0 1 0 256 0 2509 0 11 0 0 0 0 0 0 0 962 0 1201 0 8 0 13867 6 22 1398 1 0 0 35 0 2 0 369 0 2204 0 6 0 0 0 0 0 0 0 762 0 1206 0 4 0 10762 6 23 1398 1 0 0 22 0 0 0 169 1 1992 0 7 0 0 0 0 0 0 0 775 0 1336 0 1 0 12874 8 Total 5609 3 0 0 169 0 5 0 1056 1 9576 0 29 0 3 0 0 0 0 0 3289 0 4861 0 20 0 49108 20