Epidemiological Week No. 2 (6 - 12 Jan) 17 Jan 07/ Vol. 61/ DEWS 2007-02

Shelter is still a Reporting Units...... 2 problem in some EQ affected areas Photo by Dr. Majid Total number of consultations ...... 2 DEWS Data, Epidemiological Week No. 02, 2007...... 3 DEWS Data, Monthly Summary (Epidemiological Weeks No. 51-02)...... 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 Number of reported cases and deaths per District, NWFP ...... 11

ƒ In the past month (Epidemiological ƒ There was one case of measles weeks 51-2 inclusive), 129,123 health reported in districts Mansehra in week 2 events under surveillance were reported of 2007 including 91 deaths ƒ Acute jaundice syndrome cases have increased by 46% as compare with the ƒ This week, there were 302 reporting last week units contributing to the report. ƒ ARI rates are generally lower in week 1 ƒ In week 2, Total 88,585 consultations of 2007 than they were in week 1 of 2006 were reported, with 28 deaths

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, House #6, Street #20, F-7/2, 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 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

Reporting Units

The number of sites able to report increased by one this week. As all the vacations for Eid ul Adha is over it is expected that the number of reporting units will return to a normal level in the following weeks. See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 16 Dec 2006 - 12 Jan 2007. Reporting Health Facilities 30 Dec -05 16-22 Dec 23-29 Dec 06 -12 Jan Area Population Jan Week 51 Week 52 Week 1 Week2 Muzaffarabad 894,364 89 82 98 98 Bagh 452,532 42 33 42 41 Poonch 633,712 63 67 69 65 Mansehra / Balakot 1,154,804 60 64 61 65 Battagram / Shangla 592,256 37 26 31 33 Total 3,727,668 291(90%) 272(84%) 301(93%) 302(93%)

Total number of consultations

In week 2 there was an increase in the number of reporting sites, and the number of consultations also increased to 88,585. The highest number of consultations by district was in Muzaffarabad, with 31,580 and the lowest was in Battagram, at 6,670.

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 W50 W51 W52 W01 W02

Week

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 – 12 January 2007.

2 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

DEWS Data, Epidemiological Week No. 02, 2007

Between 6 - 12 January 2007, 88,585 consultations were reported through DEWS. Overall, 29% (25,374) were due to acute respiratory infections (ARI), same percentage points as compare than the rate in week 2 of 2006. 5% of consultations (4,389) were due to acute watery diarrhoea (AWD), 7% (5,888) due to fever of unknown origin (FUO), and 4% (3,621) due to injuries (INJ). All of these percentages are almost identical to the rate seen in this week last year. ARI in patients under five years is 2% lower in week 2 of 2007 compared to that of week 2 of 2006, at 39% and 41% respectively. At 26% of consultations in patients 5 or more years old, the rate of ARI is substantially the same in this age group as the rate seen in this week last year. All other reportable conditions each represented less than 1% of the total consultations in week 2.

AWD AWD AWD 4% 5% 9% ARI 25% ARI 29% ARI 39%

OTH* FUO 42% 7% OTH* OTH* FUO 59% INJ 55% 7% FUO INJ INJ 4% 7% 4% 3% ≥ 5yrs (n=65,949) < 5yrs (n=22,636) All Ages (n=88,585) Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 6 – 12 Jan2007. *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance DEWS Data, Epidemiological Week No. 01, 2007: Consultations by age

Up to this week, ARI in young children has had a significantly higher rate in winter 2006/7 than in winter 2005/6. However, in some districts the rate of 2006/7 is now lower than that seen last year, and only in Mansehra is the rate for week 2 significantly higher this year than last. See figure 3.

50.0 45.0 40.0 35.0 30.0 2006-02 25.0 20.0 2007-2 15.0 10.0 5.0 0.0

M A D

ARI as a percentARI as of all GH BA ER A BA S N OONCH FAR P

consultations in patients <5 years MA F BATTAGRA ZA U M District

Figure 3: ARI as a percent of all consultations in children under 5, by district, Earthquake Affected Areas, Pakistan 7 – 13 January 2006 and 6 – 12 January 2007

3 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

DEWS Data, Monthly Summary (Epidemiological Weeks No. 51-02)

In the past four weeks, between 16 Dec 2006 – 12 Jan 2007 (Epidemiological weeks 51-02 inclusive), 129,123 consultations for health conditions under surveillance were reported, out of a total 276,486 consultations. 30% (81,651) of consultations were due to acute respiratory infection (ARI), 5% (14,927) acute watery diarrhoea (AWD), 6% (17,715) unexplained fever (FUO) and 4% (12,422) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 16 Dec 2006 – 12 Jan 2007. Week WEEK 51 WEEK 52 WEEK 01 WEEK 02 TOTAL Event C D C D C D C D C D CFR% AWD 4020 1 3016 0 3502 1 4389 1 14927 3 0.020 BD 240 0 232 0 213 0 317 0 1002 0 0.000 AFP 1 0 0 0 0 0 2 0 3 0 0.000 MAL 376 0 312 0 231 0 364 0 1283 0 0.000 ARI 23391 7 16998 8 15888 5 25374 12 81651 32 0.039 MES 0 0 3 0 1 0 1 0 5 0 0.000 MEN 7 0 2 0 4 0 8 0 21 0 0.000 JAU 23 0 37 1 13 0 19 0 92 1 1.086 TET 1 1 0 0 0 0 1 0 2 1 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 5247 0 2993 0 3587 0 5888 0 17715 0 0.000 INJ 3690 1 2441 0 2670 0 3621 1 12422 2 0.016 OTH 42371 18 31736 13 24655 7 48601 14 147363 52 0.035 TOTAL 79367 28 57770 22 50764 13 88585 28 276486 91 RU 291 272 301 302

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 72,797 consultations were reported in the less than 5 years old group, (26% of the total consultations), of which 39% (28,708) were due to ARI, 9% (6,658) due to AWD, 7% (5,071) due to FUO and 3% (2,390) 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 16 Dec 2006 – 12 Jan 2007. Week WEEK 51 WEEK 52 WEEK 01 WEEK 02 TOTAL Event C D C D C D C D C D CFR% AWD 1819 1 1403 0 1453 0 1983 1 6658 2 0.030 BD 72 0 71 0 54 0 89 0 286 0 0.000 AFP 1 0 0 0 0 0 1 0 2 0 0.000 MAL 39 0 44 0 38 0 36 0 157 0 0.000 ARI 8454 6 5902 7 5539 5 8813 10 28708 28 0.097 MES 0 0 3 0 1 0 1 0 5 0 0.000 MEN 2 0 1 0 0 0 1 0 4 0 0.000 JAU 7 0 6 1 3 0 1 0 17 1 5.882 TET 1 1 0 0 0 0 1 0 2 1 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 1515 0 919 0 1051 0 1586 0 5071 0 0.000 INJ 783 0 459 0 494 0 654 0 2390 0 0.000 OTH 8680 5 6202 5 5145 1 9470 3 29497 14 0.047 TOTAL 21373 13 15010 13 13778 6 22636 14 72797 46 RU 291 272 301 302 4 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

In the current week, there was an increase in the number of cases of AWD with 3,502 last week and 4,389 this week. In the current week, ARI increased in the total number of cases as compared with the previous week, (15,888 last week and 25,374 this week) though the rate has declined. 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 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 W50 W51 W52 W01 W02

Week

Figure 4. Weekly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 5 November 2005 – 12 Jan 2007.

Acute Watery Diarrhoea

In week 2 there were 4,389 cases of AWD reported, with one associated death in a patient under five years of age in district Muzaffarabad. In week 1, there was an increase in the rate of AWD in almost all districts, however, this does not appear to be a trend, as the rate has declined in all districts in week 2. See Figure 5.

12.0 10.0 8.0 6.0 4.0 2.0

all consultations 0.0 AWD as a percent ofAWD 2006-51 2006-52 2007-1 2007-2 Week

BAGH BATTAGRAM MA NSERA MUZAFFARABAD POONCH

Figure 5: Trend in AWD as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 16 December 2006 – 12 January 2007

5 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

Bloody Diarrhoea

In week 2, there were 317 cases of bloody diarrhoea reported, an increase over week 1. There were no associated deaths. Bloody diarrhea as a proportion of all diarrhea cases can be used to identify increases in cases that should be investigated. In most districts, this proportion has remained relatively steady or declined in the last four weeks, with the exception of Battagram, which has seen a large increase in week 2. See figure 6

15.0

10.0

cases 5.0

0.0 Bloody diarrhea as a percent of all diarrhea 2006-51 2006-52 2007-1 2007-2 Week

BAGH BATTAGRAM MA NSERA MUZA FFA RABAD POONCH

Figure 6: Trend in bloody diarrhoea as a percent of all diarrhea consultations, by district, 16 December 2006 – 12 January 2007

Acute Jaundice Syndrome

In week 2 there were 19 cases of suspected hepatitis, an increase over the number of cases in the previous week. There were no associated deaths. Despite the increase in the number of cases, the rate of acute jaundice syndrome has declined. See figure 7.

0.2 0.15 0.1 0.05 consultations percent of all 0

5 1 1 0 09 25 29 4 45 Suspected hepatitisSuspected a as -13 -17 -33 -49 7- 6- 6 6 6- 6- 6 6- 6 0 06- 06- 0 0 00 00 0 2 2006-012 2 200 200 2006-212 200 200 2006-372 200 200 Week

Figure 7: Trend in suspected hepatitis as a percent of all consultations, Earthquake Affected Areas, Pakistan, 31 December 2005 – 12 January 2007

6 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

Malaria

In week 2, there were 364 malaria cases reported, with no associated deaths. Malaria varies considerably by district. Bagh has the lowest rate of malaria, with only 1 case for every five reporting sites, while Poonch has the highest rate, at over 3 cases per reporting site. See figure 8.

4 3.5 3 2.5 2 1.5 1 0.5

reporting site 0

Malaria cases per M A D H R A GH E A B S FARAB POONC TTAGRA MAN A F B MUZA District

Figure 8: Malaria cases per reporting site, Earthquake Affected Areas, Pakistan, 15 October 2005 – 12 January 2007

Measles

There was one case of measles reported in week 2, from district Mansehra. In all districts but Mansehra, a majority of the measles cases have been reported in patients under five years old. The largest difference between the age groups is in Battagram, where approximately twice as many cases were reported in the under five age group than the five and over age group. See figure 9.

250 200 150 <5 100 >=5 50

Measels cases 0

M A D H R RA NC BAGH O AG NSE ARABA A F PO TT M BA MUZAF District

Figure 9: Measles cases by district and age group, Earthquake Affected Areas, Pakistan, 15 October 2005 – 12 January 2007

7 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

Acute Respiratory Infection

In week 2, there were 25,374 consultations for ARI reported through the DEWS. There were twelve associated deaths, 8 in Muzaffarabad: 2 over five years and 6 under five years, and 4 deaths in Mansehra, all in patients under five years old. The rate of ARI has been higher than in winter 2005/6 for much of this winter, however, in week 2, the rates are identical for both years. See figure 10

35.0 30.0 25.0 20.0 2005/6 15.0 2006/7 10.0

consultations 5.0 0.0 ARI as a percent of all Week Week Week Week Week Week 49 50 51 52 1 2 Week

Figure 10: Trend in ARI as a percent of consultations, Earthquake Affected Areas, Pakistan, Pakistan 3 December 2005 – 13 January 2006 and 2 December 2006 – 12 January 2007

Other Reportable Diseases and Conditions

There were 8 cases of suspected meningitis in week 2, 7 in Muzaffarabad, and 1 in Mansehra. There were 2 cases of acute flaccid paralysis, in Mansehra. There was one case of tetanus, in Bagh. There were 5,888 cases of fever of unknown origin, and 3,621injuries.

Though the number of cases of fever has increased significantly in the last week, the proportion of consultations that are for unexplained fever remains fairly stable over time. See figure 11.

10.0 8.0 6.0 4.0 2.0 percent of all consultations 0.0 Unexplained fever as a 2007-1 2007-2 2006-40 2006-41 2006-42 2006-43 2006-44 2006-45 2006-46 2006-47 2006-48 2006-49 2006-50 2006-51 2006-52 Week

Figure 11: Fever of unknown origin as a percent of all consultations, Earthquake Affected Areas, Pakistan, 30 September 2006 – 12 January 2007

8 WMMR Weekly Morbidity and Mortality Report Pakistan 17 Jan 2007 / Vol. 60/ DEWS 2007 -02

Outbreak Alert and Response1

Acute Flaccid Paralysis Mansehra Two cases of suspected polio were reported from DHQ Hospital, Mansehra. The first case was a five year old girl from Hafiz Bandi Bherkund. A sample was taken and she was provisionally diagnosed with Guillain-Barre syndrome. The second case was a 3 year old boy from Kenait. On investigation, he was diagnosed with arthritis.

Acute Respiratory Infection: Mansehra A major newspaper ran a story in which the nazim of the area claimed that there had been 20 deaths due to respiratory infections in the area of Sachan Kalan, Siran Valley, district Mansehra. An investigation was carried out by IOM, Mercy Corps (which is supporting basic health units in the area), WHO staff, and the District Support Officer from the EDO-Health office of Mansehra. The investigation could confirm only three deaths since January 1, 2007. When house to house interviews were carried out, it appeared that there may be more deaths among neonates who had never been taken to a doctor, though cause of death was not certain and given the young age (mostly around 2 weeks old) is more likely to be associated with neonatal sepsis. The investigation is ongoing.

Measles Mansehra One case of measles was reported from RHC Shinkiari. On investigation, no address was found, and the patient could not be located.

Meningitis Muzaffarabad

7 cases of meningitis were reported from AIMS hospital. All had CSF examination, and were negative. Despite the testing, three cases were suspected on clinical grounds and were treated for meningitis.

Tetanus Bagh A case of tetanus was reported from BHU Khafarghar. The patient was a four year old boy who had sustained an injury in December that was not properly treated. He came to the BHU on the 9th of January with mild lockjaw and a contaminated wound. He was treated, and is showing signs of recovery.

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 17 January 2007 / Vol. 60/ DEWS 2007 -02

Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, Bagh District, Earthquake Affected Areas, Pakistan, 6 - 12 Jan 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 51 400 0 27 0 0 0 3 0 3411 0 0 0 0 0 0 0 0 0 0 0 192 0 551 0 10842 6 52 378 0 32 0 0 0 6 0 2573 0 0 0 0 0 0 0 0 0 0 0 179 0 573 0 8060 6 01 542 0 20 0 0 0 2 0 2274 0 0 0 0 0 0 0 0 0 0 0 91 0 466 0 6649 4 02 466 0 20 0 0 0 1 0 3027 0 0 0 0 0 0 0 1 0 0 0 185 0 560 0 9966 1 Total 1786 0 99 0 0 0 12 0 11285 0 0 0 0 0 0 0 1 0 0 0 647 0 2150 0 35517 17

Table 7. Number of reported cases and deaths, Poonch District, Earthquake Affected Areas, Pakistan, 6 - 12 Jan 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 51 925 0 21 0 0 0 263 0 3529 3 0 0 0 0 6 0 0 0 0 0 1577 0 562 0 5018 2 52 906 0 29 0 0 0 213 0 3969 1 0 0 0 0 1 0 0 0 0 0 1405 0 608 0 5523 2 01 980 0 24 0 0 0 157 0 2987 0 0 0 0 0 0 0 0 0 0 0 1195 0 462 0 3716 1 02 1177 0 19 0 0 0 237 0 4162 0 0 0 0 0 2 0 0 0 0 0 1930 0 595 0 5912 2 Total 3988 0 93 0 0 0 870 0 14647 4 0 0 0 0 9 0 0 0 0 0 6107 0 2227 0 20169 7

Table 8. Number of reported cases and deaths, Muzaffarabad District, Earthquake Affected Areas, Pakistan, 6 - 12 Jan 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 51 1661 0 130 0 0 0 88 0 9405 1 0 0 7 0 6 0 1 1 0 0 2252 0 2007 0 12899 6 52 916 0 106 0 0 0 25 0 5235 2 0 0 1 0 5 1 0 0 0 0 383 0 766 0 7444 0 01 1275 1 136 0 0 0 58 0 7044 2 1 0 4 0 6 0 0 0 0 0 1735 0 1372 0 7944 1 02 1480 1 170 0 0 0 72 0 10270 8 0 0 7 0 8 0 0 0 0 0 2257 0 1845 1 15478 7 Total 5332 2 542 0 0 0 243 0 31954 13 1 0 19 0 25 1 1 1 0 0 6627 0 5990 1 43765 14

10 WMMR Weekly Morbidity and Mortality Report Pakistan 17 January 2007 / Vol. 60 DEWS 2007 -02

Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 6 - 12 Jan 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 51 361 0 37 0 0 0 3 0 2060 0 0 0 0 0 3 0 0 0 0 0 296 0 195 0 2149 3 52 220 0 32 0 0 0 5 0 839 0 0 0 1 0 7 0 0 0 0 0 348 0 114 0 2157 1 01 289 0 19 0 0 0 11 0 1156 0 0 0 0 0 3 0 0 0 0 0 134 0 113 0 1555 1 02 422 0 68 0 0 0 10 0 2011 0 0 0 0 0 7 0 0 0 0 0 384 0 153 0 3615 0 Total 1292 0 156 0 0 0 29 0 6066 0 0 0 1 0 20 0 0 0 0 0 1162 0 575 0 9476 5

Table 10. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 6 - 12 Jan 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 51 673 1 25 0 1 0 19 0 4986 3 0 0 0 0 8 0 0 0 0 0 930 0 375 1 11433 1 52 596 0 33 0 0 0 63 0 4382 5 3 0 0 0 24 0 0 0 0 0 678 0 380 0 8561 4 01 416 0 14 0 0 0 3 0 2427 3 0 0 0 0 4 0 0 0 0 0 432 0 257 0 4797 1 02 844 0 40 0 2 0 44 0 5904 4 1 0 1 0 2 0 0 0 0 0 1132 0 468 0 13637 4 Total 2529 1 112 0 3 0 129 0 17699 15 4 0 1 0 38 0 0 0 0 0 3172 0 1480 1 38428 10

11