Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 2, Issue 49, Monday 12 December, 2011

Highlights Priority diseases

under surveillance Epidemiological week no. 49 (2 to 8 December, 2011) in DEWS

• 83 districts and 2 agencies provided surveillance data to the DEWS this week from Acute Flaccid Paralysis (AFP) 2,867 health facilities. Data from mobile teams is reported through sponsoring BHU or Acute Jaundice Syndrome (AJS) RHC. Acute Respiratory Infections • A total of 706,484 consultations were reported through DEWS of which 191,866 (Upper and Lower) (ARI) (27%) were acute respiratory infections (ARI); 58,331 (8%) were Skin disease; 52,347 Acute Watery Diarrhoea (AWD)/ (7%) were acute diarrhoea; and 47,750 (7%) were suspected malaria. Suspected Cholera

• A total of 94 alerts with 14 outbreaks were reported in week‐49, 2011: Altogether Acute Bloody Diarrhoea (BD) 31 alerts for Measles; 12 each for AWD and Neonatal tetanus; 8 for Leishmaniasis, 6 for Other Acute Diarrhoeas (AD) Pertussis, 3 for Malaria, 2 for Bloody diarrhoea; and 1 for Acute Jaundice Syndrome; while 19 for others non‐communicable diseases. Suspected Viral Hemorrhagic Fever (VHF) • In this week six new type‐1 polio cases were confirmed by the laboratory, including Suspected Malaria (Mal) one each from Federally Administered Tribal Areas (FR Bannu) & Khyber Pakhtunkhwa Suspected Measles (MS) (Kohat district); and four from Balochistan (Killa Abdullah, Killa Saifullah, Pishin and Harnai districts). As of 12th December, Pakistan has reported a total of 173 polio cases Suspected Meningitis (MG)

(171 type‐1 & 2 type‐3) from 56 districts/towns/tribal agencies & areas. Others

Figure‐1: Weekly trend of leading priority diseases in Pakistan, 29 July 2010 to 8 December 2011 (Epi week 31, 2010 to week 49, 2011)

50 AD BD ARI S. Malaria 45

30 Percentage 25

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 31 33 35 37 39 41 43 45 47 49 51

‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

Disease Wk-42 Wk-43 Wk-44 Wk-45 Wk-46 Wk-47 Wk-48 Wk-49

Acute respiratory infection 213,432 (24%) 193,863 (24%) 217,676 (25%) 103,082 (25%) 210,514 (25%) 224,061 (26%) 242,844 (27%) 191,866 (27%)

Skin diseases 81,161 (9%) 69,393 (9%) 77,842 (9%) 34,276 (8%) 74,134 (9%) 72,895 (8%) 77,057 (9%) 58,331 (8%)

Acute diarrhoea 74,189 (8%) 62,628 (8%) 65,701 (8%) 33,057 (8%) 64,260 (8%) 62,650 (8%) 65,718 (7%) 52,347 (7%)

Bloody diarrhoea 6,089 (0.68%) 5,461 (0.68%) 5,289 (0.60%) 2,764 (0.67%) 6,024 (0.72%) 5,478 (0.64%) 4,912 (0.54%) 4,537 (0.64%)

Suspected malaria 68,441 (8%) 58,613 (7%) 69,408 (8%) 30,218 (7%) 58,136 (7%) 56,468 (7%) 63,826 (7%) 47,750 (7%)

Total consultation 897,598 808,954 879,811 412,812 837,736 859,241 904,948 706,484 Since July 29, 2010, approximately 54,953,184 patient consultations have been reported to the DEWS from all provinces, FATA and AJ&K. While we still receive reports over 800,000 consultations per week.

The above graph shows the weekly trend of four major diseases as percentage of cases out of total consultations reported to DEWS. From last 8 weeks (42 to 49, 2011) acute diarrhoea cases have been decreased (From 8% to 7%), while at the same time cases of ARI have been increased (From 24% to 27%). A slight fluctuation in the suspected malaria cases have been seen recently after consistent seasonal increase from week 35 especially from districts in Sindh and Balochistan.

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 Epidemiological Bulletin: DEWS, Pakistan, Week no. 49 (2 to 8 December, 2011) Current week's (49/2011) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken 6 cases of suspected Leishmaniasis were reported. All patients were attended and found with typical 30‐Nov Leishmaniasis Balochistan Lasbela Bela and Winder 1 2 1 2 lesions. Health Education was given and treatment session arranged. Alert of Malaria reported. Total slides tested 17 out of which 11 were positive for P. Falciparum (SPR 65%). 29‐Nov Malaria Balochistan Lasbela RHC Lakhra 1 1 1 8 The patients were treated and information shared with DHO for necessary action. Request was also made to distribute bed nets among affected community. Village Muhammad Khan Suspected case AWD was admitted on hospital, active surveillance done, 1 stool sample was collected and 30‐Nov AWD Sindh Badin Laghari, UC Chabhralo, 1 2 0 0 tested on RDTs supplied by MSF‐H and found positive for V. Cholera species. Health education imparted, Taluka Tando Bago tabs Ciprofloxin given, EDO‐H informed and 2 water sample also taken. Village Faqir Murad Ali Suspected 8 cases AWD were admitted in hospital, Shallow dug well was the source of water, active surveil‐ 26‐Nov AWD Sindh Umer Kot Sanjrani, UC Satreyun, 1 9 2 7 lance found 11 more cases, health education imparted, Aqua tabs, Zinc tabs, ORS, Jerry cans and Hygiene Taluka Samaro kits were distributed, EDO‐H and DSM PPHI distributed and 5 water sample taken. 14 cases of Pertussis investigated, Throat Swab collected, Tab Erythromycin and Cough Syrup provided by Village Ahmed Din, UC Mian 1‐Dec Pertussis Sindh Sanghar 2 4 5 3 EDO‐H, Sensitized regarding proper vaccination and Personal Hygiene and informed EDO‐H to intensify Taluka Sanghar outreach immunization. Current week's (49/2011) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken 42 patients of suspected malaria were investigated and treated. 70 slides were tested and 42 (SPR=60%) 2‐Dec Malaria Balochistan Lasbela Civil Hospital Bela 12 13 11 6 verified positive of P. Falciparum=33 and P. Vivax=9 (FR=79%). DHO was informed and requested for bed nets provision. Probable Pertussis, 11 cases were reported. All the patients were attended and found with typical diagnosis Allah Abad UC Kohing Tehsil 5‐Dec Pertussis Balochistan Kalat 7 0 3 1 and given treatment. During active surveillance no more cases were found. Sample were collected and sent Kalat to NIH. 8 cases of typhoid were reported from same area investigation confirmed patient presented with typical 8‐Dec Typhoid Balochistan Harnai Pier sher 2 4 0 2 signs and symptoms. Treatment was advised. Health education was given and community was advised to use boiling water or use aqua tabs to disinfect drinking water. 6 cases of AJS was reported from RHC Khanpur. Blood sample was taken and sent to NIH. Health and 6‐Dec AJS KPK Haripur Khanpur 1 3 0 2 hygiene sessions were carried out for the community. LHWs and MT of the health facility were involved. EDO health was informed. 7 cases of suspected bloody diarrhoea were reported from Afghan Refugee camp Basu Mera. Water sample Afghan Refugee Camp Basu 2‐Dec BD KPK Haripur 2 2 3 0 and stool samples were taken and sent to ATH. 42 CHWs were trained on Health and Hygiene, water Mera purification and ORS. Aqua tabs, ORS and hygiene kits were distributed. 4 confirmed cases of enteric fever were reported from Afghan Refugee camp Basu Mera. Water sample and Afghan Refugee Camp Basu 3‐Dec Typhoid KPK Haripur 0 3 0 1 blood samples were taken. Typhi dot test was performed and found positive. Aqua tabs, ORS and hygiene Mera kits were distributed. AWD alert, 5 AWD cases were admitted in hospital, Kacha well was the source of water, Aqua tabs, Zinc Village Mushtaque Lund, UC 7‐Dec AWD Sindh Badin 0 1 2 2 tabs and ORS distributed, EDOH informed and 1 stool sample collected and found positive for V. c. Ogawa, 2 Haji Sawan, Taluka Matli water samples were collected. AWD alert, 1 AWD case admitted in hospital, during active surveillance 4 more cases were found, Tap Village Mangi shoro, UC water and Clay water was the source of water, health education imparted, Aqua tabs, Zinc tabs and ORS 7‐Dec AWD Sindh Jamshoro 1 1 2 1 M.shoro, Taluka Kotri were distributed, EDO‐H informed, 1 stool sample collected and found positive for V. c. Ogawa, 2 water samples were collected. AWD alert, 1 AWD case was admitted in hospital, during active surveillance 2 more cases were found, Khuda ki Basti# 1, UC 8‐Dec AWD Sindh Jamshoro 0 1 1 1 health education imparted, Tank water and Clay water were the sources of water, Aqua tabs, Zinc tabs, ORS Sonowaller, Taluka Kotri and IEC Material distributed, EDO‐H informed with 1 stool and 2 water samples were taken, result awaited. Village Haji Yar Mohammad Suspected malaria, a total of 70 RDTs were tested, out of which 49 were positive (SPR=70%) including 10 7‐Dec Malaria Sindh Khairpur Kandhar, UC Piryalo, taluka 21 15 23 11 Falciparum, 4 Vivax and 35 Mixed (FR=92%). Treatment provided to all positive cases. EDOH informed and Kingri requested for fumigation and IRS. Suspected malaria, a total of 80 RDTs were tested, out of which 57 were positive (SPR=71%) including 12 Village Ali pur, UC Piryaloi, 8‐Dec Malaria Sindh Khairpur 16 23 27 14 Falciparum, 8 Vivax and 37 Mixed (FR=86%). Treatment were given to all positive cases. EDOH informed and taluka Kingri requested for fumigation and IRS. 7 cases of probable Pertussis were investigated, Throat Swab collected, Tab Erythromycin provided by BHU Village Pir Buksh Daultani, 3‐Dec Pertussis Sindh Dadu 1 1 4 1 Khanpur and Hygiene kits, Sensitized regarding proper vaccination and Personal Hygiene and informed EDO‐ UC Torr, Taluka Johi H. Village Dur Muhammad 9 probable Pertussis cases were reported, Throat sample collected, health education imparted, Syp Erythro‐ 8‐Dec Pertussis Sindh Sanghar Laghari, UC Mian Taluka 1 5 1 2 mycin and Cough syrup distributed, Informed EDO‐H and requested to Mop up. Sanghar

Distribution of Wild Polio Virus cases Pakistan 2010 and 2011 Year 2010: The total number of polio cases reported in 2010 is 144 including 120 type‐1 cases and 24 type‐3 from 40 infected districts/ towns/agencies.

Year 2011: As of 12 December, 2011, the total number of polio cases confirmed by the laboratory is 173 (171=type‐1, and 2=type3) from 56 districts.

Cases 2010 Cases 2011 Province P1 P3 P1 P3

Punjab 6 1 5 ‐ Sindh 26 1 30 ‐ Khyber Pakhtunkhwa 19 5 19 ‐ FATA 63 11 48 2 Balochistan 6 6 68 ‐ AJ&K ‐ ‐ ‐ ‐ Gilgit‐Baltistan ‐ ‐ 1 ‐ Islamabad ‐ ‐ ‐ ‐ Total 120 24 171 2

3‐Dec ARI Mianwali BHU Muzafferpor 23 18 28 24 #

3‐Dec BD Rajanpur Basti Sher Garh, Moza khawaja 0 1 0 4 10

3‐Dec Diphtheria Chakwal Village Dhok Bastral UC Saggar Talagang 0 0 0 1 5 8‐Dec Diphtheria D. G. Khan Taratinee village UC Bowata Tribal Area 0 0 0 1

8‐Dec Measles D. G. Khan Mohalla Kalloo Usman urban Taunsa 1 0 0 0 0 Wk‐46 Wk‐47 Wk‐48 Wk‐49 2‐Dec Measles Muzaffargarh Ratyan Wala, UC City‐2 0 0 1 0

8‐Dec Measles Muzaffargarh Basti Fazal Din, Moza Bhindi Korai 0 1 0 0

8‐Dec NNT D. G. Khan DHQ Hospital; Village Pilee Baghal Raknee 1 0 0 0 Weekly number of alerts, Khyber Pakhtunkhwa (Week 46 ‐ 49, 2011) 6‐Dec Pertussis Lahore Asif Town Lahore 0 1 0 0 30 AWD BD DHF Leishmaniasis 5‐Dec Scabies Bhakkar Chak No. 63/TDA, UC Notak, Tehsil Bhakkar 1 11 1 12 25 Malaria Measles NNT + tetanus Pertussis 6‐Dec Scabies Bhakkar BHU Fazil, UC Fazil, Tehsil kalur Kot 3 8 2 11

7‐Dec Tetanus Lahore Village Chunyian Kot Maiyan 0 1 0 0 20

8‐Dec Tetanus Lahore Village Faqir wala 0 1 0 0 15 alerts 2‐Dec UXF Mianwali BHU Paki Shah Mardan 4 32 6 46 of

# 10 8‐Dec UXF Rajanpur Moza Kotla Eisan, Near Grid Station 6 21 4 14 5 Current week's Alerts: Province Balochistan 0 Wk‐46 Wk‐47 Wk‐48 Wk‐49 Date Disease District Area <5M >5M <5F >5F 3‐Dec Leishmaniasis Awaran Shikari village Jhaoo 0 0 0 1

7‐Dec Leishmaniasis Awaran Dumb Ali Mohammad Goth camp Jhaoo 1 0 0 0

7‐Dec Leishmaniasis Awaran Kundi Jhaoo 0 1 0 0 Weekly number of alerts, Punjab (Week 46 ‐ 49, 2011) 30 8‐Dec Leishmaniasis Kalat Zehri Abad UC Jeewa Tehsil Surab 0 0 0 1 AWD BD DHF Leishmaniasis 7‐Dec Leishmaniasis K. Saifullah Muslim Bagh 0 0 0 1 25 Malaria Measles NNT + tetanus Pertussis

8‐Dec Leishmaniasis K. Saifullah Urgas 0 1 0 2 20

8‐Dec Leishmaniasis Sibi Village Marghzani, Village Talli 2 1 0 0 15 alerts

2‐Dec Malaria Lasbela Civil Hospital Bela 12 13 11 6 of

# 10 5‐Dec Measles Kalat Allah Abad UC Kohing Tehsil Kalat 1 0 0 0

6‐Dec Measles Kalat Sheshari UC Kapoto Tehsil Kalat 3 0 1 0 5

3‐Dec Measles Khuzdar Kanak UC Gazgi Tehsil Khuzdar 1 1 0 0 0 Wk‐46 Wk‐47 Wk‐48 Wk‐49 7‐Dec Measles Lasbela Javaid Mari Goth UC Sakran 0 1 4 0

8‐Dec Measles Lasbela Cheezal Abad UC Beroot Hub 1 0 0 0

8‐Dec Measles Ziarat Kawas 0 0 0 1 Weekly number of alerts, Sindh (Week 46 ‐ 49, 2011) 7‐Dec NNT Chagai Killi Kani UC Chilgazi 0 0 1 0 30 AWD BD DHF Leishmaniasis 5‐Dec Pertussis Kalat Allah Abad UC Kohing Tehsil Kalat 7 0 3 1 Malaria Measles 25 NNT + tetanus Pertussis 8‐Dec Typhoid Chagai Street No.3 Faisal Colony 0 2 1 2 20 8‐Dec Typhoid Harnai Pier sher 2 4 0 2 Current week's Alerts: AJK; FATA; GB 15 ale rts

Date Disease District Area <5M >5M <5F >5F # 10 8‐Dec Measles Bagh Qandeel Colony Town Bagh 0 0 0 1 5 8‐Dec Measles Bagh Village Attar pariyan 1 0 0 0

8‐Dec Measles Poonch vill Jehri UC Hurnamera 0 0 0 1 0 Wk‐46 Wk‐47 Wk‐48 Wk‐49 8‐Dec Pertussis Bajaur Agency Village haji lawang, Tehsil Khar 0 0 1 0

3‐Dec Meningitis Skardu Village Sermik, UC Mehdi Abad 0 1 0 0

3‐Dec Pertussis Ghanche Village sino, UC Thagus 1 0 0 0

7‐Dec NNT N. Feroze Village Mino Dero, UC Khan Wahan 1 0 0 0 7‐Dec Measles Swabi Private Clinic, Maini Chok, Khalid Batay 0 0 3 0 2‐Dec NNT Qamber Village tekho khan mugheri 1 0 0 0 8‐Dec NNT Qambar Village mian Shal mohammed 0 0 1 0 9‐Dec Mumps Haripur Village Salam Khad 1 12 1 5 6‐Dec NNT Shikarpur DHQ Shikarpur 1 0 0 0 3‐Dec Pertussis Dadu Village Pir Buksh Daultani, UC Torr 1 1 4 1 9‐Dec NNT D. I. Khan D.I Khan 0 1 0 0 8‐Dec Pertussis Sanghar Village Dur Muhammad Laghari, UC Mian 1 5 1 2 3‐Dec Typhoid Haripur Afghan Refugee Camp Basu Mera 0 3 0 1 5‐Dec Tetanus Kashmore SZ Hospital, Rahim Yar Khan 0 0 0 1 Acute Respiratory Infection (ARI)

As the weather changes especially in the northern areas, the numbers of Diarrheal cases decreased while Acute Respiratory Infection (ARI) cases increased very rapidly more than 25% of all cases were of ARI dur‐ ing last few weeks, which is a threat to the community especially the children.

To reduce the morbidity and mortality due to ARI, WHO is supporting the district health system to ensure 24‐hour care to children hospitalized with pneumonia and similar illnesses in the flood‐affected districts. The interventions to control ARI can be divided into four basic categories: immunization against specific pathogens, early diagnosis and treatment of disease, improvements in nutrition, and safer environments. The first two fall within the purview of the health system, whereas the last two require multisectoral in‐ volvement. The Federal EPI program with donor support is providing vaccination while WHO is providing technical and financial support in early diagnosis and treatment of disease. It is planned that 82 ARI units in public health hospitals will be supported for 2 to 3 months in targeted districts.

The ARI units supported by WHO are in public health facilities designated in consultation with the district and provincial health departments and organized under the supervision of the hospital administration and pediatrician. The existing health staff and additional staff, where needed, are involved in two days’ training on case management of ARI imparted to them by expert trainers on WHO guidelines. In this manner, these ARI units are providing quality services for the hospitalized children 24 hours round the clock. Essential medicine for ARI and some equipment which includes Nebulizers, Ambu Bags, Oxygen concentrators and Oxygen cylinders will also be provided to the special ARI units where needed.

3500 7 2 2 7

Acute respiratory infection 3 12,407,923 (23%) 8 6 7 7 7 6 8

3000 13 6 6 6

Skin diseases 8 5,808,570 (11%) 8

8 8 8 11 2500 11 8 11 8 11

Acute diarrhoea 5,148,020 (9%) 2000 8 12 411 400 375 331 11 3375 3363 215 3354 361 3329

1500 192 3259 3259 3251 3250 26 3234 3215 3196 3156 153 3142 3120 3109 3058 26 3021 3022 2982 2935 128 2909 2867 2846 2785 Bloody diarrhoea 2777 2752 2745 2743

455,074 (1%) 105 2716 2706

2671 2648 46 2597 2564 2550 2547 2532 81 2522 2477 2466 2450 58 2404 2349 1000 2322 2262 2255 2251 2199 2022 2021 1797 1680 1488 Suspected malaria 1463

3,422,846 (6%) 500 1289

1215 1167 1158 1143 1130 999 1113 1111 967 1073 1067 949 879 854 0 3 5 7 9

Unexplained fever 2,103,446 (4%) 11 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 33 35 37 39 41 43 45 47 49 51 47 49 ‐

1 Wk Wk Wk Wk

Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Total consultations 54,953,184 Wk Epi‐week Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response Post Flood 2010 2011 (up till wk 48) Current Week (49) Total Disease A O A O A O A O Acute watery diarrhoea 209 85 1319 539 12 3 1540 627 Acute jaundice syndrome 5 2 45 15 1 1 51 18 Bloody diarrhoea 10 1 93 19 2 1 105 21 Dengue fever 81 32 784 111 865 143 Measles 48 6 1568 88 31 1647 94 Pertussis 1 ‐ 263 71 6 3 270 74 NNT + tetanus 5 ‐ 349 12 366 0 Malaria 12 7 121 80 3 3 136 90 Leishmaniasis 1 ‐ 253 29 8 262 29 Others 75 11 575 65 19 3 669 79 Total 447 144 5370 1017 94 14 5911 1175 Province Khyber Pakhtunkhwa: Figure-3: Trend of priority communicable diseases, province KPK • This week 679 health facilities from 19 districts reported to 50 DEWS with a total of 120,029 patients consultations. 45 40 The proportional morbidity of AD (7%) is same as compared • 35 with last week. 30

25 • 18 alerts were reported in this week, 10 were for Measles; 2 for 20 Percentage H1N1; while 1 each for AJS, Bloody diarrhoea, Leishmaniasis, 15 Neonatal tetanus, Mumps and Typhoid. 10

5 • 4 outbreaks, 1 each for AJS, Bloody diarrhoea, Mumps and 0 1 3 5 7 9

11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 31 33 35 37 39 41 43 45 47 49 51 45 47 49

Typhoid were received and responded this week. wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk AD BD ARI S. Malaria

Province Sindh: Figure-4: Trend of priority communicable diseases, province Sindh • This week 1,050 health facilities from 23 districts reported a 50 total of 321,681 patient consultations. AD BD ARI S. Malaria 45 • In Sindh, AD cases reported were 25,720 (8%), same propor- 40 tional morbidity as compared with last week. 35 30 • 32 alerts were reported from Sindh in this week: 12 were for 25 AWD; 9 for Measles; 6 for Neonatal tetanus; 2 each for Pertus- Percentage 20 sis and Malaria, while 1 for Tetanus. 15 10 • 7 outbreaks, 3 for AWD, 2 each for Malaria and Pertussis were 5 received and responded this week. 0 1 3 5 7 9

31 33 35 37 39 41 43 45 47 49 51 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

40 • AD cases reported were 10,283 (6%) and showing 1% higher 35 proportional morbidity as compared with last week . 30

25 20 alerts were reported in this week from Punjab; 4 for ARI; 3 • 20

each for Measles and Neonatal tetanus; 2 each for AD, Diph- Percentage 15 theria, Scabies, Unexplained fever; while 1 each for Bloody 10 diarrhoea and Pertussis. 5 0 1 3 5 7 No outbreak for any disease was received this week. 9

• 45 31 47 33 49 35 37 39 41 43 45 47 49 51 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

Province Balochistan: Figure-6: Trend of priority communicable diseases, province Balochistan • In this week, 18 districts reported to DEWS from Ba- lochistan province. 469 health centers reported a total 50 AD BD ARI S. Malaria of 68,266 patient consultations. 45 • AD reported in 5,341 (8%) of the total consultations, 1% 40 lower proportional morbidity as compared with the last 35 week. 30 25

• 18 alerts were reported in this week from Balochistan, 7 Percentage 20 for Leishmaniasis; 6 for Measles; 2 for Typhoid; while 1 15 each for Malaria, Neonatal tetanus and Pertussis. 10 • 3 outbreaks, 1 each for malaria, Pertussis and Typhoid 5 0 was received and responded this week. 2 4 6 8

46 48 32 34 36 38 40 42 44 46 48 50 52 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk Province Gilgit Baltistan:

Figure-7: Trend of priority communicable diseases, Gilgit Baltistan

• In this week, 29 health centers from 5 districts in Gilgit 50 AD BD ARI S. Malaria Baltistan sent weekly report with a total of 4,766 patient 45 consultations. 40

35 • ARI cases reported were 3,306 (27%), while Acute diar- 30 rhoea were 482 (10%). 25

20 Percentage • 2 alerts 1 each for Meningitis and Pertussis were re- 15 ceived and responded in this week. 10 5 0 47 48 49 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk State of Azad Jammu and Kashmir: FATA:

• In this week, reports were received from 127 health facilities from 10 • This week 35 health facilities in 2 agencies reported from FATA, districts with a total of 23,043 patient consultations. with a total of 4,748 patient consultations. • ARI cases reported were 4,790 (21%), while Acute diarrhoea reported • ARI cases reported were 1,379 (29%), while Acute diarrhoea was 936 (4%) cases. reported 306 cases (6%) • 3 alerts for Measles were received and responded this week. • 1 alert for Pertussis was received and responded this week.

50 50 45 AD BD ARI S. Malaria AD BD ARI S. Malaria 40 40 35 30 30 25 20 20

Percentage 15 Percentage 10 10 5 0 0 7 8 9 47 48 49 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

40 41 42 43 44 45 46 47 48 49 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk