Ministry of Naonal Health Services, Regulaons & Coordinaon Government of Pakistan Naonal Instute of Health, Islamabad, Pakistan Field Epidemiology & Disease Surveillance Division (FE&DSD) Tel: 051-9255237, 9255575 Naonal Focal Point for Internaonal Health Regulaons (IHR) 48th Issue June - September 2020 SEASONAL AWARENESS AND ALERT LETTER (SAAL) For Epidemic-prone infectious diseases in Pakistan Summer / Monsoon Season

OBJECTIVES OF SAAL Outbreak - Prone Diseases Alerts Ÿ To alert concerned health authories and professionals at all levels about the Chikungunya epidemic-prone infecous diseases in the summer/Monsoon season. Cholera (Acute watery Diarrhea) Ÿ To facilitate the preparaons for mely and efficient response to the Coronavirus disease 2019 (COVID-19) encountered alerts/outbreaks/ epidemics and thus reduce the associated Crimean Congo Hemorrhagic Fever (CCHF) morbidity and mortality. Dengue Fever DATA SOURCES Diphtheria The available naonal data collected during 2015 to May 2020 by FE&DSD, NIH, Leishmaniasis Provincial Health Departments, Provincial Disease Surveillance & Response Units Malaria (PDSRUs), Expanded Program on Immunizaon (EPI), Directorate of Malaria Control and laboratory based data from NIH has been analyzed to assess the Measles exhibited paerns of high priority communicable diseases. Meningococcal Meningis The descripon of all priority diseases has been arranged in an alphabecal order. Pertussis Addionally, under the secon of Naonal Potenal Public Health Events, Poliomyelis technical detail on the Heat stroke and Primary Amebic Meningoencephalis Typhoid Fever (XDR) infecon is included. Ebola Virus disease and Middle East Respiratory Syndrome High Alert- peak occurrence in the Summer/Monsoon season Corona Virus (MERS CoV) have been shared as Internaonal Public Health Events. Medium Alert- cases will be encountered and may show up as an outbreak

Cholera (Acute Watery Diarrhea) Reported Lab Confirmed AWD Cases month wise in Pakistan from Introducon: Cholera is an acute, diarrheal illness caused by January 2014 to May 2020 (n=4,551) infecon of the intesne due to bacterium Vibrio cholerae. It 1200 remains a global threat to public health and is global indicator 1000 of inequity and lack of social development. It is esmated that 800 every year, there are 1.3 to 4.0 million cases of cholera, and 600

21,000 to 143,000 deaths worldwide due to the infecon (1). No. of Cases 400 Clinical Picture: Cholera infecon is oen mild or without 200 symptoms, but can somemes be severe and life threatening. 0 Approximately 5-10% infected persons in the early stages will Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec have severe disease characterized by profuse watery diarrhea, Months voming, and leg cramps. In these people, rapid loss of body Average Trend 2014 2015 2016 fluids leads to dehydraon and shock (1). 2017 2018 2019 2020 Reservoir of Infecon: Humans and aquac environment are Geographical Distribuon in Pakistan: reservoirs for V. cholerae O1 and O139. Humans are considered the primary reservoir and can be asymptomac Province/Area wise Distribuon of Lab Confirmed AWD Cases in carriers (2). Pakistan from January 2014 to May 2020 (n=4,551) Infecous Agent: Vibrio cholerae (1) 80.00% 72% Mode of transmission: Infecon results from ingeson of 70.00% organisms present in contaminated food and water or directly 60.00% from person to person by the fecal–oral route (3) e (%) ag t 50.00%

Incubaon period: Few hours to 5 days (4) cen er Infecvity period: The contagious period for cholera begins as P 40.00% soon as the organism is excreted in the feces. This can occur as 30.00% early as about 6 to 12 hours aer exposure to the bacteria and 20.00% 13% 12% can last for about 7 to 14 days (5). 10.00% Seasonality: Throughout the year; higher incidence from 0.11% 1% 1.54% 0.00% 0.00% 0.00% August to November in hot, humid and rainy season (6). IslamabadPunjab Sindh KPK Balochistan AJK GB KPTDs Province/Area Alert Threshold: One suspected case of AWD is an alert (7). vaccinaon against cholera is not a substute for standard Outbreak Threshold: One lab confirmed case, or cluster of 6 or prevenon and control measures (4). more cases of AWD in one locaon, is an outbreak (7). References: References are available in online version at Case Definions: www.nih.org.pk Suspected case: Three or more abnormally loose or fluids Coronavirus Disease 2019 (COVID-19) stools in the past 24 hours and/with dehydraon Probable Case: Introducon: A Novel Coronavirus Disease (COVID-19), is a Ÿ Person aged over 5 years with severe dehydraon or death member of the coronavirus family that has never been from acute watery diarrhea with or without voming OR idenfied or encountered before. Coronaviruses are large Ÿ Person aged above / less 2 years with acute watery diarrhea family of viruses causing illness in humans as well as among in an area where there is a Cholera outbreak. animals i.e. camels, cats and bats. MERS-COV and SARS-CoV-1 Confirmed Case: Any suspected case confirmed through also belongs to the same family. isolaon of Vibrio cholerae 01 or 0139 from the stool (7) Outbreak of this viral disease started in Wuhan city, capital of Specimen Collecon and Transportaon: central China's Hubei province during late December 2019, Ÿ Place specimen in clean container and transport to when a cluster of paents were admied to hospitals in Wuhan laboratory within two hours of collecon at room with an inial diagnosis of pneumonia of unknown aeology temperature (1). The cluster was epidemiologically linked to a local seafood Ÿ If there is a 72 hours delay, place stools soaked swab in a and wet animal wholesale market, suggesve of zoonoc spill Cary-blair transport medium (7). over. Amid the rising spread of the 2019 Novel Coronavirus Case Management: ORS should be given orally every hour. Even cases globally, the World Health Organizaon has declared this with severe dehydraon, intravenous electrolyte soluons outbreak as a Public Health Emergency of Internaonal should be used only for inial rehydraon, including those who Concern (PHEIC) on January 30, 2020 (2). are in shock. Severely dehydrated paents require th st administraon of intravenous fluids. Ringer's Lactate Soluon COVID-19 cases from 26 February to 31 May, 2020 in Pakistan: (Hartman's Soluon) is the preferred fluid for intravenous Number of COVID-19 Number of COVID-19 Number of deaths rehydraon. suspected cases ll Lab. confirmed cases due to COVID-19 ll Anbiocs (Doxycycline, Ciprofloxacin, Cefixime, Co- date ll date date trimaxozole, Erythromycin) reduce the duraon of disease and 5,27,173 72,460 1,543 period of excreon of V. cholerae in the stool of an infected Infecous Agent: Severe acute respiratory syndrome paent (7). Prevenve measures & vaccinaon: Ensure adequate safe coronavirus-2 (SARS-CoV-2) belongs to the beta CoV category drinking water supply and proper sanitaon. (7). of coronavirus family. It's a single-stranded RNA genome (3). People (visitors or residents) in areas where cholera is occurring Clinical Picture: The clinical course of the COVID-19 is divided o r h a s o c c u r re d s h o u l d o b s e r v e t h e fo l l o w i n g into three categories; recommendaons: Mild Symptoms: It usually presents with symptoms of upper Ÿ Drink only boled, or chemically treated water and boled respiratory tract viral infecon, including fever, cough (dry), or canned carbonated beverages. When using boled sore throat, and nasal congeson. Some paents may present drinks, make sure that the seal has not been broken. To with gastrointesnal symptoms like nausea, voming, make water safe for drinking, it is advisable to boil or diarrhea, loss of sense of smell and taste. chlorinate it. Moderate Symptoms: Respiratory symptoms include cough Ÿ Use boled, boiled or chemically treated water to wash and shortness of breath (or tachypnea in children) with or Fruits, Vegetables & dishes and for preparing food. without fever may present, coupled with headache, muscle Ÿ To disinfect water: boil for 1 minute or filter the water and pain, or malaise and later loss of smell and taste in some cases. add 2 drops of household bleach or ½ an iodine tablet per Severe Symptoms: High grade fever is associated with severe liter of water dyspnea, respiratory distress, tachypnea (> 30 breaths/min), Ÿ Avoid drinking tap water and hypoxia (SpO2 < 90% on room air). However, the fever Ÿ Wash hands oen with soap and clean water symptom must be interpreted carefully as even in severe forms Ÿ If no water and soap are available, use an alcohol-based of the disease, it can be moderate or even absent. Cyanosis can hand cleaner (with at least 70% ethyl alcohol) occur in children. In this definion, the diagnosis is clinical, and Ÿ Clean hands especially before eang or preparing food and radiologic imaging is used for excluding complicaons. Chest aer using the bathroom imaging ulized includes chest radiograph, CT scan, or lung Ÿ Eat food that is packaged or is freshly cooked. ultrasound demonstrang bilateral opacies (lung infiltrates > Ÿ Do not eat raw and undercooked meat or unpeeled fruits 50%) (4). and vegetables Asymptomac/Atypical presentaon: Nasopharyngeal/ Ÿ Dispose off feces in a sanitary manner to prevent Oropharyngeal RT- PCR posive for SARS-CoV-2 but having no contaminaon of water and food sources (4) symptoms. Vaccinaon: A single-dose live oral cholera vaccine (lyophilized Reservoir: Its origin is not enrely understood, the genomic CVD 103-HgR) for adults 18 – 64 years old is recommended who analyses suggest that SARS-CoV-2 probably evolved from a are traveling to an area of acve cholera transmission. Two strain found in bats and snakes. The potenal amplifying other oral inacvated or non-live cholera vaccines, Dukoral® mammalian host, intermediate between bats and humans, is, and ShanChol®, are World Health Organizaon (WHO) however, not known (5). prequalified. No cholera vaccine is 100% protecve and Modes of Transmission: COVID-19 virus is primarily transmied between people through respiratory droplets via 4. Other situaons as indicated by local risk assessments. coughing, sneezing, or talking and contact routes. It may be Note: for confirmed asymptomac cases, the period of contact possible that a person can become infected by touching a is measured as the 2 days before through the 14 days aer the surface or object (fomites) that has the virus present on it and date on which the sample was taken which led to then touching their own mouth, nose, or possibly their eyes, confirmaon.(7) but this is not thought to be the main way the virus spreads. Laboratory Confirmaon: Roune confirmaon of COVID-19 Airborne transmission may be possible in specific cases is based on detecon of COVID-19 virus nucleic acid circumstances and sengs in which procedures or support (RNA) by real me RT-PCR assays. RNA can be extracted from treatments that generate aerosols are performed; i.e., samples such as oropharyngeal/nasopharyngeal swabs, nasal endotracheal intubaon, bronchoscopy, administraon of swabs/secreons, bronchoalveolar lavage fluid/washings or nebulized treatment, turning the paent to the prone posion, sputum, using any standard extracon protocols or kits. disconnecng the paent from the venlator, non-invasive Specimen Collecon and Transportaon: For transport of posive-pressure venlaon, tracheostomy, and samples (nano pharyngeal / oropharyngeal swab) for viral cardiopulmonary resuscitaon.(6) detecon, use viral transport medium (VTM) containing Incubaon Period: It ranges from 02 days to 14 days from the anfungal and anbioc supplements. Avoid repeated freezing date of last contact to infected person. and thawing of specimens. If VTM is not available sterile saline Period of Communicability: 02 days before the onset of may be used instead (in which case, duraon of sample storage symptoms and up to 10 days aer the onset of illness in mild at 4 °C may be different from what is indicated below. disease and up to 02 weeks or more in case of severe disease. Aside from specific collecon materials also assure other Note: COVID-19 is an emerging disease and with the day to day materials and equipment are available: e.g. transport evolving situaon, there is more to learn about its containers and specimen collecon bags and packaging, transmissibility, severity, and other features. coolers, and cold packs or dry ice, labels and permanent Alert Threshold: One probable case is an alert and requires an markers, PPE, materials for decontaminaon of surfaces, immediate invesgaon. etc.(8) Outbreak Threshold: One lab confirmed case of COVID-19 is an Specimen Transport to Storage ll Comments outbreak (7). laboratory at tesng Case Definions: Nasopharyngeal and 4°c =48 hours: 4 °C The nasopharyngeal and Suspected Case: A. Paent with acute respiratory illness (fever oropharyngeal Swab >48 hours: -70 °C oropharyngeal swabs and at least one sign/symptom of respiratory disease, e.g. should be placed in the cough, shortness of breath), AND a history of travel to or same tube to increase residence in a locaon reporng community transmission of the viral load. Bronchoalveolar lavage 4°c =48 hours: 4 °C COVID-19 disease during the 14 days prior to symptom onset; >48 hours: -70 °C OR Sputum 4°c =48 hours: 4 °C Ensure the material is B. A paent with any acute respiratory illness AND having been >48 hours: -70 °C from the lower in contact with a confirmed or probable COVID-19 case (see respiratory tract definion of contact) in the last 14 days prior to symptom (Endo) tracheal aspirate, 4°c =48 hours: 4 °C onset; OR nasopharyngeal aspirate >48 hours: -70 °C C. A paent with severe acute respiratory illness (fever and at or nasal wash least one sign/symptom of respiratory disease, e.g., cough, Laboratory tesng for 2019 novel coronavirus in suspected human cases. shortness of breath; AND requiring hospitalizaon) AND in the WHO/2019-nCoV/laboratory/2020.3 absence of an alternave diagnosis that fully explains the Case Management: There is no specific therapeuc presently clinical presentaon. (7) approved by the U.S. Food and Drug Administraon (FDA) to Probable Case: A. Suspected case for whom tesng for the prevent or treat COVID-19. There is no proven role of COVID-19 virus is inconclusive. OR prophylacc chloroquine or hydroxychloroquine at this me. B. A suspect case for whom tesng could not be performed for Current clinical management includes infecon prevenon & any reason. control measures and supporve care, including supplemental Confirmed Case: A person with laboratory confirmaon of oxygen and mechanical venlatory support when indicated. COVID-19 infecon, irrespecve of clinical signs and symptoms. Prevenve Measures: (7) 1. Clean hands regularly with an alcohol-based hand rub, or Contact: A contact is a person who experienced any one of the wash thoroughly with soap and water. following exposures during 2 days before and 14 days aer the 2. Clean surfaces regularly with recommended disinfectants onset of symptoms of a probable or confirmed case: (70% Ethyl Alcohol or 0.5% bleach soluon). 1. Face-to-face contact with a probable or confirmed case 3. Avoid touching eyes, nose and mouth with contaminated within 1 meter/3 feet and close contact for more than 15 hands. minutes; 4. Pracce respiratory hygiene by coughing or sneezing into 2. Direct physical contact with a probable or confirmed a bent elbow or ssue and then immediately dispose off case; 5. Wear a medical/surgical mask if you have respiratory 3. Direct care for a paent with probable or confirmed symptoms and perform hand hygiene aer disposing off COVID-19 disease without using proper personal of the mask protecve equipment; OR 6. Maintain a minimum of mandatory 2 meter or six feet distance from individuals with respiratory symptoms. Incubaon Period: 7. Healthcare workers are required to select and use Ÿ 1-3 days aer ck bite appropriate PPE. Ÿ 5–6 days aer exposure to infected blood or ssues with a Administrave controls (documented) maximum of 13 days (8). 1. Ensure the availability of IPC resources such as PPE, Seasonality: Peak of cases occur during Fall and Spring seasons, appropriate infrastructure, clear IPC policies, access to lab associated with life-cycle of cks, exposure of new born tesng, triage and paent placement, adequate staff and animals, exposure of migrant animals (9). training of the staff. Reported Lab Confirmed CCHF Cases month wise in Pakistan Environmental and engineering controls from January 2014 to May 2020 (n=356) 1. Stay in the venlated rooms 50 45 2. Clean the surfaces with recommended disinfectants. 40 Social Behavior Change: 35 30 1. Pracce social distancing, parcularly from individuals 25 20 showing respiratory symptoms. No. of Cases 15 2. Avoid mass gatherings like weddings, cinemas, crowded 10 5 shopping malls and restaurants.(9) 0 Vaccinaon: No vaccine is currently available. Trials are in JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Months process for COVID-19 vaccine. There is currently no evidence 2014 2015 2016 2017 2018 2019 2020 that people who have recovered from COVID-19 and have Geographical Distribuon in Pakistan: Since the diagnosis of developed anbodies are protected from a second infecon. first human case of CCHF in 1976, the sporadic cases have Hence it's a fallacy that detecon of anbodies to the SARS- connued to occur all over in Pakistan and predominantly from CoV-2, the virus that causes COVID-19, could serve as the basis Balochistan. for an “immunity passport” or “risk-free cerficate” that would enable individuals to travel or to return to work assuming that Province/Area wise Distribuon of Lab Confirmed CCHF Cases in Pakistan from January 2014 to May 2020 (n=356) they are protected The development of immunity to a 40% 38% pathogen through natural infecon is a mul-step process. (10) 35% References: References and Guidelines are available in online version at www.nih.org.pk 30% e (%) 25% 23% ag CRIMEAN-CONGO HEMORRHAGIC FEVER (CCHF) t

cen 20% er Introducon: A ck-borne zoonoc viral disease that is P 15% 14% 14% asymptomac in infected animals, but can be a serious threat 10% to humans (1). Human infecons begin with nonspecific febrile 6% 5% 5% symptoms, but can progress to a serious hemorrhagic 0 syndrome with a high case fatality rate (10 – 40%) (2). It is one of 0% Islamabad Punjab Sindh KPK Balochistan AJK KPTDs the most widely distributed viral hemorrhagic fevers occurring Provinces/Areas in different parts of Africa, Middle-East, Asia and Europe. CCHF Alert Threshold: One probable case is an alert and requires is endemic in Pakistan with sporadic outbreaks. (3). Occurrence immediate invesgaon (11). of virus is correlated with the distribuon of Hyalomma ck Outbreak Threshold: One lab confirmed case of CCHF is an species (Principle vector) (4). outbreak (11). Clinical Picture: Sudden onset with inial signs and symptoms Case definions: including headache, high grade fever, backache, joint pain, Suspected Case: Any person with sudden onset of fever over upper abdominal pain, voming, redness of eyes, a flushed o 38.5 C for more than 72 hours and less than 10 days, especially face, sore throat, and petechiae (red spots) on the palate. in a CCHF endemic area and those in contact with livestock such Symptoms may also include jaundice along with changes in as shepherds, butchers, animal handlers and health care mood and sensory percepon. With progression of the illness, personals (11). large areas of severe bruising, severe nose bleeds, and Probable Case: Suspected case with history of febrile illness of uncontrolled bleeding at injecon sites can be seen, usually 10 days or less with an epidemiological link AND any two of the beginning on the fourth day of illness and lasng for about two following: thrombocytopenia less than 50,000/mm3, petechial weeks(5). or purpuric rash, epistaxis, haematemesis, haemoptysis, blood Infecous Agent: Crimean-Congo Haemorrhagic Fever (CCHF) in urine and/or stools, ecchymosis and gum bleeding (11). Virus belongs to Bunyaviridae family (1) Confirmed Case: Suspected/Probable case confirmed through Reservoir: Hyalomma ck, domesc animals, such as cale, PCR and/or serology (11). goats, sheep, rodents, such as hedgehogs, rats, hares and birds Laboratory Confirmaon: Blood for PCR test and ELISA test are generally resistant with the excepon of Ostrich (6). Specimen Collecon and Transportaon: Collect 3-5ml of Mode of transmission: Bite of the infected Hyalomma ck blood in vacutainer observing strict biosafety precauons. (vector), handling of ck infested animals, direct contact with Keep in upright posion to prevent hemolysis. Transport to the blood / ssue of infected domesc animals (slaughtering); or laboratory in triple package with ice packs along with a direct contact with blood / ssue of infected paents. prominent Bio-Hazard label and complete lab request form Nosocomial infecons are common sources of transmission (7). with brief history of the paent (11). Case Management especially when they are acve (spring to fall). Ÿ Paents with probable or confirmed CCHF should be o Regular examinaon of clothing and skin for cks, and their isolated and cared for using strict barrier-nursing removal (without crushing them). techniques with recommended Infecon Prevenon & o Wearing light colored clothing, covering legs and arms, and Control (IPC) measures i.e. standard plus contact using repellents on the skin. precauons. Use addional precauons, (droplet/aerosol) o Other measures, such as wearing gloves or other protecve in case of any extensive contact/ procedure. clothing to prevent skin contact with infected ssues or Ÿ Only designated medical / para-medical staff and blood, may be taken by persons who work with livestock or aendants should aend the paent. other animals. Ÿ All medical, para-medical staff and aendants should wear For ck control, animal dipping/spraying in an inseccide recommended Personal Protecve Equipment (PPE) before soluon of Permethrin/Pyrethrin/DEET is used. Injectable entering the isolaon room and must dispose it properly inseccide like Ivermecn is also recommended. aer use. Ÿ Butchers should wear gloves and other protecve clothing Ÿ All secreons of the paent and hospital clothing in use of to prevent skin contact with freshly slaughtered meat, blood the paent and aendants should be treated as infecous and other ssues. Meat should be drained for least 30 and where possible, should be autoclaved before minutes, before distribuon to public. incinerang. Ÿ Hospitals in endemic areas should ensure standard plus Ÿ Every effort should be made to avoid spills, pricks, injury and contact precauons in OPD and emergency rooms. Ensure accidents during the management of paents. Needles injecon safety measures and maintain stock of Ribavirin should not be re-capped but discarded in proper safety with PPE. disposal box. Ÿ Bio-safety is the key element to avoid nosocomial infecon. Ÿ All used material e.g. syringes, gloves, cannula, tubing etc. Suspected or confirmed CCHF cases must be isolated and should be collected in autoclave-able bags and autoclaved cared by using barrier-nursing techniques to prevent before incinerang. transmission of infecon to health workers and others. Ÿ Aer the paent is discharged from the hospital, room Ÿ In case of death of paent posive with CCHF, family surfaces should be wiped down with disinfectant like members should be advised to follow safe burial pracces. sodium hypochlorite (Naocl) 10% soluon and the room Ÿ Exposed contacts: Those with high risk exposure (needle should be fumigated in case of risk for ck infestaon (12). sck, sharps, blood or body fluids) contacts should be Treatment: General supporve therapy is the mainstay of CCHF observed for fever for 14 days. If fever develops, Ribavirin management. Intensive monitoring to guide volume and blood should be started immediately (12). component replacement is recommended. If the paent meets Ÿ There is no approved vaccine available (13). the case definion for probable CCHF, oral Ribavirin needs to be Guideline Link: hps://www.nih.org.pk/wp- iniated immediately in consultaon with the aending content/uploads/2019/07/Advisory-CCHF-July-2019.pdf physician. Studies suggest that Ribavirin is most effecve if References: References are available in online version at given within the first 6 days of illness. Oral Ribavirin: 30 mg/kg www.nih.org.pk as loading dose, followed by 16 mg/kg every 6 hours for 4 days and then 8 mg/kg every 8 hours for net 3 days (12). DENGUE FEVER Prophylaxis Protocol: Introducon: Dengue is a mosquito-borne viral disease (also Ÿ The efficacy for post exposure Ribavirin in the management known as break bone fever), causes flu-like illness, and of hospital-associated CCHF, remains anecdotal. occasionally develops into a potenally lethal complicaon Ÿ It may be given in a high loading dose (35 mg/kg orally called severe Dengue. The global incidence of Dengue has followed by 15 mg/kg three mes daily for 10 days) and only grown dramacally in recent decades and about half of the for high-risk sengs e.g. needle sck injury, mucous world's populaon is now at risk [1]. The first confirmed membrane contaminaon, emergency resuscitave outbreak of Dengue fever in Pakistan was in 1994, but a sudden contact, or prolonged inmate exposure during transport surge in Dengue cases and the annual epidemic trend in the aer baseline blood tests. provinces has been observed mulple mes there aer [2]. Ÿ Household or other contacts of the case who may have been Clinical Picture: exposed to infected cks or animals, or who recall indirect Dengue fever: Dengue fever is defined by fever (for >3 days and contact with case body fluids should be monitored for 14 < 10days) as reported by the paent or healthcare provider and days from the date of last contact with the paent or other the presence of one or more of the following signs and source of infecon by taking the temperature twice daily. If symptoms i.e. nausea/voming, rash, aches and pains (e.g. the paent develops temperature of 38.5°C or greater, with headache, retro-orbital pain, joint pain, myalgia, arthralgia), headache and muscle pains, he/she would be considered as tourniquet test posive, Leukopenia (Platelets count a probable case and should be admied to hospital and <150,000). started on Ribavirin treatment immediately (12). Dengue Hemorrhagic Fever: Defined as Dengue fever with any Prevenve measures: Educate public about the mode of one or more of the warning signs i.e. severe abdominal pain or transmission and personal protecon. Persons living in persistent voming, red spots or patches on the skin, bleeding endemic areas must be educated on: from the nose or gums, blood in voming, black tarry stools o Avoidance of areas where ck vectors are abundant, (feces, excrement), drowsiness or irritability, pale, cold or clammy skin, difficulty in breathing, a total white blood cells Case Definions: count of <50,000/mm3 and Platelets count <100,000. OR Suspected Case: A clinically compable case of Dengue fever, Dengue shock syndrome (DSS): Defined as a syndrome due to or Dengue hemorrhagic fever [11] dengue virus with any one or more of the following scenarios: Probable Case: A clinically compable case of Dengue fever, or Ÿ Severe plasma leakage evidenced by hypovolemic shock Dengue hemorrhagic fever with an epidemiologic linkage and and/or extravascular fluid accumulaon (e.g. pleural or laboratory results indicave of probable infecon [11]. pericardial effusion, ascites) with respiratory distress, Confirmed Case: A clinically compable case of dengue fever, Ÿ Severe bleeding from the gastrointesnal tract and or Dengue hemorrhagic fever with confirmatory laboratory Ÿ Vital organs involvement [3]. results [11]. Note: In 1-3% of cases, the disease develops into the life- Lab confirmaon: threatening Dengue Hemorrhagic Fever (DHF), somemes Probable: Detecon of IgM an-DENV by validated progressing into Dengue shock syndrome (DSS) [4]. immunoassay in a serum specimen in those areas where Infecous Agent: Belonging to Flavivirus group; four different mulple flaviviruses are circulang. Dengue viruses (serotypes) are known: DEN1, DEN2, DEN3, Confirmatory: and DEN4 [5]. Ÿ Detecon of DENV nucleic acid in serum, plasma, blood by Mode of transmission: Bite of infected mosquitoes, Aedes Reverse Transcriptase-PCR, Aegyp and Aedes Albopictus [6]. Ÿ Detecon in serum or plasma of DENV Non Structural Incubaon period: 3-14 days (average 4–7 days) aer the Protein 1 (NS1) angen by a validated immunoassay. infecve bite [7]. Timings: Period of communicability: 2-7 days [7]. Ÿ PCR: Inial 4–5 days of onset of illness Seasonality: Cases are increased during and aer rainy Ÿ NS1: One day post onset of symptoms (DPO) up to 18 DPO seasons as compared to winter and summer seasons. - Serology: Relavely humidity, temperature and rain remained significant o IgM anbodies are detectable aer 4th day of onset of predictors of dengue incidence in Pakistan [8]. illness (acute). o IgG is used for the detecon of past Dengue infecon and Reported Lab Confirmed Dengue Fever Cases month wise in Pakistan from January 2014 to May 2020 (n=99,264) usually can be detected during 2nd week of illness [11]. 30000 Specimen Collecon and Transportaon: Collect 5 ml of blood,

25000 centrifuge, and separate serum for analysis, observing strict safety precauons. Transport serum specimens to the lab in 20000 triple container packing with ice packs or frozen with dry ice (for 15000 long distance) along with a prominent bio hazard label and 10000 complete lab request form with brief history of the paent [10]. Number of Cases 5000 Case Management Febrile Phase: In the early febrile phase, it is not possible to 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec disnguish DF from DHF. The treatment during febrile phase is Months symptomac and mainly supporve, as follows: Ÿ Average Trend 2014 2015 2016 2017 2018 2019 2020 Paracetamol 10 mg/kg/dose in children and 500-1,000 Geographical distribuon: From January 2014 to May 2020, mg/dose in adult. Maximum adult dose is 4 grams/day. Do KPK remained the most affected province with 30% of cases not give Aspirin or other NSAID like Ibuprofen. Ÿ Extra amounts of fluids Oral rehydraon therapy/salt (ORT/ followed by Sindh with 27% cases. ORS) is recommended for paents with moderate Province/Area wise Distribuon of Dengue Fever Cases in Pakistan from January 2014 to May 2020 (n=99,264) dehydraon. Ÿ 35% Complete blood count (CBC/CP) with follow up is an 30% important tool in the management of suspected Dengue 30% 27% paents. 25% 20% Ÿ Provide brochure for families about the “warning signs” 20% 16% together with other recommendaon. 15% Ÿ All Dengue paents must be carefully observed for the signs 10% of shock at least for 24 hours aer recovery from fever. Number of Cases 5% 4% Ÿ 2% 1% The paent who does not have any evidence of circulatory 0% disturbance and who has been afebrile for > 24 hours does Islamabad Punjab Sindh KPK Balochistan AJK KPTDs Provinces/Areas not need further observaon and may be discharged [10]. Protocol for management according to Phases of DHF Alert threshold for Dengue fever: Cluster of 3 suspected cases a. Dengue hemorrhagic fever (DHF) Grades I and II: with at least one confirmed case [10]. As in DF, during the afebrile phase of DHF Grades I and II, the Alert threshold for Dengue hemorrhagic fever: One probable paent has the same symptoms as during the febrile phase. The case is an alert and requires an immediate invesgaon to clinical signs plus thrombocytopenia and rise in hematocrit are assess differenal diagnosis with CCHF. sufficient to establish a clinical diagnosis of DHF. During this Outbreak threshold: Cluster of 6 suspected cases and one lab situaon hospitalized the paent and treat accordingly. confirmed case is an outbreak [10]. b. DHF Grades III and IV (DSS): Ÿ Common manifestaons observed during the afebrile phase of DHF Grade III are circulatory failure manifested by involvement of the mucosa, mainly ulcers, on exposed parts of rapid and weak pulse, narrowing of the pulse pressure the body, leaving life-long scars and serious disability [4]. characterized by high diastolic pressure relave to systolic (C) Mucocutaneous Leishmaniasis (MCL): MCL is due to L. pressure, e.g. 90/80 mm of Hg (this is usually due to plasma braziliensis and L. Panamensis. It has two stages: During the leakage) or hypotension (possibly due to bleeding), the first stage, there is development of a primary cutaneous lesion, presence of cold clammy skin and restlessness or lethargy. which eventually is followed by nasal mucosal involvement, Ÿ Immediately shi the paent to Intensive care unit (ICU) later on destroying the nasal septum. During the second stage, and treat accordingly. disease can progress to lips, palate and larynx [4]. Ÿ The mortality is up to 30%, without treatment but less than (D) Post Kala-Azar Dermal Leishmaniasis (PKDL): Aer a latent 1%, providing adequate treatment by experienced period of one year following kala-azar cure, skin lesions can physician in a dedicated facility [10]. appear in around 20% of cases [4]. Prevenve measures: Case Definion: Ÿ Idenfy and destroy mosquito larval habitats and indoor 1. Visceral Leishmaniasis (VL) breeding sites. Suspected case: A Person with prolonged irregular fever >2 Ÿ Community awareness sessions should be conducted in weeks, weight loss, splenomegaly, hepatomegaly, ascites, schools, through religious leaders, aiming to promote diarrhea, cough, anemia and bleeding etc. health educaon campaigns. Confirmed case: A suspected/ probable case of Visceral Ÿ Proper solid waste disposal and improved water storage Leishmaniasis with serological/parasitological confirmaon pracces, including covering containers to prevent access [5]. by egg-laying female mosquitoes. 2. Cutaneous Leishmaniasis (CL): Suspected Case: A person Ÿ Protecon against mosquitoes including use of screening, presenng with one or more lesions (skin or mucosal), skin protecve clothing and repellents [10]. lesions typically present on uncovered parts of the body; the Vaccinaon: In late 2015 and early 2016, the first Dengue face, neck, arms and legs which are the most common sites. The vaccine, Dengvaxia (CYD-TDV) was registered in several site of inoculaon may present with a nodular appearance countries for use in individuals aged 9-45 years with lab followed by indolent ulcer [5]. confirmed dengue infecon and living in endemic areas [12]. Probable case: A suspected case of VL with serological WHO recommends that countries should consider introducon evidence of infecon [5]. of the Dengue vaccine CYD-TDV only in geographic sengs Confirmed case: A suspected/probable case confirmed by a (naonal or subnaonal) where epidemiological data indicate a posive smear or culture [5]. high burden of disease [13]. Diagnosc criteria: Guideline Link: hps://www.nih.org.pk/wp-content/ (1) History of residence and travel to Leishmaniasis endemic uploads/2020/04/ Advisory-on-Dengue-Fever.pdf areas References: References are available in online version at (2) Clinically compable findings www.nih.org.pk (3) Laboratory confirmaon Leishmaniasis Note: In endemic malarious areas, visceral Leishmaniasis must be suspected when fever is not responding to an-malarial Introducon: Leishmaniasis is a parasic vector borne disease drugs and persists for more than two weeks (assuming drug- and is classified as a Neglected Tropical Disease (NTD). It can resistant malaria has also been considered). present as cutaneous, mucosal and visceral forms but the most Specimen Collecon: common form is cutaneous Leishmaniasis (1). Cutaneous Leishmaniasis: Skin biopsy is the standard Leishmaniasis is found in areas of more than 90 countries in the dermatologic technique for obtaining specimen. No tropics, subtropics, and southern Europe. The annual incidence preservaves are required for examining LD bodies or for of new cases is esmated between 1.5 and 2 million. Leishmania culture [5]. Geographical distribuon of the disease depends on sand fly Visceral Leishmaniasis: Collect 5ml of cloed blood or serum species acng as vectors (2). for serologic studies. Splenic or bone marrow aspirate collected Infecous agent: Leishmaniasis is caused by a protozoa in a tube with ancoagulant is required for the demonstraon parasite from over 20 Leishmania species (1). of amasgote. Specimen may be transported at room Mode of transmission: Spread by the bite of the sand fly on the temperature without delay [5]. skin. If animals are the primary host reservoirs, it is called Lab diagnosis: Examinaon of slides (e.g. of biopsy specimens, Zoonoc Leishmaniasis, if humans are the primary host impression smears, and dermal scrapings).Serologic tesng for reservoirs is called Anthroponoc Leishmaniasis. (Human- detecon of anbodies against organisms useful primarily for sand fly-human) (1). visceral Leishmaniasis. Incubaon period: Considered to be at least a week but may Culture: Aspirates of pernent ssue/fluid (e.g., skin lesion, extend up to several months [4]. bone marrow, lymph node, blood/Buffy coat) [6]. Clinical Features: Case Management: The treatment of Leishmaniasis depends (A) Visceral Leishmaniasis (VL): Also known as kala-azar, is fatal on several factors including type of disease, concomitant if le untreated in over 95% of cases. It is characterized by pathologies, parasite species and geographic locaon. irregular bouts of fever, weight loss, with anemia and Leishmaniasis is a treatable and curable disease which requires enlargement of the spleen and liver. an immunocompetent system because medicines will not help (B) Cutaneous Leishmaniasis (CL)-Oriental sore: It is the most rid parasites from the body, thus risk of relapse may occurs with common form of Leishmaniasis and causes skin lesions without immunosuppression of the paent. All paents diagnosed with Case Management: visceral Leishmaniasis require prompt and complete treatment Warning: Do not give Primaquine to pregnant women and .Detailed informaon on treatment of the various forms of the children < 2years of age and it is advisable to do a Glucose-6- disease by geographic locaon is available in the WHO phosphatedehydrogenase (G6PD ) test before giving this drug. technical report series 949,''Control of Leishmaniasis'' [7]. Give Primaquine preferably aer the paent has recovered References: References are available in online version at from the acute illness. www.nih.org.pk Ÿ Do not give undiluted Chloroquine or Quinine by I/M or I/V route, as it can cause sudden cardiac arrest, especially in MALARIA children Introducon: A vector borne parasic disease transmied by Ÿ Do not give Sulfadoxine/ Pyrimethamine to children <2 female Anopheles mosquito species. An esmated 98% of months of age or during first trimester of pregnancy Pakistan populaon (185million) is at varying risk for Malaria Ÿ Suspected/probable case of severe Malaria and high risk while populaon at high risk is around 29% (54.6 million). groups should be treated immediately. Clinical Picture: Fever, chills, sweats, headache, nausea and Artemisinin-based combinaon therapies (ACTs) are there voming, body aches and malaise. commended treatments for uncomplicated P. falciparum Infecous Agent: Malaria. However Artemisinin and its derivaves should not be Ÿ Plasmodium falciparum used as monotherapy. The following ACTs are recommended: Ÿ Plasmodium vivax Ÿ Artesunate plus Sulfadoxine, Ÿ Plasmodium ovale Ÿ Pyrimethamine Artemether plus lumefantrine, Ÿ Plasmodium malariae Ÿ Artemether-lumefantrine is currently available as a fixed Ÿ Plasmodium knowlesi (rarely infect humans) dose formulaon with dispersible or standard tablets Note: First two of the above species are prevalent in Pakistan. containing 20mg of Artemether and 120 mg of Plasmodium falciparum is the most life threatening form of the lumefantrine. The recommended treatment is a 6-dose disease, and other is P.vivax. regimen twice Daily (BD) over a 3-day period. The dosing is Mode of Transmission: Bite of an infecve female Anopheles based on the number of tablets per dose according to mosquito and rarely through blood transfusion from infected reported cases by month in Pakistan, predefined weight person. bands (5–14 kg: 1 tablet; 15–24kg: 2 tablets; 25–34 kg: 3 Incubaon period: P.falciparum 9-14 days, P.malarie 18-40 tablets; and > 34 kg: 4 tablets), days, P.ovale and P. vivax 12-18 days Ÿ In case of pregnant women, during first trimester Quinine Reservoir: Humans are the only known reservoir plus Clindamycin to be given for 7 days, (Artesunate plus Infecvity: Humans may infect mosquitoes as long as infecve Clindamycin for 7 days is indicated if this treatment fails). gametocytes are present in the blood. Anopheles mosquitoes Uncomplicated Vivax Infecons: Chloroquine combined with remain infecve for life Primaquine is the treatment of choice for Chloroquine- Seasonality: Malaria in Pakistan is typically unstable and major sensive infecons. Dosage is as given below: transmission period is post monsoon i.e. from August to Ÿ Chloroquine: 04 STAT, 02 aer 6 hours, then 12 hourly for November 02days. Alert threshold: Number of cases reaches two mes the mean Ÿ Primaquine: 0.25mg/kg body weight daily for 14 days number of suspected cases of the previous 3 weeks for a given treatment is prescribed for radical treatment of Vivax. locaon. Prevenve Measures: Outbreak threshold: In endemic area: Slide posivity rate Ÿ Avoid being bien by mosquitoes, especially between dusk above 50% or falciparum rate above 40%; while in non-endemic and dawn. area, evidence of indigenous transmission of falciparum. Ÿ Use an-malarial dugs (chemoprophylaxis) when Case Definions: appropriate, to prevent infecon from developing into Suspected Case: A case with clinical manifestaons of clinical disease. uncomplicated/complicated Malaria Ÿ Immediately seek diagnosis and treatment if a fever Probable Case: A suspected case with history of similar develops 1week or more aer entering an area where there manifestaons among other household members is a Malaria risk and up to 3 months (or, rarely, later) aer Confirmed Case: Clinical case with laboratory confirmaon departure from a risk area. Lab Confirmaon: Ÿ Wear long sleeves and trousers outside the houses in the Ÿ Peripheral blood smear (gold standard for idenficaon of evening. Use repellent creams and sprays. Avoid night me malarial parasite, trophozoites and gametocytes, within outside acvies RBCs) Ÿ Use mosquito's coils or vaporizing mat containing a Ÿ Rapid Diagnosc Test (Immunochromatography) Pyrethrin. Ÿ PCR Ÿ Use of Inseccide-treated mosquito nets (ITNs) Ÿ Serology (Indirect immunofluorescence and ELISA) Ÿ Indoor spraying with residual inseccides (IRS) Specimen Collecon & Transportaon: Ÿ Reduce mosquito breeding sites Peripheral Blood Film: Collect 3-5ml blood in a tube with an- Ÿ Improve vector surveillance coagulant (EDTA). Immunodiagnosc test kit: Sample may also Ÿ Opmize the use of resources for vector control through be used to demonstrate parasite angen. Transport the Integrated Vector Management (IVM) specimen at room temperature prevenng sample spillage or Recommended chemoprophylaxis: Atovaquoneproguanil, damage to the tubes. Doxycycline or Mefloquine References and guideline links: Reported Lab Confirmed Measles Cases month wise in Pakistan References and guideline links are available at online version at from January 2014 to May 2020 (n=25,097) www.nih.org.pk and hp://dmc.gov.pk/ 1400 1200 MEASLES (RUBEOLA) 1000 2014 2015 Introducon: Measles is a highly contagious viral disease 800 mostly affecng children. Caused by measles virus of genus 2016 600 2017 Number of Cases Morbillivirus. Despite community vaccinaon coverage, 400 2018 Measles outbreaks can occur among under vaccinated children 2019 200 and remains an important cause of death among young 2020 0 children globally. The virus spreads via droplets from nose, Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec mouth or throat of an infected person [1]. Pregnant women Months while infected are also at greater risk of having severe Specimen Collecon & Transportaon: Collect throat complicaons and the pregnancy may end in miscarriage or /nasal/nasopharyngeal swabs for virus isolaon, very early in preterm delivery. Immunity aer measles infecon is life long, the rash phase and preserve in Viral Transport Medium (VTM). although there are few reports of measles re infecon. The Collect 5ml blood for serology. Do not freeze the whole blood. case-fatality rate may be as high as 25% [2]. Transport the specimens in triple packaged with complete Clinical Picture: Cough, coryza, conjuncvis, fever, rash, request form by maintaining cold chain at 4-8°C [8]. photophobia, muscle pain, sore throat, ny white spots inside Laboratory diagnosis: WHO recommends ELISA as the gold the mouth (Koplik's spots) etc. [3]. The occurrence of fever standard for Measles diagnosis. An-measles IgM is detectable beyond the 3rd - 4th day of rash onset, suggests a measles- in 3 - 30 days aer the appearance of the rashes. An-measles associated complicaon. Severe measles is more likely among IgG is undetectable up to 7 days aer rash onset and poorly nourished young children, especially those with subsequently peaks about 14 days aer the appearance of skin insufficient vitamin A or whose immune systems have been rashes [8]. weakened by other infecons [5]. Prevenon and Control Measures: Immunize populaon at Incubaon period: Averages 14 days with a maximum range of risk as soon as possible. Priority is to immunize children of age 6 7-21 days [6]. months to 5 years, regardless of vaccinaon status or history of Infecvity period: It can be transmied by an infected person disease. Children who are vaccinated against measles before 9 from 4 days prior to the onset of the rash to 4 days aer the rash months of age must receive a 2nd dose of measles vaccinaon erupts [6]. at 15 months of age [6]. Alert threshold: One suspected case is an alert [7]. Treatment: Outbreak threshold: Five or more clinical cases in a single Uncomplicated cases: The treatment is mainly supporve locaon over a 30 days me period with at least one lab which includes anpyrecs, fluids and anbiocs for only confirmed case is an outbreak . It requires an immediate bacterial super infecon(s). The WHO recommend Vitamin- A invesgaon and prompt response [7]. supplementaon for 2 days with the dose of 50,000IU in <6 Case Definions: months, 100,000 IU in 6-11 months, 200,000IU in >12 months Suspected Case: Any person in whom a clinician suspects and for children with ophthalmologic evidence of Vitamin- A measles infecon, OR deficiency, doses should be repeated on day 2 and 28. Any person with fever, maculopapular rash (i.e. non-vesicular) Anbiocs should be prescribed to treat eye and ear infecons, and 3C's; cough, coryza (i.e. runny nose) or conjuncvis (i.e. and pneumonia [10]. red eyes) Complicated cases: Pneumonia complicated cases should be Probable Case: Any person with history of fever, rash and linked referred to the health care facility immediately aer Vitamin- A epidemiologically to a laboratory confirmed case of measles supplementaon [10]. Confirmed Case: A suspected case, which is laboratory- References: References are available in online version at confirmed (posive IgM anbodies; 3 days aer appearance of www.nih.org.pk rash). Discarded case: If an acvate search in the community does not POLIOMYELITIS find evidence of measles transmission and there is no history of Introducon: A potenally fatal viral infecous disease that can travelling to areas where measles virus is known to be affect nerves and can lead to paral or full paralysis among a circulang, the case should be discarded [8]. proporon of infected children; mainly under 5 years of age. Note: Adequate blood specimen: while IgM ELISA tests are Once affected, the paralysis has no cure, but it can be easily more sensive between days 4 and 28 aer the onset of rash, a prevented through safe and effecve vaccines administered single serum sample obtained at the first contact with the orally (OPV) as well as through injecons (IPV]. health care system within 28 days aer onset is considered The disease is marked for global eradicaon through the World adequate for measles surveillance [8]. Health Assembly resoluon in 1988.The efforts so far reduced Seasonality: Peak incidence in Pakistan is usually during April endemic countries from 125 to only 03 including Pakistan, and May. Afghanistan and Nigeria. Unl poliovirus transmission is Geographical Distribuon in Pakistan: During 2014-2020, KPK interrupted in these 03 countries, all countries remain at risk of (45%) and Sindh (30%) remained the most effected provinces in importaon of polio, especially vulnerable countries with weak Pakistan [9]. public health and immunizaon services and travel or trade links to endemic countries. The annual case count during the Suspected Case: Acute/Sudden onset of weakness and me has been reduced from over 350,000 to only 33 in 2018. floppiness in a child aged <15 years; OR Paralyc illness in a Year Wise Lab. Confirmed Polio Cases by Province/Area in Pakistan, 2012-2020 person of any age whom Polio is suspected (9). Polio-compable AFP: A case in which one adequate stool Province/Area 2012 2013 2014 2015 2016 2017 2018 2019 2020 specimen was not collected from a probable case within 2 Islamabad 0 0 0 0 0 0 0 0 0 weeks of the onset of paralysis, and there is either an acute Punjab 2 7 5 2 0 1 0 12 2 paralyc illness with polio-compable residual paralysis at 60 Sindh 4 10 30 12 8 2 1 30 17 days, or death takes place within 60 days, or the case is lost to Khyber 27 11 68 17 8 1 2 follow-up (9). Pakhtunkhwa 92 20 Vaccine-associated Paralyc Poliomyelis case: A case with KPTDs 20 65 179 16 2 0 6 acute paralyc illness in which vaccine-like poliovirus is isolated Balochistan 4 0 25 7 2 3 3 12 11 from stool samples, and the vaccine derived virus is believed to GB 1 0 0 0 0 1 0 0 0 be the cause of the paralysis (9). AJK 0 0 0 0 0 0 0 0 0 Confirmed Polio case: A case with acute paralyc illness, with

Total 58 93 307 54 20 8 12 146 50 or without residual paralysis, and isolaon of wild poliovirus from the stools of either the case or its contacts (9). Polio was declared a Public Health Emergency of Internaonal Discarded case: A case with acute paralyc illness for which Concern (PHEIC) by WHO on 5th May, 2014 and connues to one adequate stool specimen was obtained within 2 weeks stay as such ll date. Pakistan is classified by the Internaonal aer onset of paralysis and was negave for poliovirus (9). Health Regulaons (IHR) as a state infected with WPV1, cVDPV1 Specimen Collecon & Transportaon: Collect 2 stool samples or cVDPV3 with potenal risk of internaonal spread. about 8 grams each (about the size of the p of both thumbs) at Therefore the Government of Pakistan has also declared Polio an interval of 24 to 48 hours for virus isolaon as soon as as a naonal public health emergency and an annually updated possible or within 14 days of onset of illness in a clean, leak Naonal Emergency Acon Plan (NEAP) is being implemented proof, screw-capped container, preferably in a transport naonwide under the overall supervision of the Naonal Task medium like Minimal Essenal Medium or Eagle's Medium. Force led by the Prime Minister of Pakistan and taking on board Seal the container with tape and place samples immediately all provincial chief ministers as well as Prime Minister of AJK. aer collecon in refrigerator at 2-8°C or in a cold box with Clinical Picture: There are three basic phases of Polio virus frozen ice packs. Transport specimens to the lab maintaining infecon: subclinical, non-paralyc, and paralyc. Mostly cold chain with duly filled request form within 72 hours aer infecon remains asymptomac but Poliovirus may cause collecon. The set of specimens from a single paent should be Acute Flaccid Paralysis (AFP); one in 200 infecons. The onset of placed in a single plasc bag just large enough to hold both the asymmetric paralysis is usually sudden coupled with fever. The containers (10). severity of weakness also varies with the level of immunity Public Health Measures: Four pillars of polio eradicaon as among the affected child rendered through immunizaon. public health measures include: Weakness is ascending and may vary from one muscles or 1. Achieving a high level of coverage with at least 4 doses of group of muscles, to quadriplegia, and respiratory failure. the oral poliovirus vaccine (OPV) and one dose of IPV in Proximal muscles usually are affected more than distal muscles roune. and lower limbs more than the upper limbs. Reflexes are 2. Providing supplementary doses of OPV to all children < decreased or absent while sensory examinaon may be 5years old during NIDs and SNIDs, as well as the case normal. (6). response planned by the Polio Eradicaon Programme. Infecous agent: Poliovirus belong to genus Enterovirus 3. Acve and Passive Surveillance for all cases of acute subgroup, family Picornaviridae, having three serotypes of flaccid paralysis Poliovirus, labelled P1, P2, and P3 (7). 4. House-to-house OPV campaigns, targeng areas in which Reservoir: Humans are the only known reservoir (7). transmission of wild Poliovirus persists, based on Naonal Mode of transmission: Primarily person to person spread Emergency Acon Plan (NEAP 2018-19) (11). through the fecal-oral route. Aer inial infecon with the References: References are available in online version at poliovirus, the virus is shed intermiently in faeces for several www.nih.org.pk weeks Note: Aer inial infecon with poliovirus, the virus is shed Extensively Drug Resistant (XDR) Typhoid Fever: intermiently in faeces for several weeks Salmonella enterica serovar typhi causes typhoid fever, a life- Incubaon Period: 7-14 days for paralyc cases (range 3 - 35 threatening illness that affects more than 21 million people in days) (7) the developing world. The bacterium is transmied by Alert & outbreak threshold: One suspected case of polio is an contaminated water and food and tends to spread in areas with alert/outbreak and requires an immediate noficaon and poor sanitaon. Anbioc resistance to Salmonella typhi is a stools sample collecon for confirmaon (8) major public health threat. Muldrug-resistant (MDR) isolates Case Definion: This sensive case definion will capture are prevalent in parts of Asia and Africa and are associated with Poliomyelis but also other diseases, including Guillain-Barre the dominant H58 haplotype. Reduced suscepbility to syndrome (GBS), Transverse Myelis and Traumac Neuris, , Fluoroquinolones is also widespread, and sporadic cases of such that each case with limping must be invesgated carefully resistance to third-generaon Cephalosporin or Azithromycin (9). have also been reported. In Pakistan the first large-scale emergence and spread of a Now cases are being reported from other parts of the country novel S. typhi clone harbouring resistance to three first-line as well. Addionally, travel associated XDR typhoid cases have drugs (Chloramphenicol, Ampicillin, and Trimethoprim- been idenfied abroad as well. Sulfamethoxazole) as well as Fluoroquinolones and third- Clinical manifestaons: Paent presents with high grade fever generaon Cephalosporin has been idenfied in Sindh, which (103°F to 104°F), weakness, abdominal pain, headache and loss was classified as extensively drug resistant (XDR). of appete. In some cases, paents have a rash of rose-colored spots. Blood complete picture and blood/ stool/ urine cultures Reported XDR Typhoid Fever Cases in Sindh by Years (November 2016 to 31 May, 2020) are performed to confirm the diagnosis of typhoid fever. Prevenve measures and control: Along with the appropriate Years Karachi Hyderabad Other Sindh treatment, prevenve measures are urgently needed, Districts Total 2016 0 12 0 12 including improved sanitaon, food safety and vaccinaon. The anbioc resistance strains have been treated with 2017 175 485 4 664 Azithromycin and Meropenem. Typbar-TCV® vaccine, a 2018 3712 891 207 4810 trivalent conjugate vaccine that was recently prequalified by 2019 7292 1645 998 9935 the World Health Organizaon, is recommended. The vaccine 2020 (upto ND 321 209 530 has long-lasng immunity, requires only one dose, and can be June) given to children as young as 6 months. 11179 3354 1418 15951 References: References are available in online version at (Source: FDSRU-NIH weekly Report Volume 2-- Issue 21, May 31 – June 6, www.nih.org.pk 2020 Date: June 9, 2020) Naonal Public Health Events Primary Amebic Meningoencephalis (Naegleria fowleri) In Pakistan, according to the Lancet infecous disease, first case of PAM was reported in 2008, and up unl May 2020, 148 cases have been reported from Karachi. Primary Amebic Meningoencephalis (PAM) is caused by parasite Naegleriafowleri; a rare, with about 99% CFR. Naegleriafowleri "brain-eang amoeba” is a unicellular, free-living microscopic organism & grows best at higher temperature up to 46°C.It is naturally found in warm freshwater environments feeding on bacteria and other microbes. Extended summers and prolonged humid condions due to climate change provide an ideal environment for amoebas to flourish in bodies of water. Transmission occurs primarily through inhalaon of infested water during swimming or pung contaminated water in to the nose during abluon. Symptoms start 1-9 days (median 5 days) aer nasal exposure to Naegleria-containing water. People may die 1-18 days (median 5 days) aer symptoms begin. Inial symptoms of PAM usually start from 1-7 days aer infecon which may include headache, fever, nausea or voming. Clinical manifestaons are similar to bacterial meningis (severe frontal headache, fever, voming, meningeal signs, sff neck, seizures and focal neurologic deficits) with increase chance of misdiagnosis. Aer the start of symptoms, the disease progresses rapidly and while death may occur in 1-12 days of illness, because of rapid progression, the diagnosis is usually made aer death. Prevenon & Control: Both trophozoites and cysts forms are sensive to adequate levels of chlorinaon. The municipality public health authories, therefore must ensure that adequate levels of disinfectants like chlorine are maintained in the supplied tap water along with strict monitoring arrangements. Any of the suspected cases should immediately be reported to health authories. Awareness and educaon in the affected areas must also be undertaken to educate and sensize communies on prevenve measures. Advisory link: hps://www.nih.org.pk/wp-content/uploads/2019/05/Advisory-for-Naegleriasis-May-2019.pdf

Heat stroke: Introducon: Heat stroke is a medical emergency and is a form of hyperthermia in which the body temperature elevates dramacally and can be fatal if not promptly and properly treated. The body's temperature rises rapidly, the sweang mechanism fails and the body becomes unable to cool down consequently, the body temperature can rise to 104°F or higher within 10 to 15 minutes. Signs & Symptoms: It include profuse sweang or the absence of sweang, with hot red or flushed dry skin, weakness/ lethargy, chills, throbbing headache, high body temperature, hallucinaons, confusion/ dizziness and slurred speech. Heat stroke can cause death or permanent organ damage or disability if not properly treated in me. Infants, elder persons, athletes and outdoor workers are at high risk for heat stroke. Treatment: Vicms of heat stroke must receive immediate treatment. Monitor body temperature with a thermometer and connue cooling efforts unl the body temperature drops to 101°F to 102°F. Anpyrecs may be given once the body temperature drops to 101°F or below. Prevenve Measures: Heat/ sun stroke is a preventable condion. Public should be educated through awareness messages to drink plenty of water while liming me in direct sunlight in hot/ humid weather or in places with high environmental temperatures, avoid becoming dehydrated and to refrain from vigorous physical acvies in hot and humid weather. Public should be made aware of early signs/ symptoms of dehydraon and subsequent evolving signs and symptoms of heat/ sun stroke such as muscle cramps, nausea, voming, light-headedness and even heart palpitaons. Persons working under the sun should prevent dehydraon and heat stroke by taking me out of the sun and drinking plenty of water/ fluids. The paents should avoid use of alcohol and caffeine containing so drinks and/or tea, which may exacerbate dehydraon. Public should be encouraged to consume salty foods, wear hats and light-colored, lightweight and loose clothes during the hot/ humid environmental condions. Guidelines link: hps://www.nih.org.pk/wp-content/uploads/2018/07/Heat-SunStroke_2.pdf Internaonal Public Health Events Ebola Virus Disease (EVD) Ebola Virus Disease (EVD) or Ebola hemorrhagic fever (EHF) is the most virulent human viral hemorrhagic disease caused by the Ebola virus; with the average case fatality rate is around 50%. Symptoms may appear from 02 to 21 days (incubaon period) aer exposure which typically include fever, headache, joint and muscle aches, weakness, diarrhea, voming, stomach pain, lack of appete and may follow by rash, red eyes, difficulty in breathing, difficulty in swallowing, and bleeding from different sites of the body. A person infected with Ebola virus is not contagious unl symptoms appear. The first Ebola virus disease outbreak occurred in remote villages in Central Africa, near tropical rainforests. The outbreaks of EVD in West Africa mainly affected Democrac Republic of the Congo (DRC), Uganda, Guinea, Liberia and Sierra Leone. Risk assessment: The risk is low at global level due to the remoteness and inaccessibility of the area as well as the rapid response launched by the MoH of DRC, WHO, and all the other coordinang partners and agencies. Public Health Measures: WHO recommends the implementaon of proven strategies for the prevenon and control of Ebola outbreaks. These strategies include (1) coordinaon of the response, (2) enhanced surveillance, (3) laboratory confirmaon, (4) contact idenficaon/tracing and follow-up, individuals are monitored for up to 21 days in the case of EVD, (5) case management, (6) infecon prevenon and control, (7) safe and dignified burials, the IFRC has called funerals "super-spreading events" as burial tradions include kissing and generally touching bodies. Safe burial teams formed by health workers are subject to suspicion (8) social mobilizaon and community engagement, (9) logiscs, (10) risk communicaon, (11) vaccinaon, (12) partner engagement, (13) research and (14) resource mobilizaon. Vaccinaon: On November 2019, the World Health Organizaon prequalified an Ebola vaccine, rVSV-ZEBOV, for the first me against EVD. WHO stated that the rVSV-ZEBOV-GP vaccine had been 97.5% effecve at stopping Ebola transmission, relave to no vaccinaon. The ring vaccinaon strategy was effecve at reducing EVD in contacts of contacts (terary cases), with only two such cases being reported. Guidelines link: hps://www.nih.org.pk/wp-content/uploads/2018/03/Guidelines-for-Prevenon-and-Control-of-Ebola-Virus- Disease-EVD-August-2014.pdf Middle East Respiratory Syndrome Coronavirus (MERS - CoV) Introducon: First reported case of MERS-CoV was from Saudi Arabia in September 2012. MERS is a viral respiratory illness caused by corona virus from the same family which caused outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003. Its Incubaon period is 1-2 weeks. The clinical presentaon of MERS ranges from asymptomac to very severe pneumonia with acute respiratory distress syndrome, sepc shock and mul-organ failure resulng in death and clinical course is more severe in immune- compromised paents and persons with underlying chronic co-morbidies. At the end of November 2019, a total of 2494 laboratory-confirmed cases of Middle East respiratory syndrome (MERS), including 858 associated deaths (case–fatality rate: 34.4%) were reported globally; the majority of these cases were reported from Saudi Arabia (2102 cases, including 780 related deaths with a case–fatality rate of 37.1%). From 1st December 2019 to 31st January 2020, Saudi Arabia has reported 19 addional cases of MERS-CoV (WHO). Sample Collecon and Transportaon: Collecon of lower respiratory specimens (sputum or broncho-alveolar lavage) is strongly recommended however, nasopharyngeal swab, oropharyngeal swab, sputum, serum, and stool/rectal swab may be collected. Repeat sequenal sampling for PCR tesng is strongly encouraged in the respiratory tract (upper and lower) and mulple other body compartments. Wear personal protecve equipments (PPE) and adherence to infecon control precauons is mandatory and nofy to district health departments immediately if suspect MERS-CoV infecon in a person. Treatment and Prevenon: No specific treatment/ drugs and vaccines are currently available. Treatment is mainly supporve and based on the clinical condion of the paent. Prevenve measures include standard plus aerosol, droplet precauons and opng good hand hygiene pracces. Guidelines link: hps://www.nih.org.pk/wp-content/uploads/2018/03/Guidelines-for-the-Prevenon-Control-and- Management-of-Middle-East-Respiratory-Syndrome-Coronavirus-MERS-CoV-updated-MAY-2014.pdf اٹ ن Mosquito Alert Pakistan

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