Floods in Pakistan Pakistan Health Cluster Bulletin No 18- Focus on Malaria 20 September 2010

Railway Hospital Sukkur- Photograph by Syed Haider Ali (WHO).

HIGHLIGHTS

The Ministry of Health (MoH) and Health Cluster partners are preparing for a significant rise in the number of cases of malaria. The disease is being increasingly reported in all flood-affected districts; up to 2.2 million cases are expected over the next six months.

In Sindh, the situation in Hyderabad is exacerbated by an acute shortage of humanitarian staff on the ground. The Executive Director of Health in the town of Dadu has asked the UN and partners for help dealing with the worsening situation, especially in the area around lake Manchar.

The Pakistan Flood Emergency Response Plan (PFERP) was launched in New York on 17 September. The plan - a revision of the initial response plan (PIFERP) - proposes a comprehensive set of relief and early recovery activities.

The Disease Early Warning and Surveillance (DEWS) system is functioning well: so far, the MoH and partners have managed to avert a second wave of deaths from disease.

In Punjab province, Multan hub reports that between 65 and 90% of internally displaced people (IDPs) are returning home.

Senior officials from WHO, UNICEF and WFP will visit affected areas from 22 to 25 September.

Situation overview and current scale of disaster

In Khyber Pukhtoonkhwa (KPK) and Punjab, the situation continues to stabilize. People are gradually returning to their homes and villages. The Health Cluster coordinator in Multan reports that between 65% and 90% of IDPs in the area have returned. Nevertheless, the severe damage to infrastructure, agriculture and homes cannot be overstated. The Health Cluster will need to begin implementing early recovery programmes to address the needs of these returnees. In addition, outbreaks of malaria in southern Punjab, an area with low rates of endemic malaria, are giving rise to some concern.

In northern Sindh more than half of the IDPs are returning home. Although the situation is stabilizing in some areas, it remains critical in the south. The city of Dadu is cut off, and the Hub Coordinator in Hyderabad reports an acute shortage of humanitarian partners on the ground. Moreover, sanitary conditions in some IDP camps are reported to be rudimentary, with overcrowding and open defecation within the camp area. Stagnant rain water is used to wash utensils and clothes. There is no safe drinking water and food is cooked and eaten by IDPs in unhygienic conditions.

Security issues due to the murder of MQM party convener Dr Imran Farooq in London on 16 September have hampered humanitarian operations in Sindh (in both Sukkur and Hyredabad), and in Karachi. Humanitarian activities as well as general services were completely halted on 17 September, and international staff were assigned to residence. The situation improved on 18 September; activities on the ground are now resuming.

Health impact

Acute diarrhoea, acute respiratory infections, skin diseases and suspected malaria remain the leading causes for seeking health care in the flood-affected areas.

Basic statistics update • Out of 5.3 million consultations conducted up to 17 September, 708 891 (13%) were for acute diarrhoea, 802 670 (15%) were for acute respiratory infections (ARI), 986 843 (18%) were for skin disease and 182 762 (3%) were for suspected malaria. • The number of suspected malaria cases is rising in Baluchistan and Sindh provinces compared to KPK and Punjab. A total of 40 415 cases of suspected malaria were reported from 4 to 10 September. • There are around 500 000 pregnant women among the affected population. This means that many deliveries each month will be in an unsafe environment, without access to skilled birth attendants. • Acute respiratory tract infections (ARI) are the leading cause of morbidity. However, the number of cases of suspected malaria is rising fast: over the last 24 hours, the reported number of malaria cases accounted for 17% of consultations in Baluchistan province and 13% in Sindh province.

New concerns and latest needs; upcoming and recent concerns • A total of 389 snake bites were reported in Sindh from 31 July to 14 September. • 4 alerts of AWD and one alert of meningitis were reported and responded to from 11 to 17 September. • Paediatric malnutrition is increasingly a concern: 30 to 50% of children arriving at health facilities show symptoms of acute malnutrition. Before the floods, paediatric malnutrition was not foreign to Pakistan: according to the last National Nutrition Survey, the global acute malnutrition rate was 13%. A total of 10% of children had moderate acute malnutrition (MAM), and 5% had severe acute malnutrition (SAM). • Around 500 000 women are pregnant among the affected population. This means that around 83 000 deliveries will take place per month, many of which will be in an unsafe environment without access to skilled birth attendants.

Malaria Situation Focus

Malaria is endemic in 36 of the 77 flood-affected districts. The floods have favoured vector breeding, resulting in high densities of disease-transmitting mosquitoes. This, together with the high exposure of the population (IDPs) has greatly increased the transmission potential of the disease.

Punjab province • Six districts located in the low-endemic province of Punjab that have reported sporadic cases in the past have shown a decline in Slide Positivity Rate (SPR-current 20%) compared with the highest rate in the first week of September. The number and percentage of vivax cases is disproportionately high in Southern Punjab. The total number of reported cases from the highly endemic district of Mozaffargarh since 1 September is 1420. The data from five other districts are not available.

Sindh and Balochistan provinces • In Sindh, except for the central districts of Karachi city, all districts are highly endemic for malaria. The situation is deteriorating in the districts affected by floods. The situation is expected to reach epidemic levels in coastal (Thatta, and Badin) and southern districts (Dadu, T.Muhammad Khan etc). • In Balochistan, there have been confirmed malaria outbreaks in north-eastern districts (Zhob, Loralai, Musakhail) that have received heavy rainfall this year. The falciparum proportion has reached 95%, and the overall SPR is 50%, which is the highest in the country. • The situation in districts Sibi, Naseerabad and Mastung (Balochistan) is not encouraging. Mastung has shown a rise in falciparum cases in recent days, due to the influx of IDPs from Sindh. Information from other districts is lacking due to the non-functioning surveillance system. • Balochistan has the highest burden of malaria in the country. This poses challenges for the malaria control programme when trying to cope with emerging needs.

KP Province • The situation in KPK is stable, with normal transmission patterns.

Government Response

• On 16 September 2010, the Federal Secretary for Health and the Coordinator of the National Health Emergency Preparedness and Response Network (NHEPRN) briefed members of the Standing Committee on Health on the health response to the floods. The Committee requested the Ministry of Health to continue health care services in the flood-affected areas as well as continue its efforts to contain disease outbreaks and thus avoid epidemics. • The third meeting of the National Steering Committee on Health Emergencies, chaired by Mr Kushnood Lashari, Federal Secretary of Health, was held at NHEPRN Centre on 16 September 2010. The Committee, established by the Prime Minister of Pakistan, comprises of all Provincial Secretaries, Heads of UN Agencies, the President, CPSP, PMDC and PMA. All Provincial Secretaries present weekly reports (including needs) on a common reporting format developed by NHEPRN. • The committee expressed its satisfaction over improved coordination at various levels, resulting in a better use of resources and the avoidance of duplication. A subcommittee of the MoH, WHO and UNICEF was formed to work out the distribution of long-lasting insecticidal nets (LLINs) being donated by various countries. • MoH has asked the national Disaster Management Authority (NDMA) to provide water filtration plants to the provinces through UNICEF and the Water, Sanitation and Hygiene (WASH) Cluster. • To facilitate information-sharing, NHEPRN launched its official website on 15 September on a trial basis. • NHEPRN is organizing the deployment of foreign field hospitals and medical teams in the provinces, depending on the affected population and damaged health facilities. Seven field hospitals donated by the Italian Government are being deployed at Charsaddah, Nowshera, Bhakhar, Layyiah, Mianwali, Giligit and Balochistan. Health Cluster Response

CARE

Update from 8 to 14 September: KPK A total of 807 patients have been treated via four BHUs in Upper Swat (KPK) including 285 women and 368 children. CARE has conducted 15 Mobile clinics (via three mobile teams) in the district of Charsadda, treating 2556 patients including 761 women and 1042 children. CARE also held 36 health and hygiene sessions for 742 people. CARE operated four mobile clinics (via four mobile teams) in the district of Nowshera (KPK) and treated 1580 patients including 481 women and 692 children. It also held 23 health and hygiene sessions for 796 persons.

Punjab Primary health care (PHC) services were provided via 10 mobile clinics in Rajanpur (South Punjab). A total of 2866 patients including 979 women and 1388 children were treated.

Sindh CARE provided PHC services to 837 patients including 258 women and 422 children via mobile medical camps in districts Sukkur, Kasmore and Shikarpur.

CHURCH WORLD SERVICE – CWS P/A

KPK Three mobile health units (MHUs) are operating in districts of Mansehra, Kohistan District and Swat, especially in remote areas where these MHUs are providing essential medicines and consultations for patients, with a special focus on women and children. A total of 7855 consultations were made. Lady health visitors (LHVs) examined 156 ante- and 32 postnatal clients, who were registered and given medicines. A total of 1252 children under five years of age were examined. CWS-P/A teams conducted 208 health education sessions on common health issues including personal hygiene, HIV/AIDS, skin infections, safe drinking water, sanitation and locally endemic diseases.

CITIZENS' COMMISSION FOR HUMAN DEVELOPMENT (CCHD) CCHD has begun work ensuring that health and sanitations needs are met, plus other daily necessities. CCHD is 1) providing direct services (medical camps, food items, clothing etc), 2) coordinating among local organizations and the government, and 3) facilitating the availability of doctors and other medical staff to local organizations. CCHD has also treated 5500 patients. It operates eight medical camps, each staffed by a doctor and paramedical staff. A total of 1500 children suffering from diarrhoea have been provided with mineral water and oral rehydration salts (ORS). Over 150 families have been given food items. CCHD collaborates with other organizations in providing services. Twenty tents have been provided to widows, and over 800 new dresses and other items of clothing have been donated to children, women and men for Eid. CCHD is monitoring cases of epidemics, and common diseases and infections. 0300 8

IDEA KPK Wooden frames for 35 latrines have been completed, of which 15 have been installed successfully. Work is in progress on another 20 latrines being installed in Khema Basti Nawa Kili of District Nowshera. Five water tanks have also been installed. Stickers and banners with hygiene messages have been pasted on latrines. In mobile medical camps, 5760 water purification sachets have been distributed, which benefited 480 families (30 sachets per family) of District Nowshera. Another 7689 sachets were distributed in Upper Swat. IDEA conducted 20 mobile medical camps in the target Union Councils of District Nowshera. Total consultations reported in the week are 6455, out of which 1855 are male, 2945 are female and 1665 are children. IDEA also held 301 health and hygiene sessions for 3570 people (1530 female, 1389 male and 651 children). A water purification plant was installed in District, Nowshera, UC kheshkai payan, with funding from CARE International. IDEA received 13 small water purifier plants from GEO TV Network and Rotary Club Peshawar. It has installed the plants in selected UCs.

INTERNATIONAL MEDICAL CORPS (IMC) KPK As of 17 September, the organization has conducted 39 946 health consultations in 14 static units in three districts (Peshawar, Charsadda, Nowshera). In addition, IMC has opened diarrhoea treatment centres at DHQ Nowshera and Mardan Medical Complex. All IMC's psychosocial support members will be attending psychosocial support training for three days: there will be no health statistics kept for these three days.

ISLAMIC RELIEF PAKISTAN KPK Islamic Relief Pakistan is running two static health camps with outreach capacity at two civil dispensaries in Union Councils Nissata and Zandu Banda in districts Charsadda and Nowshera respectively. A total of 6663 consultations have been undertaken since 25 August. During this period 46 cases of suspected malaria have been seen and treated. Skin problems and acute respiratory infection are the two main health concerns, followed by eye infections and acute diarrhoea cases. Islamic Relief has also distributed 4003 hygiene kits to the most affected population in the area.

Punjab In Muzaffargarh Islamic Relief has one mobile health clinic working since 5 September in four Union Councils. A total of 1934 consultations have been undertaken so far. A total of 253 cases of suspected malaria have been treated in these four UCs. Islamic Relief has also distributed 1479 hygiene kits to the most affected population in the area.

HELPING HAND FOR RELIEF AND DEVELOPMENT-HHRD • Since the floods began in Pakistan, HHRD provided free consultations and medicines to flood affectees by organizing medical camps • Till 19 September, HHRD held 396 medical camps in 13 districts including Charsada, Nowshehra, Dir, swat, Buner( KPK) Mianwali, Muzafargarh, Layyah, D.G. Khan (Punjab) Nawabshah, Sukkur, Karachi, Larkana ( Sindh). • So far, more than 71,500 patients were treated and 6 safe deliveries have been conducted in medical camps • Major diseases observed: Diarrhoea, Scabies, eye and Skin infection, Malaria etc

JAPAN DISASTER RELIEF MEDICAL TEAM Punajb The Japan Disaster Relief team has been working in Southern Punjab since 5 September. The Japanese government has extended its assistance and sent a new (second) medical team to replace the first one. A total of 17 medical professionals among 23 team members have been working since 14 September. Since 5 September, the team has treated 2248 patients including 1178 females and 1131 children. Major diseases (up to 14 September) are: digestive (30%), respiratory (13%), skin (14%) and malaria (9%).

MALTESER INTERNATIONAL

KPK A total of 5442 patients have been treated over the last six weeks through PHC services in three health facilities, with an average number of 60 patients per day and per facility. Malteser also organized ten medical camps, where over 3577 patients were treated by two mobile medical teams (MMTs). Several hundred children have been vaccinated (EPI protocol + Influenza) by the EDO Health Office's vaccination team; these medical camps were organized in UC remote areas, Transitional Camps of Islampur UC, and Tahirabad quarter of Mingora Town. MMTs are also providing intensive hygiene awareness campaigns in areas with suspected acute water diarrhoea (AWD) cases (Barikot, Margazal and Ahunbaba of Islampur UC and Mingora Town). Every week, several hundred families have been enrolled, and hygiene printed materials, Aqua-Tabs, soap and ORS sachets have been distributed. MSTs/MMTs also distributed 3000 jerry-cans, 800 kgs of soap and several hundred thousand Aqua-Tabs donated by WHO, UNICEF and Oxfam.

The main challenges on the ground are 1) the lack of access to the beneficiaries and health facilities in the the Upper Swat Valley and Kohistan district, and 2) the ongoing outbreaks of AWD, measles and the approaching malaria outbreak.

MERLIN

KPK

A total of 6234 consultations were conducted in Merlin health facilities and by Merlin MHUs in KPK on 16 September 2010. Nowshera: Merlin is providing health and nutrition services through five MHUs in six UCs of Nowshera and through six 24/7 static clinics in Jalozai. In addition one Diarrhoea Treatment Centre (DTC) is functional since 29 August. It has seen 2382 patients; cases have stabilized but have not decreased. Merlin is covering an approximate catchment population of 280 000 in Nowshera. Swat: Merlin is providing health services through nine MHUs (eight in Upper Swat and one in Lower Swat) and 12 health facilities (HFs). One DTC was established at THQ Matta and has been functional since 27 August (total patients seen: 922). Merlin is covering an approximate catchment population of 590 036 in Swat. Buner: Through 10 HFs and three MHUs, Merlin is providing comprehensive PHC including reproductive health and early warning systems in Buner. Two DTCs have been established at DHQ Doggar and have been functional since 2 September. One DTC at THQ Pachakalay is also functional (total number of cases: 415). Merlin is covering an approximate catchment population of 337 808 in Buner. Charsadda: The DTC At DHQ Charsadda has been functional since 1 September (total number of cases: 1390). Another DTC at CH SHABQADAR has also been functional since 1 September (total number of cases: 625).

Punjab

Muzzafargarh: One 24/7 DTC is fully functional at DHQ Muzafargarh since 3 September 2010; to date, 2200 (1123 male, 1077 female) consultations have been conducted. Merlin is also in the process of conducting assessments and is planning to launch five static clinics and five MHTs (two initially) to provide PHC and nutrition services to flood-affected people in Muzaffargarh district.

MOBILINK: Mobilink has donated 244 pre-fabricated structures to WHO. WHO has already devised a system to prioritize the distribution and erection of these structures. Health cluster partners were asked to submit requests for these structures in case of need.

NETWORK FOR THE ADVANCEMENT OF GENDER EQUALITY (NAGE) PAKISTAN (Reporting from 30 August to 17 September) NAGE-Pakistan is providing medical health services through a static and mobile medical camp in Union Council n°s 3, 4 and 5 of Tehsil Kotadu in district Muzzafar Garh. From 30 August to 17 September, NAGE-Pakistan medical teams treated 1847 patients, including 578 female (31%), 498 male (27%) and 771 children (42%) under five. Major diseases include fever (34%), diarrhoea (21%), eye infections (14%), skin infections (12%) and respiratory infections (11%). NAGE- Pakistan also formed five "Health Watch Committees", conducted eight health and hygiene sessions , and provided clean drinking water with ORASAL-F to 250 families in Union Council Pattal n° 4 of Kotadu (Muzzafar Garh).

RELIEF INTERNATIONAL (Reporting from 8 to 17 September)

KPK District: Swat: A total of 867 consultations were held from 8 to 17 September. Rising trends in acute watery diarrhoea and URTI were registered in all age groups. Preventive health measures include community awareness sessions on the prevention of diarrhoeal diseases and use of ORS during diarrhoeal episodes. Sixteen health education sessions were conducted, which included hand-washing demonstrations. An ORT corner is present for the purpose. Moreover, 25 pregnant women were registered for antenatal visits and 11 women received postnatal checkups. An ambulance is present to transport critical patients.

District Dir Lower: A total of 340 consultations were held from 8 to 14 September, and 11 health and hygiene education sessions were conducted, as well as IYCF sessions with 82 PLWs. Thirteen pregnant women were registered for antenatal visits and six women received postnatal checkups. Since the start of September, RI’s mobile health teams in Lower Dir have distributed Unimix and multi-micronutrient tablets to 4151 pregnant and lactating mothers, and 3443 children have been provided with high-energy biscuits and multi-micronutrient sachets .

Baluchistan District: Kachi: A total of 1160 consultations were held from 8 to 17 September. Acute watery diarrhoea is still a rising trend; mitigating measures include regular health education sessions in the camp (17 sessions conducted, with an ORT corner that is used to help diarrhoeal patients rehydrate effectively). RI is negotiation with UNICEF for supplies of Plump doze for blanket distribution. RI conducted one postnatal and 35 antenatal check ups.

PAIMAN – USAID Sindh USAID/PAIMAN supported the establishment of new IDP camps in Khairpur by supplying water tanks and jerry cans. A total of 43 320 jerry cans and 5230 water tanks have been delivered to DCO offices for distribution to affected families and communities. USAID/PAIMAN also donated 2,600 insecticide- treated bednets to EDO-Health Jaffarabad, Swat and Charsadda.

USAID/PAIMAN NGOs are running accelerated health camps and holding health education sessions for the flood-affected population. Over 4000 people have received health care. Women have received pre- and postnatal care, TT vaccinations and general check ups. A total of 24 health and hygiene education sessions have been held, attended by 1736 people (361 men, 989 women and 386 children).

USAID/PAIMAN's relief team attends health cluster meetings in Islamabad as well as at Province and district levels, and shares information on its activities with the Provincial Health Department, DCO, and EDO-H.

UNAIDS

The population most at risk of HIV/AIDS in the affected areas are injecting drug users (IDUs), transgenders and sex workers. UNAIDS is mainly focusing on five affected districts (Sukker, Hyderabad, Jacobabad, Larkana and Sargodha). The transgender population has become internally displaced in Jacobabad, Sukker, Larkana, and Hyderabad districts. Pakistan has had concentrated HIV epidemics since 2005, with a prevalence of 21% among IDUs, 6-7 % among transgenders, and 1-2% among sex workers. The humanitarian response working group of the joint team on HIV and AIDS met immediately after the floods and identified the following priority actions: 1) continuity of antiretroviral therapy for people living with HIV and ensuring their access to treatment centres; 2) integration of HIV prevention services and messages in reproductive health services; 3) integration of HIV educational materials into general health education materials; 4) assessment of the impact of floods on most-at-risk population. A total of 1200 people living with HIV/AIDS were given care and support packages, in collaboration with provincial and national aids control programmes.

SAVE THE CHILDREN

Save the Children has medical teams in six districts (Multan, DG Khan, Rajanpur districts in Punjab, Sukkur, Shikapur, and Jacobabad districts of Sindh).

WHO

WHO has provided essential medicines for 4 million people, including supplies to treat 187 500 cases of diarrhoea. It has distributed a total of 375 diarrhoeal disease kits (21 in Balochistan, 2 in Gilgit Bilistan, 154 in KPK, 67 in Punjab, 130 in Sindh and 1 in AJK). It is continuing to set up DTCs across the affected areas, with an initial target of 81 DTCs.

The International Center for Diarrhoeal Disease Research, Bangladesh (ICDDRB) has also been deployed to support efforts to control potential disease outbreaks.

WHO is working with partners to plan the refurbishing of first-level care facilities in the affected districts.

The initial target of 81 DTCs should be met (not necessarily operational) by the end of next week. As of 15 September, 42 DTCs had been established, as reported by partners (NGOs). o A team of experts from the International Centre for Diarrheal Disease Research, Bangladesh (ICDDRB), will train 15 master trainers next week on managing a DTC, including case management, reporting, and infection control. The master trainers will then train DTC staff in their respective hubs. o The ICDDRB team has conducted field visits in all four hubs to evaluate currently operational DTCs and address issues identified on the ground. They have given special attention to case management shortcomings. o Next step for the DTCs will be to implement a solid routine of monitoring and evaluation.

WHO is planning to scale up its intervention in the southernmost affected areas of Pakistan. More international staff are being deployed to the most affected areas. WHO is working with partners to plan the refurbishing of first-level care facilities in the affected districts.

To address the increasing rates of malnutrition in the flood areas and limit morbidity and mortality due to malnutrition among children under five, WHO, MoH and partners are screening each child brought to a DTC using mid-upper arm circumference (MUAC) standardized tape. Children with severe acute malnutrition will either be treated in the DTC or will be referred to the nearest stabilization centre. UNICEF has pledged to provide supplies for such treatments, in particular therapeutic milks (F-75 and F- 100). WHO will also train MoH staff and NGO partners on the facility-based management of severe acute malnutrition.

Malaria Response

MERLIN

Merlin has been working in malaria control in Pakistan since 2007, in close collaboration with federal and provincial malaria control programmes. The programme covers around 6 million people living in several locations in FATA, KPK and Baluchistan.

Baluchistan Province: As a sub-recipient of Global Fund malaria R-7 grant, the programme (covering Sibi, Harnai, Noshki and Naseerabad districts) addresses the timely diagnosis and effective treatment of malaria through 27 malaria microscopy and 21 rapid diagnostic test (RDT) centres established or strengthened by Merlin. These centres are functioning within public sector primary and secondary level health care facilities. A total of 287 health care providers trained by Merlin provide case management services to the target population. Merlin has established another 10 RDT centres in Sibi and Naseerabad, where access to public sector facilities was interrupted by the floods. It aims to expands its operations to five more districts (Zhob, Qila SaifUllah, Loralai, Turbat and Gawadar), with the support of the Federal Directorate of Malaria Control.

KPK and FATA Merlin's malaria control programme is well established in Bannu and Kakki Marwat districts and Kurrum, Khyber and Bajaur Agencies, and is working through 54 malaria microscopy and 23 RDT centres. Malaria case management services are provided by 777 health care providers trained by Merlin on national case management guidelines. Merlin is providing PHC services in Nowshera, Charsadda, Swat and Buner and other districts. Malaria case management services according to the national guidelines are provided through these centres.

Beside malaria cases management, Merlin will expand its vector control (IRS) and outbreak response interventions to all parts of SWAT and Buner this week. All logistical arrangements have been finalized. Merlin will also upgrade an additional 30 public health facilities for malaria microscopy and treatment in SWAT and Buner districts. The expansion foresees the establishment of 30 case management and outbreak response centres in Charsadda and Nowshera districts.

Expansion Plans to Punjab and Sindh Expansion of malaria case management and outbreak response services are currently being made for Muzafargarh in Punjab and four uncovered districts in Sindh province.

NAGE- PAKISTAN

NAGE is working in the Punjab districts of Muzzafar Garrh and Layyah. The targeted locations (Union Councils n°s 3, 4 and 5 of Tehsil Kotadu of district Muzzafar Garrh) are situated near Tonsa Bairaage (about 100 km from Multan) and are among the most affected UCs in the district. NAGE-Pakistan medical teams are reporting increasing rates of malaria. NAGE is forming "Health Watching Committees" at village level to promote preventive measures against malaria, and is arranging awareness-raising seminars and corner meetings in flood-affected communities. Through seminars, NAGE is encouraging the population to use mosquito nets while sleeping, burn smoky fires at night, and fill stagnant any water ponds near dwellings with mud. It is also raising funds for 15 000 mosquito nets for targeted communities.

RELIEF INTERNATIONAL Reporting period: 8-17 September 2010

KPK No suspected case of malaria has been reported in DEWS, one of main reasons being the RI clinic's high- altitude location and the cold weather. The medical team remains vigilant, and has Para Check strips to diagnose Falciparum Malaria if suspected cases are reported.

Baluchistan The weather is warm and humid in Kachi, Balochistan, and four or five suspected malaria cases are being reported each day. The medical team has the facility to diagnose all suspected cases for Falciparum malaria, but no case has been confirmed until now. Other cases are referred to the laboratory in DHQ hospital Kachi. RI's two female health educators inform the community about preventive measures for malaria, and refer all suspected cases with positive symptoms.

SAVE THE CHILDREN Save the Children has medical response in six districts - Multan, DG Khan, Rajanpur districts in Punjab; and in Sukkur, Shikapur, Jacobabad districts of Sindh. It is currently seeing a rise in fever cases in its mobile clinics. It plans to procure and distribute LLINs to 36 000 families in coordination with Health Cluster partners and the MoH, and provide diagnosis and treatment using rapid diagnostic tests, and Artemisinin-based combination therapy (ACT) according to national guidelines.

USAID/PAIMAN USAID/PAIMAN plan to provide 8000 LLINs and 2000 Rapid Malaria Diagnostic Kits (RDKs) to the flood- affected population in nine districts. Each kit contains 40 tests. So far 2600 LLINs have been delivered to EDO-Health.

WHO WHO is working with MoH and partners to address potential malaria outbreaks in the most affected areas:

Punjab province • The first round of indoor residual spraying and thermal fogging has almost been completed in all the six districts, showing its effectiveness in reduction of vector densities and resulting decline in overall incidence. • A total of 50 000 RDTs to detect both vivax and falciparum received from WHO Kabul have been shifted to Punjab province earlier this month. The kits are being used at FLCFs. • Currently, there are sufficient quantities of antimalarial drugs to treat confirmed cases, except for Primaquine tablets, which will be out of stock in the next few days. A consignment of 30 000 Primaquine tablets requested by the Director of Malaria Control, Islamabad were shifted from KPK to the WHO Hub in Multan on 18 September to fill the gap. • The overall situation in Punjab is well under control. Sindh and Balochistan provinces • The surveillance system is generating daily reports. • A total of 20 000 RDTs have been shifted to Hyderabad and Sukkur to strengthen early diagnosis and effective treatment. • Four districts of Sindh (Khairpur, Dadu, Thatta and Tharparkar) are the target districts of the Global Fund in the R-7 grant, but the floods have diluted the effectiveness of the interventions due to the rising trend of the disease and the interrupted supply of RDTs, ACT and LLINs in these districts. • A total of 75000 LLINs out of 14 5000 being procured by WHO will be distributed to Sindh province in September as soon as the consignment arrives. • A total of 15 000 RDTs have been distributed to Balochistan. • Sindh and Balochistan are waiting for the arrival of WHO logistic support materialized through the outbreak prevention plan accepted by donors amounting to US$4.2 million.

Situation in KPK National and international staff are being recruited to enhance capacities to implement planned anti- malaria interventions over the coming year. They are expected to begin arriving on 15 October 2010.

Drugs including ACT, Chloroquine, Primaquine and Artemether , together with LLINs and RDTs, are expected to arrive within five weeks. Donations are required to procure spraying equipment, insecticides for IRS and thermal fogging.

A total of 55 000 LLINs were received from Hanoi on 19 September, and are being distributed to WHO hubs. Another 40 000 LLINs are on their way from Hanoi and will arrive in Pakistan on 20 September.

Coordination

GOVERNMENT COORDINATION

On 4 September, federal, provincial and district authorities, along with WHO, UNICEF and UNFPA representatives, met to discuss and plan malaria control and diarrhoeal disease treatment and reproductive health interventions. The needs of provinces in these three areas were identified with a view to understanding the resources needed to fill gaps. A follow-up meeting will be held on 13 September to measure progress.

HEALTH CLUSTER COORDINATION

Islamabad Health cluster meetings are taking place twice a week in Islamabad. The participants are national and international NGOs, MoH and donor representatives, Economic Affairs Division and UN agencies.

Pakistan Floods Response Plan: The Pakistan Floods Response Plan (PFERP) was launched in New York on Friday 17 September. This is the largest humanitarian appeal ever, asking the international community for more than $2 billion to assist 14 million people for the next year in flood-ravaged Pakistan. The Health Cluster is appealing for US$ 200,771,963 to fund 95 projects prepared by six UN agencies, 19 international and 31 national NGOs.

Damage and Needs Assessment (DNA): The Asian Development Bank, in collaboration with the International Monetary Fund, the World Bank and WHO, carried out a Damage and Needs Assessment (DNA) across all flood-affected districts. The assessment found out that 558 of the total 97 000 health facilities in the flood-affected districts were either destroyed or severely damaged. An overwhelming number of health facilities are partially damaged. The exact data will be released soon. The DNA assessment team has estimated that around US$40 million is required to rebuild and rehabilitate all 558 damaged or destroyed health facilities.

Multan As of today, seven cluster coordination meetings have been conducted since 12 August. The Health Cluster coordinator (HCC) arrived on 30 August. The weekly cluster coordination meetings in Multan (chaired by the MoH (EDO Multan) and co-chaired by WHO) are attended by representatives of the MoH, UN Agencies, the Pakistani Army and the NDMA, as well as over 50 international and national NGOs. More NGOs (from Islamabad and Lahore) are contacting the cluster for guidance on establishing activities in non- covered areas. The Who Does What, Where (3W) database is 80% completed; a draft mapping of partners' activities will be available this week. To improve coordination at the district levels, NGO and representatives have been identified as focal points to support the EDOH. Currently, four districts have focal points, and coordination meetings have started in three districts (Muzaffargah, Ranjanpur and DGK), with RYK district to follow this week. Focal points will be selected to cover all districts. WHO surveillance officers will also help the EDOH to coordinate partners. The HCC has frequent ad hoc meetings with local goverment authorities (the District Commissioner, the Southern Punjab DG of Health, the Multan Health EDO, the Army medical corps brigadier, and the NDWA provincial representative) and receives daily updates on procurements and epidemiological reports.

Sukkur At the 12 th Health Cluster meeting on 16 September, EDOs from all nine districts of Sukkur hub were requested to participate and share information on the status of functional, damaged, partially damaged and affected health facilities. They were asked to expound on the exact location of diarrhoea cases to help Health Cluster partners identify the root causes of the disease and take remedial action. The meeting focused on the current disease situation, including surveillance, cholera case management, control and prevention strategy for AWD, improving capacity and measures to mitigate the problems of the flood-affected population. Disease trends and reporting sites of partners were highlighted. Partners were requested to share their activities and data to help WHO map all activities and affected sites and work with WASH to complete the first phase of strengthening hygiene and sanitation. During the meeting, Dr Nevio Zagaria (WHO/HQ) introduced the new “survival strategy” adopted by the four clusters (Health, WASH, Food and Nutrition). The strategy aims to focus on coherent and synergetic actions between the four clusters in order to enhance the efficiency and effectiveness of the humanitarian response and minimize the damage caused by this unprecedented catastrophe. An issue of concern was the very low presence of NGOs working in the health sector, a point that was repeatedly mentioned by the EDUs responsible for the different districts.

Hyderabad

The ICDDRB Team has cancel the planned training on the weekend owing to movement restrictions. Dadu’s Executive Director of Health (EDO) has asked the UN and partners for help to deal with the worsening situation in the town, especially the area around lake Manachar EDO Badin has asked for assistance dealing with the influx of IDPs to Golachari area and Badin town. There is a health cluster meeting on Wednesday the 22rd at 11am to which it is proposed to join nutrition WASH and food.

WHO is working with colleagues in the nutrition, WASH and food cluster to prepare for the visit of the senior officials delegation of Wednesday. There will be an inter cluster meeting at OCHA to discuss the visit. WHO is coordinating with District authorities and NGO partners for the Hyderabad and Jamshoro visits. It is also hoped the Delegation will attend the intra cluster meeting for 30 minutes.

Two new partners (IMC and MDM) come forward for Dadu and Sejawl (Thatta)

INTER-CLUSTER COORDINATION: The Inter-Cluster Survival Plan

Four senior officials from WHO, UNICEF, WFT and UNFPA are visiting Pakistan this week to launch the Survival Plan. They plan to visit KP and Sindh.

Alfred Dube Health Cluster Coordinator email: [email protected] Telephone: +92- 03004005934

Maria Anguera de Sojo Communications Officer email: [email protected] Telephone: +92- 03018551459

Syed Haider Ali Communications officer email: [email protected] Telephone: +92- 3004005944