Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 3, Issue 14, Wednesday 14 April 2012

Highlights Priority diseases under surveillance Epidemiological week no. 14 (1 to 7 April 2012) in DEWS

Acute (Upper) Respiratory Infection • In week 14, 2012, total 82 districts including 3 agencies provided surveillance data to the Pneumonia DEWS on weekly basis from around 1,973 health facilities. Data from mobile teams is reported Suspected Diphtheria through sponsoring BHU or RHC. Suspected Pertussis Acute Watery Diarrhoea Bloody diarrhoea • A total of 621,004 consultations were reported through DEWS of which 20% were acute Other Acute Diarrhoea respiratory infections (ARI); 8% were acute diarrhoea; 4% were suspected malaria; while 4% were Suspected Enteric/Typhoid Fever Skin disease. Suspected Malaria Suspected Meningitis Suspected Dengue fever • A total of 226 alerts reported while 23 outbreaks were identified in week 14, 2012: Alto‐ Suspected Viral Hemorrhagic Fever gether 131 alerts for Measles; 16 for Leishmaniasis; 14 Pertussis; 12 for Typhoid; 11 for NNT and Pyrexia of Unknown Origin Tetanus; 9 for ARI; 8 each for Acute diarrhoea and Scabies; 6 for AWD; 5 for Bloody diarrhoea; 3 Suspected Measles Suspected Acute Viral Hepatitis for AJS; 2 for Dengue fever; while 1 for Unexplained fever. Chronic Viral Hepatitis

Neonatal Tetanus • In this week no new polio cases was reported. As of 9 April 2012, the total number of polio Acute Flaccid Paralysis cases confirmed by the laboratory is 15 from 10 districts/towns/tribal agencies and areas. Scabies Cutaneous Leishmaniasis Others

Figure‐1: Weekly trend of Acute diarrhoea, Bloody diarrhoea, ARI and Suspected malaria in Pakistan, Week‐1, 2011 to week‐14, 2012.

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

Percentage 20 15 10 5 0 9 7 5 3 1 9 7 5 3 1

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

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

Table 1: Most common communicable diseases syndromes reported weekly

Disease Wk-7 Wk-8 Wk-9 Wk-10 Wk-11 Wk-12 Wk-13 Wk-14

Acute respiratory infection 159,074 (26%) 153,111 (24%) 157,828 (23%) 155,186 (23%) 162,325 (23%) 144,691 (21%) 154,763 (20%) 124,220 (20%)

Skin diseases 29,199 (5%) 28,820 (4%) 29,430 (4%) 30,909 (4%) 31,713 (4%) 28,641 (4%) 31,370 (4%) 27,140 (4%)

Acute diarrhoea 30,607 (5%) 31,623 (5%) 34,918 (5%) 38,427 (6%) 40,950 (6%) 41,368 (6%) 50,813 (7%) 50,021 (8%)

Bloody diarrhoea 2,730 (0.45%) 2,765 (0.43%) 3,094 (0.45%) 2,874 (0.42%) 3,651 (0.51%) 2,864 (0.42%) 3,455 (0.45%) 2,829 (0.46%)

Suspected malaria 22,883 (4%) 23,483 (4%) 28,265 (4%) 29,599 (4%) 30,594 (4%) 29,448 (4%) 32,758 (4%) 27,706 (4%)

Total consultation 605,633 650,423 680,221 688,813 717,186 680,126 767,785 621,004

• The above graph shows the weekly trend of ARI; Acute diarrhoea; Bloody diarrhoea and Suspected malaria as proportional morbidity (percentage of cases out of total consultations) reported to DEWS on weekly basis.

• The above table provides the total consultations for each of the last 8 weeks proportional morbidity of five disease syn‐ drome. Proportional morbidity of ARI is highest in Sindh and Khyber Pakhtunkhwa while acute diarrhoea is highest in Ba‐ lochistan and Sindh (please see the graphs for every province in page 6 and 7).

This weekly Epidemiological Bulletin is published jointly by the National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083; E-mail: [email protected]. 01 Special Bulletin: DEWS, Pakistan, Week no. 14 (1 to 7 April 2012) Previous week's (13/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken During Monitoring visit to the HF of AR Taimar Camp, 2 cases of CL were identified in the OPD register and were under treatment from same HF. During Active surveillance 7 more cases were identified in the area and Khyber Village Baroon, UC 4 patients recieved 2 doses of Inj Glucantime. On job training of AR health staff was conducted for Intrale‐ 27‐Mar Leishmaniasis Pakhtunk‐ Lower Dir 0 7 0 2 Munjai, Tehsil Balmbat sional adminstration of Inj Glucantine. Health & Hygiene sessions conducted, Camp Incharge/RBM was hwa informed and requested for residual spray before the favorable season for vector breeding and transmission. EDO Health and focal person was informed . 8 cases of suspected measles were found during the follow up survey of the area. Vitamin (A) drops given. Total 50 children were assessed for their routine immunization, 60% found unvaccinated. Information shared Khyber Village Nagrai bazaar with the district EPI staff. Mopup activity conducted and 50 children were vaccinated on the same day. In 28‐Mar Measles Pakhtunk‐ Buner near CD Amazai tehsil 1 3 3 1 addition, residents were requested to bring rest of their children to CD Amazai and RHC Nagrai for vaccina‐ hwa Mandan tion. Health education session conducted with the elders and advocate them to vaccinate all their children in future. Khyber 6 cases of suspected measles were found on active surveillance. Vitamin A drops provided.12 children were Village pariwal near BHU 28‐Mar Measles Pakhtunk‐ Buner 2 3 1 0 assessed for their routine immunization coverage, out of which 4 children found unvaccinated. Health and Langow tehsil Mandan hwa hygiene education imparted. Line list shared with EPI staff for mopup activity. Alert of one suspected measles case was generated by BHU Tofkian. Vitamin (A) provided, Health education imparted, on active surveilliance found 4 more cases of post Measles & prodermal phase, Two blood samples Khyber Village Gakhra, UC collected & sent to NIH, routine immunization of the area was checked and found 4 children had no measles 26‐Mar Measles Pakhtunk‐ Haripur 2 1 1 1 Tofkian vaccine, 6 children were missing measles‐2 vaccine, 2 children had no BCG scar, 1 child was missing penta 3 hwa and 1 child was totally unvaccinated. Missed children were referred to BHU Tofkian for completion of vacci‐ nation. Follow‐up was done and found no more cases. EDO H and EPI coordinator were informed. Alert of 2 suspected cases of Measles were reported from BMC Swabi. During investigation 6 more cases Khyber found iin the same locality. Vit.A given,health education sessions conducted,EDO H and EPI coordinator 29‐Mar Measles Pakhtunk‐ Swabi BMC Swabi, Punjpir 1 4 2 1 Informed, Measles Mopup Vaccination done in the Relevant Village. WHO EHA and PPHI provided the essen‐ hwa tial medicines to the relevant Health Facilities. Nomades near Railway 9 Suspected cases of measles reported by DSC . All cases were Nomades. On active Surveillance 3 more cases 26‐Mar Measles Punjab Bhakkar Crossing, Behal Road,UC 7 0 5 0 were found. Alltogether 51 Children were checked for vaccination( BCG+ Measles) and 100% of children were Bhakkar Urban II found unvaccinated. mopup activity conducted on the same day. Vit A drops given, health and hygiene Five suspected cases found on active surveillance, vitamin (A) drops was given, 1 blood sample collected and Street 4 near Xblock 28‐Mar Measles Punjab D. G. Khan 1 0 0 4 sent to NIH. On field investigation only 43% children found vaccinated. Health education session conducted. Model TOWN uc urban 6 Mop up activity planned for community after informing DDOH and DSV of the District . Alert was received through automated SMS from eDEWS alert generation system, 07 cases of TF reported from RHC. Line list was obtained. 4 cases were reported from Khanbela Town. On further investigation, 1 more suspected case was identified and refered to RHC. 2 of the cases had a history of travelling to District Rahim Yar Khanbela, Tehsil Liaqat‐ Kashmore and on the way ate street food. Widal Test was positive for both cases. All the patients were 28‐Mar Typhoid Punjab 0 4 1 2 Khan pur prescribed with oral antibiotics. Aqua Tabs and Jerry cans were distributed among community, Health facility and LHWs for further distribution. 02 Health Education sessions were conducted with the community. 03 LHWs were mobilized to conduct further health education sessions on Safe drinking water, safe food handling and hygiene. 5 suspected cases of measles were found on active surveilliance visit, vitamin(A) drops provided, house to Fazal abad colony, UC 29‐Mar Measles Sindh Badin 1 2 1 1 house immunization status was checked and found 12 childrens, all were vaccinated, health education Mati, taluka matli, regarding importance of vaccination was imparted, EDOH informed and 1 Blood sample collected. Alert of one suspected measles case was reported from private clinic, on active surveilliance found 4 more Shahee bazar, Thakur das cases,On house to house survey, 9 children were assessed but only 3 childrens were found vaccinated, 30‐Mar Measles Sindh Hyderabad 2 0 2 1 gali, taluka Hyderabad Vitamin(A) drops given, health education imparted, DHO, DSC, DSV and FP‐Measles was informed and 2 Blood sample collected for lab confirmation. Alert of one Suspected case was admitted in NIH, active surveilliance of the area was done, Vitamin(A) dose was given, Immunization status was checked and found(BCG/OPV=71%, OPV1/PENTA1=36&, OPV2/ Street # 25. Hijrat colony, 28‐Mar Measles Sindh Karachi 3 0 3 0 PENTA2=36%, OPV3/PENTA3=36%, Measle1=7%, Measles2=0% and fully vaccinated=7%), health education UC. 9, Saddar town and community sensitizing was done, THMT was requested for crush Measles program, THO informed and 1 Blood sample collected. Current week's (14/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken 2 Suspected Measles cases were reported from Community. Patients were investigated. After active Surveil‐ lance 6 more cases were found. VIT A and symptomatic treatment was given. 2 blood samples were collected Village Karam Shah, UC 4‐Apr Measles Balochistan Kech 1 1 3 3 and sent to NIH. All information was shared with DHMT. Mopup activity planned. All patients were found Kumbail, Tehsil Dasht unvaccinated because refusal by the members of the community. HE sessions was conducted and advocate them for immunization.

Possible measles outbreak reported by the community. 14 cases were found during active search. Patients Villagea Noke Abad, UC presented with typical maculopapular rashes, children were found unvaccinated or partially vaccinated. One 4‐Apr Measles Balochistan Panjgur 2 4 3 5 Gramkan . blood sample was collected. Follow‐up domne and it reflects that disease is spreading in the locality. EPI centre was made functional at BHU Gramkan. Outreach team was advised to immunized children.

8 suspected cases of measles were reported by EPI Tech.The response was given, ADHO and DSV were Afghan Refugee Camp infromed.Two teams were sent to affected area.On active surveillance 5 more cases were found,so a total of Khyber 2‐Apr Measles FATA Warsak, UC Pindi Lalma, 9 2 0 2 13 cases were detected.Mass measles vaccination of 300 children done.Pentavalent +polio 1st dose given to Agency Tehsil Mulagori 5 children.And Pentavalent +polio 2nd dose given to 3 children.Vitamin A given. Health education im‐ parted.Two blood samples were taken.Reports were shared with the Agency surgeon and DSV.

3 measles cases were detected in OPD of CD Qadam on routine visit.Medicines and Vit A were given. Meeting was held with DHO and DSV.Reponse teams were formed sent to their respective areas. In village Qadam Khyber Village Qadam, UC 2‐Apr Measles FATA 2 0 3 0 mass measles vaccination done to 72 children.On active surveillance 2 other suspected cases of measles were Agency Jamrud, Tehsil Jamrud deteced.Vitamin A given to measles cases.Health education imparted.The blood samples were tried to be taken but it was failed.Report was shared with ADHO and DSV.

EPI surveyor reported a possible measles outbreak in the village Barkalay, 04 cases of suspected measles with Rash and Fever from the same house, Blood samples were taken and sent to the lab. Active surveillance in the neaby 07 houses were conducted, 03 suspected case were detected. Total of 20 children were checke‐ dout of which 12 were vaccinated , 7 no vaccinated and 1 partially vaccinated. Overall vaccination was 60% 1‐Apr Measles KPK Shangla Village Barkalay/Alpurai 2 2 1 2 fully vaccinated, 35% non vaccinated and 05%partially vaccinated. Non vaccinated were started vaccination and the partially vaccinted were fully vaccinated, Vitamin A given and distributed in close contacts. Health and hygiene session was conducted. Outbreak was declared EDOH office informed. Proposal for mass vacci‐ nation has been put forward to DOH. Follow Up planned.

A case of CL was reported from HF of AR Taimar Camp. In response Active surveillance was conducted and 6 Village Mandesh, UC more cases were detected in the same area. onjob training of AR & DOH health staff was conducted for 3‐Apr Leishmaniasis KPK Lower Dir Khall, Tehsil Timargara, 0 4 1 2 Intralesional adminstration of Inj Glucantine. Health & Hygiene sessions conducted, Camp Incharge/RBM was Lower Dir. informed and requested for residual spray before the favorable season for vector breeding and transmission. EDO Health and focal person was informed .

This weekly Epidemiological Bulletin is published jointly by the National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083; E-mail: [email protected]. 02 Special Bulletin: DEWS, Pakistan, Week no. 14 (1 to 7 April 2012) Cont’d Current week's (14/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken An alert of suspected Measles case was reported from Private Clinic. It was investigated and responded in the presence of Health department personelle. During investigation 4 more 4‐Apr Measles KPK Swabi Private Clinic, Topi 1 1 2 1 cases found iin the same locality. Vit.A given,health education sessions conducted,EDO H and EPI coordinator Informed, Measles Mopup Vaccination planned in the Relevant Village. WHO EHA and PPHI provided the essential medicines to the relevant Health Facility. An alert of 2 suspected measles cases was generated by BHU. Active surveillance was carried out in the area. 6 more cases were identified who had developed measles in past month and their history suggested measles. 3 children had active measles. Children were given Vit A. Vaccination status was assessed in the surrounding. Out of 12 houses and 38 children were 5‐Apr Measles KPK Haripur Afghan Refugee camp 3 2 1 4 1 assessed, 29% children had no measles 2 vaccine. 8% children had no BCG sca 5% children were totally unvaccinated. The rest were completely vaccinated. Missed children were re‐ ferred to BHU STC 4 for completion of vaccination. Blood samples were taken and sent to NIH. Follow‐up was done. Health session was conducted. EDO H, Save the children and EPI coordi‐ nator were informed of possible outbreak. Alert of suspected measles was notified. Active Surveillance conducted, 5 more cases were found in the same family surounding camp. EPI staff was requested for routine outreach AR Taimar Camp, Timar‐ 6‐Apr Measles KPK Lower Dir 4 0 2 0 vaccination in the area. Vit‐A was given, Blood Sample Collected for confirmation of antibod‐ gara Lower Dir. ies, Health education session conducted with the family members and community, patient isolated, EDO‐H & EPI Coordinator were informed. An alert of 2 suspected cases of Measles reported by MO BHU. SO along with two EPI vaccina‐ tor visited the area on next day and examined the children presented with signs and symp‐ Kukkoo Mera Shergarh toms of Measles, (runny nose, conjunctivitis, flu, fever and rashes) there were four children in 6‐Apr Measles KPK Mansehra 2 1 1 2 Oghi one house. on house to house visit, two more suspected cases were found in that area. vit A given. Total 52 children vaccinated under 15 years of age in the area only 6 children were not vaccinated before, HE conducted, one sample taken and sent to NIH for confirmation Alert of 2 suspected measles cases were reported by Pediatrician THQ Hospital. Field investi‐ gation revealed that there were 16 more measles cases in the same area. All the cases had a history of fever, rash, conjuctivitis and cough within last 30 days.Vaccination status of 42 Basti Farooqabad, UC 4‐Apr Measles Punjab Rajanpur 4 8 5 1 children was checked randomly. Only 2 children had BCG scar while all others were not vacci‐ Basti Khoja, DG Khan nated at all. 5 Blood samples were collected and sent to NIH. Vit A drops provided. HE session was conducted for the community about importance of routine immunization.Findings were shared EDOH Rajanpur for mop up measles vaccination campaign in the affected area. 2 suspected cases of measles notified by a medical officer of RHC from Village Shakal Chandio. During field investigation, five more suspected cases of measles were found, informed to S Benazira‐ Village shakal khan DHO, DSC and DSV for containment measures, routine immunization was checked for 16 2‐Apr Measles Sindh 1 1 4 1 bad chandio UC kazi ahmed 2 children in which 6 childrens were fully immunized and 5 were partially immunized and 5 were unvaccinated. report shared to DHMT, vitamin A capsules given and also health educa‐ tion imparted. Suspected Pertussis was reported from Villagers, active surveilliance done, childrens were not Village Mamoon Muhalla, vaccinated, Cluster for immunization was assessed, where 8 childrens were checked and 2‐Apr Pertussis Sindh Badin 3 1 0 1 UC Seerani, taluka Badin found unvaccinated, health education imparted, Erythrisine was given, DHMT and HCPs were informed and requested for immunization and 1 Throat sample collected. Suspected case of measles was investigated in village, active surveillance done, Vitamin(A) Village Sher Muhammad drops provided, vaccination status was checked for 27 children where 7 children were found 4‐Apr Measles Sindh Dadu Rustumani, UC T.R Khan, 3 2 3 2 vaccinated against BCG and only 1 child found vaccinated against Measles, health education taluka Johi regarding importance of immunization was delivered, EDOH, FP‐EPI, DSM and MO were informed and 3 Blood sample collected. Alert of suspected Measles case was notified by a community person, active surveillance Village Shah baig Jamali, done, Vitamin(A) was given, cluster for routine immunization was checked and found 4‐Apr Measles Sindh Larkana UC Ratokot, taluka 0 0 0 5 Larkana BCG=67%, Penta=35%, Measles=46%, health education was imparted, community sensitized for routine immunization, EDOH informed and request for routine immunization. Alert of suspected measles case was reported from private practitioner, active surveilliance done and found 4 more cases, Mop‐up was conducted by area vaccinator, Vitamin(A) was Yaqoob Buriro, UC 4‐Apr Measles Sindh Shahdadkot 3 0 2 0 given to cases, immunization status was checked and found BCG=10%, Measles= 0% and Gebidero, taluka Kambar Measles1=0%, sensitized community regarding vaccination, THO informed and 3 Blood sam‐ ple collected. Alert of suspected pertussis case was notified by Dispenser. During active search five more Village Noor Muhammad cases were found. House to House cluster was taken. Only 15% children were found vacci‐ 4‐Apr Pertussis Sindh Ghotki 2 0 2 2 Mahar UC Bereri nated against BCG scar.Complete dose of erythromycin was provided to all patients and close contacts. informed EDOH & DSV for vaccination and health promotion in the area. Suspected cases of pertussis were investigated and all of them found unvaccinated, health Village Malhar Wassan, education regarding importance of immunization was imparted, cluster of 20 houses were 4‐Apr Pertussis Sindh Sanghar UC Shah Sikandarabad, 8 0 0 2 taluka Sanghar taken, 33% of the children had only BCG scar whereas rest found unvaccinated. Erythromycin tabs and Cough syrups was given, EDOH and THO informed and 1 Throat swab collected. Borhi Mohalla Kambar, An alert of 3 suspected measles cases were reproted from Larkana SO as Epilinked Cases, 5‐Apr Measles Sindh Shahdadkot UC Kambar #2, taluka 2 0 3 0 during active surveilliance found 2 more cases, Vitamin (A) given, DHMT were informed for Kambar implementation of routine immunization and 3 blood samples were taken. 2 suspected cases of AJS were admitted in DHQ, active surveillance done in the area and Village Choocha Junejo, found 157 more cases, investigation completed in 2 days, Aqua tabs, Hygiene kits, essential 6‐Apr AJS Sindh Tharparkar UC Harho, taluka Nagar‐ 0 70 0 89 parkar medicines provided, 139 patients got vaccination for Hepatitis B, DEWS team received com‐ plete support from EDOH, 4 blood and 3 water samples were taken. 2 deaths due to post Measles was repoted from community, active surveillance was done and Village M. Urs Mallah, UC 6‐Apr Measles Sindh Karachi 3 1 1 3 found 7 more cases of post Measles, cluster of 10 houses was collected and found all children Ghaghar Bin Qasim unvaccinated, health education imparted, Vit (A) was given, 4 blood samples were collected. An alert of suspected Measles case was reported from GP. On field investigation 4 more cases DO Bulding office colony, were found, Vit (A) drops given to patients, 4 blood samples were collected & handed over to 6‐Apr Measles Sindh Shikarpur 2 1 1 1 khanpur road shikarpur DSC, Routine immunization for 29 children (only 6 had BCG, and no one had Measles vaccina‐ tion), information shared with DHMT. mop up activity is planed for the area.

Distribution of Wild Polio Virus cases Pakistan 2011 and 2012

As of 9 April 2012, the total number of polio cases confirmed by the labora‐ tory is 15 from 10 districts/towns/tribal agencies and areas.

Cases 2011 Cases 2012 Province P1 P3 P1 P3 P1+P3 Punjab 9 ‐ 1 ‐ ‐ Sindh 33 ‐ 2 ‐ ‐ Khyber Pakhtunkhwa 23 ‐ 4 ‐ ‐ FATA 57 2 4 1 1 Balochistan 73 ‐ 2 ‐ ‐ AJ&K ‐ ‐ ‐ ‐ ‐ Gilgit‐Baltistan 1 ‐ ‐ ‐ ‐ Islamabad ‐ ‐ ‐ ‐ ‐ Total 196 2 13 1 1

Number of alerts by province, week 14, 2012 Province Sindh Cont’d Province Sindh Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 1‐Apr Measles Hyderabad American Quarted, Badin lane 0 0 1 0 4‐Apr Measles Thatta Village Ali Muhammad Ameen Jat 1 0 1 0 2‐Apr AWD Mirpur Khas DTC Center Village Karim Buksh 2 0 0 0 4‐Apr Pertussis Ghotki Village Noor Muhammad Mahar 2 0 2 2 2‐Apr AWD Tando Allah Yar Madina Colony, UC #2 0 1 0 2 4‐Apr Pertussis Ghotki Village Umaid Mahar UC Mithi 0 1 1 0 2‐Apr AWD Tando Allah Yar Village Shahnawaz Muhajir 0 0 1 0 2‐Apr Measles Dadu Babar Muhalla, Channo Shahabad 2 1 0 0 4‐Apr Pertussis Sanghar Village Malhar Wassan 8 0 0 2 2‐Apr Measles Hyderabad Ali Abad colony, near Grid station 1 0 0 0 5‐Apr Measles Ghotki Village Wahid Bux Mahar 1 0 0 0 2‐Apr Measles Hyderabad Nishtar colony, Latifabad # 05 0 0 0 1 5‐Apr Measles Jamshoro Hussaini Gali, Nagoline taluka Kotri 0 0 0 1 2‐Apr Measles Hyderabad Noorani Basti, near Mustafa park 1 0 0 0 5‐Apr Measles Karachi Near Madni Masjid, Delhi colony 0 0 1 0 2‐Apr Measles Karachi Azam Basti, Malapar, Jamshed town 3 0 0 0 5‐Apr Measles Q Shahdadkot Borhi Mohalla Kambar, UC Kambar #2 2 0 3 0 2‐Apr Measles Karachi Manzoor colony, Jamshed town 1 0 0 1 5‐Apr Measles Q Shahdadkot Village Dadu Hulio , UC Rawanti 0 0 0 1 2‐Apr Measles Karachi Near filter plant, Christian colony 1 2 0 0 5‐Apr Measles Q Shahdadkot Village Mok , UC Ber Sharif 1 0 0 0 2‐Apr Measles Larkana Jatoi street Bhains colony 2 2 0 0 2‐Apr Measles Larkana Near govt dispensery Murad wahan 1 0 1 0 5‐Apr Measles Thatta Village Nawab Rind Shah Bunder 1 0 0 0 2‐Apr Measles Larkana Village Mehar Ghanghro 0 0 3 1 5‐Apr Pertussis Badin Patoli Muhalla, UC 2, taluka Matli 1 1 0 1 2‐Apr Measles Q Shahdadkot Burira colony, UC Kambar 2 1 0 0 0 5‐Apr Pertussis Sukkur Near kaladi Goth, bundo Arrore 1 0 0 0 2‐Apr Measles S Benazirabad Muhala Sardar colony UC kazi ahmed 1 0 1 0 0 5‐Apr Typhoid Larkana Ghareebabad Muhalla, UC 2 0 1 0 1 2‐Apr Measles S Benazirabad Village Nangar Khan 0 0 3 0 6‐Apr AJS Tharparkar Village Choocha Junejo 0 70 0 89 2‐Apr Measles S Benazirabad Village shakal khan chandio 1 1 4 1 6‐Apr Leishmaniasis Shikarpur Soomra Muhalla OLD saddar shikarpur 0 0 0 1 2‐Apr Measles Sukkur Bhutta road near kaif masjid 1 0 0 0 6‐Apr Measles Karachi Village M. Ibrahim Katyar 1 1 0 0 2‐Apr Measles Sukkur Miyani road makka street 1 0 0 0 2‐Apr Measles Thatta Village M. Murad Soomro 1 0 2 1 6‐Apr Measles Karachi Village M. Urs Mallah 3 1 1 3 2‐Apr Pertussis Badin Village Mamoon Muhalla 3 1 0 1 6‐Apr Measles Shahdadkot Qabool Teevena, UC Deera 1 0 0 0 2‐Apr Typhoid Mirpur Khas Mehran colony, UC #2 1 0 1 1 6‐Apr Measles Shikarpur DO Bulding office colony 2 1 1 1 3‐Apr AWD TM Khan Village Sharif, Naon Mile 1 1 1 0 6‐Apr Measles Shikarpur Near bair waari masjid 0 0 0 1 3‐Apr Measles Dadu Village Muradabad Channa taluka Dadu 1 1 0 1 6‐Apr NNT Larkana Village Mehmood Kalhoro 0 0 1 0 3‐Apr Measles Hyderabad Near Jhanday wala Baba 0 0 0 1 6‐Apr Pertussis Kashmore Village Mohabbat khan mazari 1 0 1 1 3‐Apr Measles Hyderabad Quaid‐e‐azam colony 0 1 0 0 6‐Apr Pertussis Q Shahdadkot Launder Near Mian Rato 2 0 0 0 3‐Apr Measles Karachi Gulshan‐e‐Sikandar 0 0 1 0 6‐Apr Scabies Hyderabad Hashmat Bano colony, Phuleli park 1 3 2 5 3‐Apr Measles Karachi Near Husani Masjid 0 1 0 0 6‐Apr Scabies Umer Kot Village and UC Kharwaro 1 3 2 3 3‐Apr Measles Matiari Shaikh Muhalla 0 1 0 1 3‐Apr Measles Q Shahdadkot Ahmed Khan Buledi 1 0 0 0 Province Balochistan 3‐Apr Measles Q Shahdadkot Bhangar Acha, UC Boohar 0 0 1 0 Date Disease District Area <5M >5M <5F >5F 3‐Apr Measles Sanghar Ward #5, UC 1, taluka Sinjhoro 2 0 0 0 2‐Apr Leishmaniasis Kech Miranidam, UC Kuntadar 0 0 0 1 3‐Apr NNT Ghotki Village Golo Abro 1 0 0 0 3‐Apr Leishmaniasis Jhal Magsi Village Noshehra, UC Khari 1 1 1 0 3‐Apr Pertussis Ghotki Village Changlani 1 1 0 2 3‐Apr Pertussis Ghotki Village Nabi Buksh Mahar 1 0 0 1 3‐Apr Measles Chagai Killi Koi Khan, UC Sadder 0 1 0 0 3‐Apr Pertussis Sukkur Mirani Muahallah 1 0 1 0 BHU Ghareebabad 4‐Apr Leishmaniasis Jaffarabad 0 1 0 0 3‐Apr Scabies Umer Kot Village Bheero khan 0 5 1 3 Usta Mohammad 3‐Apr Scabies Umer Kot Village Lal Khan 0 7 0 1 4‐Apr Leishmaniasis Nushki Village Qazi Abad, UC Town 0 0 1 0 3‐Apr Scabies Umer Kot Village Shadi khan 0 5 1 3 Village Karam Shah, UC Kumbail, Tehsil 4‐Apr Measles Kech 1 1 3 3 3‐Apr Typhoid Umer Kot Gharibabad colony 0 1 0 2 Dasht 3‐Apr Typhoid Umer Kot Prem Ngar colony 0 2 0 2 4‐Apr Measles Panjgur Villagea Noke Abad, UC Gramkan . 2 4 3 5 4‐Apr Measles Dadu Village Sher Muhammad Rustumani 3 2 3 2 5‐Apr Leishmaniasis Kech Village Hirronk, UC Sami 0 1 0 0 4‐Apr Measles Ghotki Mahar Market UC II Ghotki 1 0 0 0 4‐Apr Measles Ghotki Muhalla Jamia masjid UC I Ghotki 1 0 0 0 5‐Apr Leishmaniasis Lasbela Village Dam, UC Sonmiani 1 1 1 0

4‐Apr Measles Ghotki Odhar muhalla, UC 2 0 0 1 0 5‐Apr Leishmaniasis Panjgur Village and UC sordo 0 1 0 0 4‐Apr Measles Ghotki Village Umaid Mahar UC Mithri 1 0 0 0 Village Shahozai, UC Shahozai, Tehsil 5‐Apr Measles Jaffarabad 0 0 1 0 4‐Apr Measles Larkana Ghareebabad Muhalla, UC 2 0 0 0 1 Gandakha 4‐Apr Measles Larkana Village Shah baig Jamali 0 0 0 5 5‐Apr Pertussis Quetta Pediatric Unit of BMCH, Quetta 0 1 0 0 4‐Apr Measles Q Shahdadkot Yaqoob Buriro, UC Gebidero 3 0 2 0 4‐Apr Measles Sukkur City point, near Dadu Canal 0 1 1 0 6‐Apr Measles Lasbela Rind Market,UC Allah Abad Hub 0 1 3 0 This weekly Epidemiological Bulletin is published jointly by the National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083; E-mail: [email protected]. 04 Special Bulletin: DEWS, Pakistan, Week no. 14 (1 to 7 April 2012) Province Khyber Pakhtunkhwa Province Punjab Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 1‐Apr Measles Shangla Village Barkalay/Alpurai 0 2 0 2 1‐Apr ARI Multan Basti Alamgeer 11 44 7 49 1‐Apr Measles Shangla Village Basi Chna Patai 1 0 0 1 1‐Apr ARI Multan Mardan pur Bosan 15 49 9 59 2‐Apr Leishmaniasis Lower Dir Village Anderey‐Malakand 0 2 0 2 2‐Apr AD Multan Nawab pur 15 2 11 4 2‐Apr Measles Abbottabad Banda Sahib Khan, Langra Havallian 0 0 0 1 2‐Apr ARI Mianwali RHC Chakrala 45 21 77 32 2‐Apr Measles Abbottabad hulgulab Road, Near ATH 1 0 0 0 2‐Apr ARI Muzaffargarh RHC Rohillanwali 3 8 1 3 2‐Apr Measles Nowshera Kalenjar, Bahram Kalay 0 0 1 0 2‐Apr DHF Lahore Allama Iqbal Town 0 0 0 1 2‐Apr Measles Nowshera Tent 1757, Phase 8, Jalozai IDP's Camp 0 0 1 0 2‐Apr Measles Lahore Kach kahna Road Nishter Town 0 0 0 1 2‐Apr Measles Nowshera Tent: 22, Sector: A,Jalozai IDP Camp 1 0 0 0 2‐Apr Scabies Multan Nawab pur 12 68 7 60 2‐Apr NNT Swabi BMC Swabi, Gandaf Adda 0 0 1 0 2‐Apr Scabies Multan Pujani, Basti bootay wala 3 16 1 25 3‐Apr Leishmaniasis Lower Dir Village Mandesh, UC Khall 0 4 1 2 3‐Apr Leishmaniasis Nowshera Maira, Dak Ismail Khel 1 1 0 1 2‐Apr Typhoid Layyah BHU 90ML ,UC 90 ML, Tehsil Karor 0 0 0 2 3‐Apr Measles Abbottabad POF Coloney, Havallian Cant. 0 0 1 0 2‐Apr Typhoid Layyah BHU Laskani wala, UC Basira, Tehsil Karor. 0 1 0 3 3‐Apr Measles Abbottabad Sumlala, Near Ayub Pul, Langra 0 1 0 1 2‐Apr Typhoid Muzaffargarh RHC Seetpur 0 2 0 0 3‐Apr Measles Battagram Village Gul sher, Tarand, UC Tarand 0 0 0 1 2‐Apr Typhoid Rajanpur UC Rajanpur Fharbi 0 23 0 8 3‐Apr Measles D. I. Khan Qayyum Nagar, City 01 1 0 0 0 3‐Apr AD Muzaffargarh Mohalla Qazian Wala, UC City‐2, Kotaddu 42 35 13 27 3‐Apr Measles D. I. Khan Ramak, UC Miran, Paroa Road 1 0 0 0 3‐Apr AJS R Yar Khan SZ Hospital, Rahim Yar Khan 1 3 1 1 3‐Apr Measles D. I. Khan Village Budh, Paniala, Tehsil Pahar Pur 0 0 2 0 3‐Apr DHF Lahore Gulberg Town 0 1 0 0 3‐Apr Measles D. I. Khan Village Makkar, Paroa Road, Paroa 1 0 0 0 3‐Apr Leishmaniasis Rajanpur Railway Colony, UC Fazilpur 1 0 0 0 3‐Apr Measles D. I. Khan Village Shidai, Tehsil Pahar Pur 1 0 0 0 3‐Apr Measles D. G. Khan Moza Jaj Dalana uc Mubarkee 1 0 1 1 3‐Apr Measles Mansehra Mental Chowk Attershisha 1 0 0 0 3‐Apr Measles Lahore Yateem Khana Chowk 0 0 0 1 3‐Apr Measles Swat Village Qalagay lovani dramon 1 0 0 0 3‐Apr Measles Mianwali Mohalla Buland Kheel Moch 0 0 1 0 4‐Apr AWD Kohat Union Council Lachi, tehsil Lachi 0 1 0 2 3‐Apr Tetanus Lahore Abdullah colony LHR 0 1 0 0 4‐Apr AWD Kohat Village Kachai, UC Usterzai 0 2 0 2 3‐Apr Typhoid Bhakkar THQ Hospital Mankera, UC Mankera 0 2 0 4 4‐Apr Leishmaniasis Lower Dir Village & UC Khagram, Tehsil Warri 1 1 1 1 3‐Apr Typhoid Layyah THQ Karoor, UC Urban 0 1 0 1 4‐Apr Measles Charsadda village Abdar Mian Kallay Januku 1 0 0 0 3‐Apr Typhoid Muzaffargarh RHC Chowk Sarwar Shaheed 0 2 1 0 4‐Apr Measles Charsadda village Mehmood abad 1 0 0 0 3‐Apr Typhoid Muzaffargarh RHC Gujrat, Tehsil Kotaddu 0 1 0 1 4‐Apr Measles Hangu Village & UC Muhammad Khwaja 1 0 0 0 4‐Apr Measles Mansehra Dab # 1 Mansehra 1 0 0 0 4‐Apr AD Bhakkar BHU Kohawar Kalan , UC Kohawar Kalan 12 8 18 4 4‐Apr Measles Mansehra Bafa doraha 0 0 1 0 4‐Apr ARI Layyah BHU Shauwala, UC Sahuwala, Tehsil Kror 14 17 11 31 4‐Apr Measles Nowshera Mohallah Kulalaan, Zando Banda 0 1 0 0 4‐Apr ARI Mianwali BHU Shadia 23 5 25 5 4‐Apr Measles Nowshera Muqbara Road, Zando Banda 1 0 0 0 4‐Apr ARI R Yar Khan Garhi Ikhtiar Khan, Tehsil Khanpur 23 48 37 59 4‐Apr Measles Nowshera Near CD Zando Banda, Zando Chowk 1 0 0 0 4‐Apr ARI R Yar Khan UC Adam Arain 31 55 43 68 4‐Apr Measles Nowshera Sher Abad, Jalozai IDP Camp 1 0 0 0 4‐Apr BD Bhakkar BHU Daggar Rehtas , UC Daggar Rehtas 1 1 0 1 4‐Apr Measles Nowshera Village Marhati, Misri Banda 1 0 0 0 4‐Apr BD Mianwali BHU Muxafferpur 2 0 3 0 4‐Apr Measles Nowshera Village Zakhi Qabristaan 0 0 0 1 4‐Apr BD R Yar Khan Pacca Laran, Tehsil Khanpur 1 5 0 3 4‐Apr Measles Swabi Private Clinic, Mohallah Shadon 0 1 0 0 4‐Apr Leishmaniasis R Yar Khan UC 38 ‐i, Basti Noray Wali Rahim Yar Khan 0 3 0 0 4‐Apr Measles Swabi Private Clinic, Topi 1 1 2 1 4‐Apr Measles D. G. Khan Shah Jamali Astana uc Mana Ahmedani 1 1 1 1 4‐Apr Measles Swat Village and UC Qalagay Mula pati 0 0 1 0 4‐Apr Measles Lahore Green Town LHR 1 0 0 0 4‐Apr Measles Swat Village and UC Tirath, Tehsil Bahrain 1 0 1 1 4‐Apr Measles Mianwali Mohallah Mubarak Abad,Daudkheel 0 0 1 0 5‐Apr Measles D. I. Khan Basheer Abad, Zafar Abad Colony 1 0 1 0 4‐Apr Measles Multan NHM (Babar town, Domra basti) 0 0 0 1 5‐Apr Measles D. I. Khan Gomal Kalan, Tank Road, 0 1 0 0 4‐Apr Measles Rajanpur Basti Farooqabad, UC Basti Khoja 4 8 5 1 5‐Apr Measles D. I. Khan Kaali Wanda, Abdul Khail 1 0 0 0 5‐Apr AD Bhakkar BHU Daggar Kotli , UC Patti Bilanda 9 0 16 2 5‐Apr Measles D. I. Khan Marhaba Colony, UC Chehkan 1 0 3 0 5‐Apr Measles D. I. Khan Mohallah Saggu, UC Hassam 0 0 1 0 5‐Apr AD Mianwali BHU Jalalpur 10 5 11 2 5‐Apr Measles D. I. Khan Village Arra, Din Pur Road, 1 0 0 0 5‐Apr AD Mianwali THQ Piplan 17 2 15 4 5‐Apr Measles D. I. Khan Zafar Abad Colony, UC Lachra 1 0 0 0 5‐Apr AD Rajanpur Moza Kotla Diwan, UC Kotla Diwan 2 39 1 19 5‐Apr Measles Haripur Afghan Refugee camp 3 2 1 4 1 5‐Apr ARI R Yar Khan BHU Ghouspur,UC Chandia 31 57 36 61 5‐Apr Measles Haripur Khalabut Township 1 0 0 0 5‐Apr Leishmaniasis R Yar Khan Pak Rangers, 2nd Wing HQ, Kashmore 0 4 0 0 5‐Apr Measles Lower Dir Village Gudar‐shal kandai 1 0 0 1 5‐Apr Measles D. G. Khan near Govt Schoool Mangrotha 0 1 0 0 5‐Apr Measles Mansehra Tajal UC trangri sabir shah 0 0 1 0 5‐Apr Measles Muzaffargarh Basti Gajjo Wahin, UC Uperpur Janobi 0 1 0 0 5‐Apr Measles Mansehra Children Hospital 1 0 0 0 5‐Apr Measles Muzaffargarh Basti Mir Pur, Moza Tal Kot 0 1 0 0 5‐Apr Measles Mansehra Dhermia, Commerce College 0 0 1 0 5‐Apr Measles Muzaffargarh Basti Mulla Wali Khooi, Moza Mond 1 0 0 0 5‐Apr Measles Swat Village Haji Asghar Mohallah 1 0 0 0 5‐Apr Measles Muzaffargarh Basti Pir Bukhari, Moza Gajjo Wahin 2 0 1 0 5‐Apr Measles Swat Village Nawagai Gidaro Cham 1 0 0 0 5‐Apr NNT Khanewal Multan (Chah kikri wala pull bagar 1 0 0 0 6‐Apr BD Haripur Peena, Village Nullah, UC Jabree 1 1 0 2 5‐Apr Pertussis D. G. Khan Bhaaja uc Vahova 1 0 0 0 6‐Apr Measles Lower Dir AR Taimar Camp, Timargara Lower Dir 4 0 2 0 5‐Apr Pertussis D. G. Khan Jhok Mohane wali uc Mangrotha 0 0 1 0 6‐Apr Measles Lower Dir Village kotkay, UC Rabat 0 1 0 0 5‐Apr Scabies R Yar Khan UC Rukanpur 5 24 3 19 6‐Apr Measles Mansehra Kukkoo Mera Shergarh Oghi 2 1 1 2 5‐Apr Tetanus Lahore Nishter Town Lhr 0 1 0 0 6‐Apr Measles Mansehra Village Dhangri. Mansehra Deh 0 1 0 0 6‐Apr AD R Yar Khan Chak 42 A, Tehsil Liaqatpur 11 4 8 9 6‐Apr Measles Swat Village Galoch, UC Kala Kale 1 0 0 0 6‐Apr Measles Swat Village Gunagar Malam Jabba 1 0 0 0 6‐Apr AJS Lahore Lohari Gate Lahore 1 1 0 1 6‐Apr UXF Haripur Village Kotla, UC Muslimabad 0 0 0 1 6‐Apr BD Mianwali RHC Kammar machani 7 3 8 2 7‐Apr Measles Mansehra Syed Abad near Madni Masjid MC‐1 1 0 0 0 6‐Apr Measles Rajanpur Basti dareshak, Moza Kot Bahadur 1 0 0 0 This weekly Epidemiological Bulletin is published jointly by the National Institute of Health, Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: [email protected]; WHO: Tel : +92-051-9255184-5, Fax : +92-051-9255083; E-mail: [email protected]. 05 Special Bulletin: DEWS, Pakistan, Week no. 14 (1 to 7 April 2012) Table‐1: Leading causes of seeking health care in districts, Wk‐31, 2010 to Figure‐2: Number of consultations by age and gender, week 14, 2012 Wk 14, 2012, compiled from weekly reports Number of Diseases Consultations 180000 160000 Acute respiratory infection 15,044,276 (23%) 140000 Skin diseases 6,377,957 (10%) 120000 100000

80000 Acute diarrhoea 5,791,661 (9%) consultations

of 60000

Bloody diarrhoea 506,206 (<1%) 40000 20000 Suspected malaria 3,896,784 (6%) Number 0 < 1 yr 1‐4 yr 5‐14 yr 15‐50 yr 50 + yr Unexplained fever 2,456,776 (4%) Male 21724 51208 61255 98594 45097 Female 21540 47076 63517 160292 50701 Total consultations 65,577,051 Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response 2010 2011 2012 (up till week 14) Total Disease A O A O A O A O Acute watery diarrhoea 209 85 1350 543 84 3 1643 631 Acute jaundice syndrome 5 2 51 17 41 3 97 22 Bloody diarrhoea 10 1 98 20 40 3 148 24 Dengue fever 81 32 785 111 22 2 888 145 Measles 48 6 1710 91 1041 61 2799 158 Pertussis 1 0 287 81 181 59 469 140 NNT + tetanus 5 0 399 0 190 594 0 Malaria 12 7 131 88 18 7 161 102 Leishmaniasis 1 0 298 33 267 26 566 59 Others 75 11 643 69 412 43 1130 123 Total 447 144 5752 1053 2296 207 8495 1404 Province Khyber Pakhtunkhwa: Figure-3: Trend of priority communicable diseases, province KPK • 464 health facilities from 17 districts of Khyber Pakhtunkhwa reported to DEWS on weekly basis with 50 AD BD ARI S. Malaria a total of 122,252 patients consultations in week 14, 45 2012. 40 35 • 63 alerts were reported in week 14; Altogether 54 for 30 Measles; 4 for Leishmaniasis; 2 for AWD; while 1 each 25 for Bloody diarrhoea, NNT and Unexplained fever. Percentage 20 15 • 6 outbreaks, 5 for Measles; while 1 for Leishmaniasis 10 were identified and appropriate measure were taken. 5 0 1 3 5 7 9 1 3 5 7 9

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

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk Province Sindh: Figure-4: Trend of priority communicable diseases, province Sindh • 454 health facilities from 23 districts in Sindh reported on weekly basis to DEWS with a total of 212,654 patient 50 AD BD ARI S. Malaria consultations in week 14, 2012. 45 40 • 77 alerts were reported; Altogether 49 for Measles; 11 for 35 Pertussis; 5 for Scabies; 4 each for AWD and Typhoid; 30 25

2 for NNT; while 1 each for AJS and Leishmaniasis, . Percentage 20 15 • 11 outbreaks, 7 for Measles; 3 for Pertussis; while 1 for 10 AJS were identified and appropriate measures were 5 taken. 0 1 3 5 7 9 1 3 5 7 9

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

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

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

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk Province Balochistan: Figure-6: Trend of priority communicable diseases, province Balochistan • 441 health facilities from 20 districts in Balochistan reported to DEWS, with a total of 59,241 patient consul- 50 AD BD ARI S. Malaria tations. 45 40 • 13 alerts were reported in week 14 from Balochistan; 35 Altogether 7 for Leishmaniasis; 5 for Measles; while 1 30 for Pertussis. 25 Percentage 20 • 2 outbreaks for Measles were identified and appropri- 15 ate measures were taken. 10 5 0 8 6 4 2 8 6 4 2

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

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

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

50 • 5 health facilities from 1 district in Gilgit Baltistan AD BD ARI S. Malaria 45 reported to DEWS in week 14, with a total of 543 pa- 40 tient consultations. 35 30 • Less number of report were received because of ongo- 25 ing unstable situation in Gilgit Baltistan. Percentage 20 15 10 • No alerts were received for any disease from any area 5 of Gilgit Baltistan. 0 1 2 3 4 5 6 7 8 9

47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 52 51 50 49 48 14 13 12 11 10

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

• 139 health facilities from 10 districts reported to DEWS in this • 54 health facilities from 3 agencies reported from FATA in week with a total of 26,500 patient consultations. this week, with a total of 15,482 patient consultations.

• 1 alert for Measles was received and appropriated measures • 11 alerts, 5 each for Measles and NNT, while 1 for Leishma- were taken. niasis were received and appropriate measures were taken.

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

Percentage 15 Percentage 10 10 5 0 0 6 8 2 4 6 8 2 4 6 8

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

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

Date Province District Outbreaks of Diagnosis Hepatitis

2011 KPK Haripur 7 5 HAV IgM, 2 are Unknown 4 May 11 Mardan 1 HEV IgM 6 Sep & 21 Dec AJK Poonch 2 Unknown 11

9 May 11 Bagh 1 HEV IgM 20 June 11 Muzafarabad 1 HEV IgM 22 June 11 Neelum 1 HEV IgM 20 Sep 11 Hattian 1 HEV IgM 2 April 11 Sindh Hyderabad 1 Unknown 15 Nov 11 Badin 1 19 May 11 GB Astore 1 HEV IgM Total 17

Prevention and Control measures: Safe drinking water: In an outbreak of jaundice, and if Hepatitis A or E is suspected, providing safe drinking water is the most accepted method of control. This would include: Immediate provision of safe drinking water from safe source. Health education of the community to boil drinking water if feasible may be resorted to. Provision of safe water is the responsibility of the department of water supply and should be co-ordinated by the BDO / CEO / Collector. However, the health department should be involved in this measure and should advise the water supply department about the areas to be tar- geted.

Sanitary disposal of human waste: During an outbreak the community has to be educated on the need for observing basic sanitary practices. These include Using of sanitary toilets wherever possible If they resort to open-air defecating then they must be instructed to ensure that they are not next to a water source, that they cover the faeces with mud mixed with slaked lime. The importance of washing of hands after defecating must be emphasized. Washing of patient’s soiled linen and clothes should be done only after soaking them in a solution of bleaching powder. Also washing should not be done with 10 m of a water source.

Food sanitation: Steps should be taken to ensure proper hygiene and sanitation while preparing and distribution of food. Sale of food items must be strictly monitored and food should not be exposed to houseflies. The food should be freshly prepared and served hot. Proper washing of hands by food handlers is essential for food safety. Sale of cut fruits and eating of raw vegetables like salads without thorough washing with safe water should be discouraged.

Vaccines: While not available in routine vaccination in Pakistan, Hepatitis A vaccine, containing inactivated HAV, stimulates active immunity and pro- tects against the virus in more than 95% of cases, continuing for at least ten years. The vaccine is available both for adults and children aged 2 years or older and is administered I/M with a recommended vaccination schedule of 0, 1, and 6-12 months. At present, no commercially available vaccines exist for the prevention of hepatitis E.

Health Education: Health education is the most effective prophylactic measure and should be mainly directed at early reporting and prompt treatment, importance of safe water, hygienic food practices and personal hygiene.