June 16, 2014 DISEASE EARLY WARNING SYSTEM WER-23 (8th Yr) WEEKLY EPIDEMIOLOGICAL REPORT

Summary:

 The surveillance data collected for this weekly report is from 7 – 13 June 2014.  Out of 387 functional Sentinel sites (SS), 386 (99.7%) have submitted reports for Week-23 of 2014.  Out of a total of 364,787 consultations (157,408 male, 207,379 female) recorded in Week-23 of 2014, 33.9% or 123,779 (60,414 male, 63,365 female) consultations were reported due to DEWS targeted diseases.  Main causes of consultations this week were Acute Respiratory Infections (ARI) (16.9%) and Acute Diarrheal Diseases (ADD) (16%) from total clients in a continuing trend from the week before.  A total of 38 deaths reported due to DEWS targeted Diseases, which includes 18 deaths (10 male, 8 female) caused by Pneumonia, 8 deaths (6 male, 2 female) caused by Diarrheal Diseases, 11 deaths (7 male, 4 female) caused by Meningitis/Severely Ill Children and 1 death (1 male, 0 female) caused by Tetanus.  In this reporting week, two Suspected CCHF Outbreaks reported from , two Suspected Measles Outbreaks and a Suspected Food Poisoning Outbreak reported from Paktya province and a Suspected Measles Outbreak reported from and Takhar provinces.

Reports Received From Reporting Sites:

As of June 13, 2014, 387 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of . In this reporting week, 386 sentinel sites have sent their reports on new cases of DEWS target diseases recorded during the reporting week. Out of all events recorded in DEWS sentinel sites, 15 target diseases (priority diseases) are included in DEWS weekly epidemiological reports.

Table-1: Status of Reports Received from DEWS Regions during Epidemiological Week-23, 2014

Region

Central Central East Central West North North East West South East South East Total No. of Expected Reports from 55 33 58 55 40 52 49 45 387 Sentinel Sites No. of Reports Received in this 55 33 58 55 40 51 49 45 386 week

Figure-1 DEWS Sentinel Sites: Table-2: DEWS Epidemiological Regions and Figure-1(Map) shows the Sentinel Sites by type in Week- 23, 2014 distribution of DEWS sentinel

sites established in the

regions/provinces by June 13,

Type of SS

2014. Table-2 shows the SS

East Central West North North East West South East South East Total distribution by type of health Central facility. Data on 15 DEWS target CHC/BHC 28 20 43 44 26 42 39 37 279 diseases are being collected from DH 12 9 10 7 9 5 7 4 63 these sentinel sites (SS). The symbols on the map show the PH/RH/SH 13 4 5 4 4 5 3 4 42 number of sentinel sites in each Poly Clinic 2 0 0 0 1 0 0 0 3 region/province, and do not Total 55 33 58 55 40 52 49 45 387 indicate the GPS of the SS CHC=Comprehensive Health Center, DH=District Hospital, PH=Provincial locations. Hospital, RH= Regional Hospital, SH= Specialized Hospital

DEWS Data in Epidemiological Week-23 of 2014: Out of a total of 364,787 clients recorded in week-23 Fig-2: Percentages of DEWS Target Diseases by of 2014, 14.6% (53,245) of consultations were reported due to Cough and Cold and 2.3% (8,259) of 18.00 Gender in W23-14 16.00 consultations was reported due to Pneumonia. In the 14.00 same reporting period, 16% or 57,962 events were 12.00 reported due to diarrheal illnesses (12% due to Acute 10.00 8.00

Watery Diarrhea, 2.9% due to Bloody Diarrhea and Percentage 6.00 1.1% due to Acute Watery Diarrhea with 4.00 2.00 Dehydration). In comparison with the previous week 0.00 ARI Men/SI (W22 of 2014) the percentage of ARI disease has ARI Pn AwD BD AwDw AVHep Measle Malaria C&C C decreased by 0.9% to 16.9%, and the percentage of Male Acute Diarrheal Disease has increased by 1.3% to 16.07 2.63 13.93 3.23 1.22 0.06 0.05 0.06 0.52 16%. These variations could be due to changes in Female 13.48 1.99 10.46 2.60 0.94 0.05 0.04 0.03 0.40 temperature /weather during the reporting week. Total 14.60 2.26 11.96 2.87 1.06 0.05 0.04 0.04 0.45 Figure-2 (right) shows the percentages of DEWS target diseases by gender in week-23 of 2014. Percentage of ARI by Weeks and by Age Groups: In the epidemiological week-23 a total of 61,504 events of ARI were reported. 20.3 % of total clients less than 5 years of age were Cough & Cold patients and 11.9% were among the age group 5 years and over. The percentage of C&C (<5 years) consultations in week-14, in comparison with the percentage of C&C in week-23 of 2014, decreased by 9.9%, whereas in case of 5 years and above decreased by 4.3% to 11.9% in this reporting week. The trend of ARI diseases in last 10 weeks can be read in Table-3. The percentages of consultations on Pneumonia cases of age group less than 5 years decreased by 4% in last 10 weeks, whereas the percentage of age group 5 years and over decreased by 0.6% to 1.2% .

Table-3: Percentages of ARI Diseases during 10 recent weeks by age groups and by weeks Disease Age Week- Week- Week- Week- Week- Week- Week- Week- Week- Week- 14-14 15-14 16-14 17-14 18-14 19-14 20-14 21-14 22-14 23-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 30.2 28.2 28.3 26.2 25.1 24.2 22.9 23.5 21.8 20.3 Years ≥5 16.2 15.8 15.6 14.8 13.9 13.9 13.4 13 12.4 11.9 Years ARI- <5 8.6 7.5 6.8 6.6 6.6 5.9 5.9 5.5 5.1 4.6 Pneumonia Years ≥5 1.8 1.7 1.6 1.5 1.5 1.4 1.5 1.2 1.2 1.2 Years

In the reporting week-23 of 2014, the highest percentages of Cough & Cold were recorded in Khost, Parwan and Kapisa provinces with 28.4%, 26.3% and 24%, whereas the lowest percentages of C&C were reported from Nimroz, Farah and Zabul provinces with 5.4%, 5.7% and 7.2% respectively. The highest percentages of Pneumonia cases were reported from Bamyan, Balkh and Samangan provinces with 5.7%, 5.6% and 4.2% respectively, whereas the lowest percentages of Pneumonia cases were recorded in Zabul, Urozgan and Herat provinces with 0.2% and 0.3% respectively. (Fig-3)

35 Fig-3: Percentages of ARI from Total Clients in Week-23 of 2014 30 25 20

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SAM BAM Province WAR Pneumonia Cough&Cold

Percentages of Diarrheal Diseases by Weeks and by Age Groups: Figure-4 below shows the percentages of diarrheal diseases (Acute Watery Diarrhea, Bloody Diarrhea and Acute Watery Diarrhea with Dehydration)

30 Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-23 of 2014

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BAM WAR Provinces AWD BD AWDwD

From week-14 to week-23 of 2014 from total clients, Acute Watery Diarrhea among children less than five years of age has increased from 10.4% in week-14 to 22.5% in the reporting week, whereas Acute Watery Diarrhea among age group 5 years and above has been increased by 3.8% to 6.9% (Table-4). Bloody Diarrhea in age group less than 5 years increased by 1.6% in last 10 weeks, while in case of age group 5 years and above has been increased by 0.8%. Acute Watery Diarrhea with Dehydration in age group less than 5 years show an increase by 1.1 % in last 10 weeks, while in case of five years and above AWDwD increased by 0.4% in last 10 weeks.

Table-4: Percentages of Diarrheal Diseases from Total Clients during 10 recent weeks by age groups

Week- Week- Week- Week- Week- Week- Week- Week- Week- Week- Disease Age 14-14 15-14 16-14 17-14 18-14 19-14 20-14 21-14 22-14 23-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 10.4 11.1 12.4 14.7 16.7 18 17.6 20.6 21.5 22.5 Diarrhea ≥5 Years 3.1 3.5 3.8 4.5 4.6 5.3 5.3 5.9 6.3 6.9 <5 Years 2.6 2.8 3.1 3.4 3.6 3.7 3.9 3.9 4.3 4.2 Bloody Diarrhea ≥5 Years 1.4 1.5 1.6 1.6 1.7 1.9 2.1 2 2.2 2.2 Acute Watery <5 Years 0.8 1 0.8 1.2 1.4 1.3 1.6 2 1.6 1.9 Diarrhea with ≥5 Years 0.2 0.3 0.3 0.4 0.5 0.5 0.5 0.7 0.5 0.6 Dehydration

Percentages of suspected Meningitis/SIC, Malaria and Typhoid Fever by Region:

In the epidemiologic week-23 of Fig-5: Percentages of Meningitis, Malaria & Typhoid Fever from Total 2014, a total of 196 suspected cases Clients in W23-14 of Meningitis/Severely Ill Child 1 were reported from all regions and the highest percentage was 0.8 recorded in North, Central East and West regions. In the same reporting 0.6 week, from all regions, 1638 Malaria consultations were Percentage 0.4 reported by Sentinel Sites and the highest percentages of Malaria cases were reported from East, 0.2 South and South East regions with 1.66% and 0.62% respectively. Out 0 of the total clients, 2116 cases or SR CER CWR WR ER NR NER SER 0.6% at the national level were Men/SIC 0.03 0.06 0.02 0.05 0.00 0.15 0.04 0.04 reported to be suspected Typhoid Malaria 0.62 0.05 0.12 0.03 1.66 0.18 0.11 0.62 Fever and the highest percentages Typhoid Fev 0.92 0.21 0.57 0.38 1.11 0.50 0.39 0.66 of Typhoid Fever cases were reported from East, South and South East regions with 1.11%, 0.92% and 0.66% respectively.

Vaccine Preventable Diseases: Among DEWS target diseases (priority diseases) seven vaccine preventable diseases are included, and their occurrences are changing by seasonal variations. Among these diseases Meningitis/Severely Ill Child is being reported mostly from the North region. In this week out of total 196 cases in country level, 86 cases have been reported from North region, 44 cases from the Central East region and 19 cases from the West region.

In general the highest number of cases of Acute Viral Hepatitis has been reported from the East and South East regions, so in the reporting week out of total 158 cases, 47 cases reported from Central East region, 26 cases were reported from East and 25 cases were reported from North East regions. From a total of 154 Measles cases reported in the reporting week, 49 cases were recorded in South, 26 cases were reported from East and 25 cases were reported from North East regions. Table-5 (below) shows the distribution of vaccine preventable diseases across all reporting regions. Table-5: Suspected Cases of Vaccine Preventable Diseases in W- 23 of 2014 by Region Meningitis/ Acute Viral Acute Flaccid Total Regions Severely Ill Measles Pertussis Diphtheria Tetanus Hepatitis Paralysis Children 12 15 49 0 0 0 1 77 SR 44 47 15 0 0 0 4 110 CER 4 1 3 0 0 0 2 10 CWR 19 17 2 0 0 0 1 39 WR 2 26 39 0 0 1 1 69 ER 86 4 35 0 0 2 1 128 NR 16 25 6 0 0 1 2 50 NER 13 23 5 0 0 0 0 41 SER 196 158 154 0 0 4 12 524 Total

Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks (trend from W24 of 2013 to W23 of 2014): Among the DEWS target diseases, Acute Respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) are the leading causes of morbidity and mortality, having the highest frequency of consultations. The following line-chart shows the trend of ADD and ARI from week-24 of 2013 to week-23 of 2014. In week-24 of 2013, the ARI and ADD curves crossed each other, as ARI started decreasing and ADD changed its course to increase. By the end of the summer season in 2013, these curves crossed one another again in week-35 and from that time to week-7 of 2014; the percentages of ARI were increasing, while the percentages of ADD were decreasing and both of these groups of diseases reached their Extreme points (maximum and minimum values) respectively, In this regard we can say that week-7 of current year was a turning point for both of these groups of diseases, namely ARI percentages will decrease, while ADD percentages will increase till end of summer season. Comparing this week data with previous week-22 of 2014, ARI decreased by 0.9% to 16.9%, while ADD increased by 1.3% to 16% (Fig-6).

Fig-6: Trend of ARI/ADD as Propotion of Total Clients From Week-24 of 2013 to Week-23 of 2014 40.0

35.0 ARI ADD

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0.0 W24 W26 W28 W30 W32 W34 W36 W38 W40 W42 W44 W46 W48 W50 W52 W1 W3 W5 W7 W9 W11 W13 W15 W17 W19 W21 W23

Weeks of the Year

Mortality: Among DEWS target diseases Pneumonia, Diarrheal Diseases and Meningitis/Severely Ill Children (SIC) are main causes of mortality which generally amount to more than 95% of total deaths of surveillance target diseases. Usually deaths due to diarrheal diseases increase during the summer season, while the number of deaths due to Pneumonia increases during the cold period/Winter Season. In this week a total of 38 deaths reported due to DEWS targeted Diseases, which includes 18 deaths (10 male, 8 female) caused by Pneumonia, 8 deaths (6 male, 2 female) caused by Diarrheal Diseases, 11 deaths (7 male, 4 female) caused by Meningitis/Severely Ill Children and 1 death (1 male, 0 female) caused by Tetanus. (Fig-7)

Fig-7: Deaths due to DEWS targeted diseases in week-23 of 2014

3.90% 8.78% 5.37% 0.49%

Pn

Diarrheal Disease 81.46% Men/SIC

Tetanus

Other

Report of Outbreaks: Last week, a Scabies Outbreak reported from Nimroz province and two Suspected CCHF Outbreaks and a Suspected Measles Outbreak reported from Herat province and in this reporting week two Suspected CCHF Outbreaks reported from Herat province, two Suspected Measles Outbreaks and a Suspected Food Poisoning Outbreak reported from Paktya province and a Suspected Measles Outbreak reported from Balkh and Takhar provinces.Table-7 (below) shows the number of outbreaks investigated in 2014 with details of week-22 and week-23 of 2014.

Table-7: Reported outbreaks since first week of 2014 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 3 3 Avian/Swine Flu 1 1 ARI 4 2 2 Measles 68 1 67 Diarrhea Meningitis Hepatitis Malaria Typhoid CCHF 10 10 Bl. Diarrhea Chickenpox 6 6 Other 13 1 12 Total 105 4 101

Epidemiological week- 22

 Scabies Outbreak: Reported from Prison of Zaranj city of Nimroz Province on June 02/2014, the team investigated the area on the same day, During the investigation there were 60 scabies cases ,it was clinical confirm outbreak . The cases treated and health education session conducted in the prison, the active surveillance has been established for investigation of further cases.  Suspected CCHF Outbreak: Reported from Sargangal village of Guzara of Herat Province on June 01/2014, the team investigated the case at regional hospital on the same day, During the investigation there was one suspected CCHF cases , the patient is 65 years old young man who had contact with animal ,it was clinical confirm outbreak . The team collected lab samples and send them to CPHL, the case treated, health education session conducted to his caretakers, the active surveillance has been established for investigation of further cases  Suspected CCHF Outbreak: Reported from Charchah village of of Herat Province on June 1/2014, the team investigated the case at regional hospital on the same day, During the investigation there was one suspected CCHF cases, the patient is 35 years old man and had slaughtered an animal 10 days ago and also had contact with animal, due to insecurity field investigation was not done .it was clinical confirm outbreak. The team collected lab samples and send them to CPHL, the case was treated, health education session conducted to his caretakers, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Area 3 of Herat city, Herat Province on June 01 /2014, the team investigated the area on the following day, Vaccination coverage is 100%. During the investigation there were 11 suspected measles cases ,it was clinical confirm outbreak , There were no cases of under five years old but 11 cases of over five years old .Based on sex, there was 6 female and 5 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases. Epidemiological week- 23

 Suspected CCHF Outbreak: Reported from Zairat village of of Herat Province on June 7/2014, the team investigated the case at regional hospital on the following day, During the investigation there was one suspected CCHF cases, the patient is 45 years old man and had contact with animals, due to insecurity field investigation was not done .it was clinical confirm outbreak. The team collected lab samples and send them to CPHL, the case was treated, health education session conducted to his caretakers, the active surveillance has been established for investigation of further cases.  Suspected CCHF Outbreak: Reported from Chah shirin village of Gulran district of Herat Province on June 6/2014, the team investigated the case at regional hospital on the following day, During the investigation there was one suspected CCHF cases, the patient is 13 years old boy and had contact with animals, due to insecurity field investigation was not done .it was clinical confirm outbreak. The team collected lab samples and send them to CPHL, the case was treated, health education session conducted to his caretakers, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Baghcha village of , Paktya Province on June 01 /2014, the team investigated the area on the following day, Vaccination coverage is 20%. During the investigation there were 6 suspected measles cases ,it was clinical confirm outbreak , There were 2 cases of under five years old and 4 cases of over five years old .Based on sex, there was 2 female and 4 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Kharuti village of Danda Patan district, Paktya Province on June 03 /2014, the team investigated the area on the following day, Vaccination coverage is 20%. During the investigation there were 6 suspected measles cases ,it was clinical confirm outbreak , There were 4 cases of under five years old and 2 cases of over five years old .Based on sex, there was 3 female and 3 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected food poisoning Outbreak: Reported from Bilowat village of Jaji Aryob district, Paktya Province on May 30 /2014, the team investigated the area on June 1/2014. During the investigation there were 31 suspected food poisoning cases ,it was clinical confirm outbreak , There were 8 cases of under five years old and 23 cases of over five years old .Based on sex, there was 15 female and 16 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated and health education session conducted in surrounding villages, the outbreak is controlled.  Suspected Measles Outbreak: Reported from Dilmargh village of , on June 09 /2014, the team investigated the area on the following day, Vaccination coverage is 80%. During the investigation there were 16 suspected measles cases ,it was clinical confirm outbreak , There were 14 cases of under five years old and 2 cases of over five years old .Based on sex, there was 7 female and 9 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Youchokhsh village of Warsaj district , on June 11 /2014, the team investigated the area on June 13/2014, Vaccination coverage is 85%. During the investigation there were 8 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old and 3 cases of over five years old .Based on sex, there was 5 female and 3 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.

Recommendations:

 High number of deaths due to Pneumonia and Meningitis/SIC can be analyzed/discussed at provincial level among stakeholders to find out the gaps results the high morbidity and mortality, especially in East and North regions.  High incidence of Pneumonia overall up to 2.3% and 4.6% in the age group of less than five years should be analyzed and stakeholders should ensure the adequate amount of medicine for the treatment of the cases.  The high number of Meningitis in North, high number of Meningitis and Acute Viral Hepatitis cases in Central East, high number of Measles cases in South, East and North East regions should be analyzed at peripheral level.  The increase in the outbreaks of Measles in South and CCHF in West regions is to be given serious consideration at the provincial level coordinating agencies.  DEWS focal points should coordinate AFP cases with the provincial AFP surveillance focal point.

ANNEX: Mapping of Density Cases of Selected Diseases in Week-23 of 2014 by Province