June 2, 2014 DISEASE EARLY WARNING SYSTEM WER-21 (8th Yr) WEEKLY EPIDEMIOLOGICAL REPORT

Summary:

 The surveillance data collected for this weekly report is from 24 – 30 May 2014.  Out of 385 functional Sentinel sites (SS), 382 (99.2%) have submitted reports for Week-21 of 2014.  Out of a total of 365,649 consultations (155,175 male, 210,474 female) recorded in Week-21 of 2014, 34.2% or 125,009 (60,156 male, 64,853 female) consultations were reported due to DEWS targeted diseases.  Main causes of consultations this week were Acute Respiratory Infections (ARI) (18.9%) and Acute Diarrheal Diseases (ADD) (14.2%) from total clients in a continuing trend from the week before.  A total of 57 deaths reported due to DEWS targeted Diseases, which includes 21 deaths (11 male, 10 female) caused by Pneumonia, 16 deaths (6 male, 10 female) caused by Diarrheal Diseases, 16 deaths (9 male, 7 female) caused by Meningitis/Severely Ill Children, 2 deaths (1 male, 1 female) caused by Measles, 1 death (0 male, 1 female) caused by Malaria and 1 death (1 male, 0 female) caused by Acute Viral Hepatitis.  In this reporting week, a Suspected Measles Outbreak reported from Paktya, Zabul, Badghis and Kunar provinces, a Suspected Pertussis Outbreak reported from and a Suspected CCHF Outbreak reported from Kandahar and Herat provinces.

Reports Received From Reporting Sites:

As of May 30, 2014, 385 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of . In this reporting week, 382 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-21, 2014

Region

Central Central East Central West North North East West South East South East Total No. of Expected Reports from 55 33 58 54 40 51 49 45 385 Sentinel Sites No. of Reports Received in this 54 33 58 53 40 50 48 45 382 week

Figure-1 DEWS Sentinel Sites: Table-2: DEWS Epidemiological Regions and Figure-1(Map) shows the Sentinel Sites by type in Week- 21, 2014 distribution of DEWS sentinel

sites established in the

regions/provinces by May 30,

Type of SS

2014. Table-2 shows the SS

entral entral

East Central West North North East West South East South East Total distribution by type of health C facility. Data on 15 DEWS target CHC/BHC 28 20 43 43 26 41 39 37 277 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 54 40 51 49 45 385 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-21 of 2014: Out of a total of 365,649 clients recorded in week- 21 of 2014, 16.3% (59,651) of consultations were Fig-2: Percentages of DEWS Target Diseases by reported due to Cough and Cold and 2.6% (9,396) 20.00 Gender in W21-14

18.00 of consultations was reported due to Pneumonia. In 16.00 14.00 the same reporting period, 14.6% or 52,016 events 12.00 were reported due to diarrheal illnesses (10.5% due 10.00 8.00

to Acute Watery Diarrhea, 2.6% due to Bloody Percentage 6.00 Diarrhea and 1.1% due to Acute Watery Diarrhea 4.00 2.00 with Dehydration). In comparison with the previous 0.00 Men/SI ARI C&C ARI Pn AwD BD AwDw AVHep Measle Malaria week (W20 of 2014) the percentage of ARI disease C has decreased by 0.4% to 18.9%, and the percentage Male 17.92 3.04 12.36 2.95 1.31 0.05 0.05 0.06 0.47 of Acute Diarrheal Disease has increased by 1.5% Female 15.13 2.22 9.11 2.37 0.99 0.03 0.04 0.04 0.36 to 14.2%. These variations could be due to changes Total 16.31 2.57 10.49 2.61 1.13 0.04 0.05 0.05 0.41 in temperature /weather during the reporting week. Figure-2 (right) shows the percentages of DEWS target diseases by gender in week-21 of 2014. Percentage of ARI by Weeks and by Age Groups: In the epidemiological week-21 a total of 69,047 events of ARI were reported. 23.5 % of total clients less than 5 years of age were Cough & Cold patients and 13% were among the age group 5 years and over. The percentage of C&C (<5 years) consultations in week-12, in comparison with the percentage of C&C in week-21 of 2014, decreased by 6.6%, whereas in case of 5 years and above decreased by 4.9% to 13% 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 3.6% in last 10 weeks, whereas the percentage of age group 5 years and over decreased by 1.1% 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- 12-14 13-14 14-14 15-14 16-14 17-14 18-14 19-14 20-14 21-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 30.1 31 30.2 28.2 28.3 26.2 25.1 24.2 22.9 23.5 Years ≥5 17.9 17.6 16.2 15.8 15.6 14.8 13.9 13.9 13.4 13 Years ARI- <5 9.1 9.6 8.6 7.5 6.8 6.6 6.6 5.9 5.9 5.5 Pneumonia Years ≥5 2.3 2 1.8 1.7 1.6 1.5 1.5 1.4 1.5 1.2 Years

In the reporting week-21 of 2014, the highest percentages of Cough & Cold were recorded in Parwan, Wardak and Khost provinces with 26.1%, 22.7% and 22%, whereas the lowest percentages of C&C were reported from Nimroz, Farah and Ghor provinces with 4.8%, 5.3% and 7.3% respectively. The highest percentages of Pneumonia cases were reported from Bamyan, Saripul and Samangan provinces with 7.1%, 5.5% and 5% respectively, whereas the lowest percentages of Pneumonia cases were recorded in Zabul, Herat and Nimroz provinces with 0.3%, 0.4% and 0.5% respectively. (Fig-3)

35 Fig-3: Percentages of ARI from Total Clients in Week-21 of 2014 30 25 20 15 10

5 Percentage

0

HIL

PIA

FYB

BAL

BGL

FAR

SAR

ZAB

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BDS

LAG

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KAP PKA

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LOG

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KNR

PAN

NIM

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BDG

KHO

KUN

NUR GHA

URO

JOW

NAN

GHO

SAM

BAM WAR Province 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)

25 Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-21 of 2014

20

15

10

5 Percentage Percentage

0

HIL

PIA

FYB

BAL

BGL

FAR

SAR

ZAB

TAK

BDS

LAG

HER

KAP PKA

PAR

KAB

LOG

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KNR

PAN

NIM

KAN

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KHO

KUN

GHA

NUR

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NAN

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SAM

BAM WAR

Provinces AWD BD AWDwD

From week-12 to week-21 of 2014 from total clients, Acute Watery Diarrhea among children less than five years of age has increased from 8.3% in week-12 to 20.6% in the reporting week, whereas Acute Watery Diarrhea among age group 5 years and above has been increased by 3.1% to 5.9% (Table-4). Bloody Diarrhea in age group less than 5 years increased by 1.5% in last 10 weeks, while in case of age group 5 years and above has been increased by 0.6%. Acute Watery Diarrhea with Dehydration in age group less than 5 years show an increase by 1.3% in last 10 weeks, while in case of five years and above AWDwD increased by 0.5% 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 12-14 13-14 14-14 15-14 16-14 17-14 18-14 19-14 20-14 21-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 8.3 9.2 10.4 11.1 12.4 14.7 16.7 18 17.6 20.6 Diarrhea ≥5 Years 2.8 2.9 3.1 3.5 3.8 4.5 4.6 5.3 5.3 5.9 <5 Years 2.4 2.4 2.6 2.8 3.1 3.4 3.6 3.7 3.9 3.9 Bloody Diarrhea ≥5 Years 1.4 1.3 1.4 1.5 1.6 1.6 1.7 1.9 2.1 2 Acute Watery <5 Years 0.7 0.6 0.8 1 0.8 1.2 1.4 1.3 1.6 2 Diarrhea with ≥5 Years 0.2 0.2 0.2 0.3 0.3 0.4 0.5 0.5 0.5 0.7 Dehydration

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

In the epidemiologic week-21 of Fig-5: Percentages of Meningitis, Malaria & Typhoid Fever from Total 2014, a total of 149 suspected Clients in W21-14 cases of Meningitis/Severely Ill 1 Child were reported from all regions and the highest percentage 0.8 was recorded in North East, North and West regions. In the same reporting week, from all regions, 0.6

1484 Malaria consultations were Percentage reported by Sentinel Sites and the 0.4 highest percentages of Malaria cases were reported from East, 0.2 South and South East regions with 1.57%, 0.54% and 0.48% 0 respectively. Out of the total SR CER CWR WR ER NR NER SER clients, 1936 cases or 0.5% at the Men/SIC 0.03 0.03 0.01 0.06 0.00 0.07 0.09 0.02 national level were reported to be Malaria 0.54 0.05 0.12 0.03 1.57 0.16 0.08 0.48 suspected Typhoid Fever and the highest percentages of Typhoid Typhoid Fev 0.86 0.23 0.47 0.41 0.93 0.46 0.28 0.72 Fever cases were reported from East, South and South East regions with 0.93%, 0.86% and 0.72% 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 149 cases in country level, 41 cases have been reported from North region, 38 cases from the North East region and 25 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 178 cases, 61cases reported from Central East region, 25 cases were reported from South East and 22 cases were reported from West and East regions. From a total of 169 Measles cases reported in the reporting week, 69 cases were recorded in South, 37 cases were reported from East and 35 cases were reported from North 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- 21 of 2014 by Region Meningitis/ Acute Viral Acute Flaccid Total Regions Severely Ill Measles Pertussis Diphtheria Tetanus Hepatitis Paralysis Children 12 19 69 9 0 0 2 111 SR 23 61 16 0 0 0 4 104 CER 2 7 2 0 0 0 0 11 CWR 25 22 10 0 0 0 2 59 WR 2 22 37 0 0 0 0 61 ER 41 4 35 0 0 0 1 81 NR 38 18 0 0 0 0 2 58 NER 6 25 0 0 0 0 0 31 SER 149 178 169 9 0 0 11 516 Total

Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks (trend from W24 of 2013 to W21 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-21 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-20 of 2014, ARI decreased by 0.4% to 18.9%, while ADD increased by 1.5% to 14.2% (Fig-6).

Fig-6: Trend of ARI/ADD as Propotion of Total Clients From Week-24 of 2013 to Week-21 of 2014 40.0

35.0 ARI ADD

30.0

25.0

20.0

15.0Percentages

10.0

5.0

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

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 57 deaths reported due to DEWS targeted Diseases, which includes 21 deaths (11 male, 10 female) caused by Pneumonia, 16 deaths (6 male, 10 female) caused by Diarrheal Diseases, 16 deaths (9 male, 7 female) caused by Meningitis/Severely Ill Children, 2 deaths (1 male, 1 female) caused by Measles, 1 death (0 male, 1 female) caused by Malaria and 1 death (1 male, 0 female) caused by Acute Viral Hepatitis . (Fig-7)

Fig-7: Deaths due to DEWS targeted diseases in week-21 of 2014

10.82% 8.25% 8.25%

Pn

70.62% 1.03% Diarrheal Disease 0.52% Men/SIC Measeles Malaria Other

Report of Outbreaks: Last week, an Update of Measles Outbreak reported from Zabul province, two Suspected Measles Outbreaks reported from , a Suspected Measles Outbreak reported from Kabul, , Paktika, Khost and Farah provinces, and a Pertussis Outbreak reported from Zabul province and in this reporting week a Suspected Measles Outbreak reported from Paktya, Zabul, Badghis and Kunar provinces, a Suspected Pertussis Outbreak reported from Zabul province and a Suspected CCHF Outbreak reported from Kandahar and Herat provinces.Table-7 (below) shows the number of outbreaks investigated in 2014 with details of week-20 and week-21 of 2014.

Table-7: Reported outbreaks since first week of 2014 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 1 1 Avian/Swine Flu 1 1 ARI 4 2 2 Measles 63 1 62 Diarrhea Meningitis Hepatitis Malaria Typhoid CCHF 6 6 Bl. Diarrhea Chickenpox 6 6 Other 13 1 12 Total 94 4 90

Epidemiological week- 20

 Update of Measles Outbreak: Reported from Shawz Villages ,, on May 08 /2014, the team investigated the area on the following day, Vaccination coverage is poor. During the investigation there were 106 measles cases associated with 3 deaths, the team collected lab samples and send them to CPHL and the result was positive, 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 Khawaja chashet Village Dehsabaz district on May 07/2014, the team investigated the area on the following day, Vaccination coverage is unknown. During the investigation there were 15 suspected measles cases ,it was clinical confirm outbreak , There were 11 cases of under five years old and 4 cases of over five years old .Based on sex, there was 3 female and 12 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 Dehdadi Village Dehdadi district on May 21/2014, the team investigated the area on the following day, Vaccination coverage is 50%. During the investigation there were 10 suspected measles cases ,it was clinical confirm outbreak , There were 2 cases of under five years old and 8 cases of over five years old .Based on sex, there was 6 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 Pertussis Outbreak: Reported from Tazee Village Zabul Province on May 21/2014, the team investigated the area on the following day, Vaccination coverage is 21%. During the investigation there were 6 suspected pertussis cases ,it was clinical confirm outbreak , There were 3 cases of under five years old and 3 cases of over five years old .Based on sex, there was one 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 and also health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Buny Village Wama district Nuristan Province on May 18/2014, the team investigated the area on May 20/2014, Vaccination coverage is 65%. During the investigation there were 17 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old and 12 cases of over five years old .Based on sex, there was 2 female and 15 male cases with one 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 Shurik valley Monogi district Nuristan Province on May 21/2014, the team investigated the area on the following day, Vaccination coverage is 42%. During the investigation there were 11 suspected measles cases ,it was clinical confirm outbreak , There were 6 cases of under five years old and 5 cases of over five years old .Based on sex, there was 4 female and 7 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 Meast village of Yousuf khil district on May 21/2014, the team investigated the area on the following day, Vaccination coverage is unknown. During the investigation there were 4 suspected measles cases ,it was clinical confirm outbreak , There were 2 cases of under five years old and 2 cases of over five years old .Based on sex, there was one 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 Measles Outbreak: Reported from Dadwal lahan khil of Mandozi district on May 21/2014, the team investigated the area on the following day, Vaccination coverage is 10%. During the investigation there were 21 suspected measles cases ,it was clinical confirm outbreak , There were 14 cases of under five years old and 7 cases of over five years old .Based on sex, there was 9 female and 12 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 Farah jail of Farah city, on May 17/2014, the team investigated the area on the following day, Vaccination coverage is unknown. During the investigation there were 9 suspected measles cases ,it was clinical confirm outbreak , There were no cases of under five years old and 9 cases of over five years old .Based on sex, there was 9 female and no 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- 21

 Suspected Measles Outbreak: Reported from Zandikhil village of Ahmad Aba district, Paktya Province on May 27/2014, the team investigated the area on the following day, Vaccination coverage is 25%. During the investigation there were 6 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old and one 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 Measles Outbreak: Reported from Kakaran of , Zabul Province on May 25/2014, the team investigated the area on the same day, Vaccination coverage is 28%. During the investigation there were 13 suspected measles cases ,it was clinical confirm outbreak , There were 7 cases of under five years old and 6 cases of over five years old .Based on sex, there was 5 female and 8 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 Pertussis Outbreak: Reported from of Mosazee village of Shahjoy district, Zabul Province on May 26/2014, the team investigated the area on the following day, Vaccination coverage is poor. During the investigation there were 5 suspected pertussis cases ,it was clinical confirm outbreak , There were 3 cases of under five years old and 2 cases of over five years old .Based on sex, there was 3 female and 2 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases  Suspected CCHF Outbreak: Reported from Merwais regional Hospital of Kandahar city of, on May 25/2014, the team investigated the area on the same day, During the investigation there was one suspected CCHF case, it was clinical confirm outbreak and had the following Sign and symptoms: Fever, headache, body pain and gum bleeding, The patient was a 16 year old boy and had contact history with animals. 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 Post number one of Herat city of, on May 25/2014, the team investigated the area on the same day, During the investigation there was one suspected CCHF cases ,it was clinical confirm outbreak and the patient had occupational exposure . 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 Measles Outbreak: Reported from Qar Qaitu village of Qala Naw district, on May 17/2014, the team investigated the area on the following day, Vaccination coverage is 80%. During the investigation there were 5 suspected measles cases ,it was clinical confirm outbreak , There were 3 cases of under five years old and 2 cases of over five years old .Based on sex, there was 2 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 Measles Outbreak: Reported from Chinar khuar, Bakary,Jishu village of Ghazi abad district, on May 17/2014, the team investigated the area on the following day, Vaccination coverage is 20%. During the investigation there were 22 suspected measles cases ,it was clinical confirm outbreak , There were 14 cases of under five years old and 8 cases of over five years old .Based on sex, there was 7 female and 15 male cases with 2 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 Central East and North regions.  High incidence of Pneumonia overall up to 2.6% and 5.5% 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, North and East regions should be analyzed at peripheral level.  The increase in the outbreaks of Measles in South, South East and East 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-21 of 2014 by Province 8 Density Cases of Pneumonia in Week-21 of 2014

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Zabol (Zabul) Legend Province_34 Helmand Kandahar Pn Nimruz 13 - 41 42 - 135 136 - 310 311 - 763 764 - 2166

8 Density Cases of Typhoid Fever in Week-21 of 2014

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Zabol (Zabul) Legend Province_34 Helmand Kandahar TF Nimruz 2 - 18 19 - 36 37 - 71 72 - 112 113 - 214

8 Density Cases of Malaria in Week-21 of 2014

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Zabol (Zabul) Legend Province_34 Helmand Kandahar Mal Nimruz 0 - 10 11 - 37 38 - 73 74 - 131 132 - 529

8 Density Cases of Acute Viral Hepatitis in Week-21 of 2014

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Zabol (Zabul) Legend Province_34 Helmand Kandahar AVH Nimruz 0 - 1 2 - 4 5 - 13 14 - 20 21 - 60