Weekly Morbidity and Mortality Report (WMMR) IDP Hosting Districts, NWFP, Pakistan Week # 27 (27 Jun – 3 July), 2009
Emergency Humanitarian Action (EHA) Islamabad, Pakistan
Children with Leishmaniasis attended for treatment in Jalozai II, IDP camp (Picture by WHO Team)
Highlights: • Two alerts of AWD cases received (one from district Mardan and another from
IDP camp Palosa‐II, district Charrsada) were investigated and identified as severe
acute diarrhoea.
• During this week, 198 health facilities reported 67430 patients’ consultations
through the DEWS network
• Acute Diarrhoea was reported in 8% (5682) of the total consultations in all age
groups, while it accounts for 15% of consultations in children <5 years of age and 7% of the consultations in the patients above 5 years age
• Acute Respiratory Infections (ARI) continues to be the leading cause of morbidity, with a total of 14036 consultations (21% of total consultations) in IDP hosting
districts NWFP.
• In children less than 5 years of age, ARI accounts for 4129 (28%) of the total consultations.
The WMMR is published by the World Health Organization (WHO), Emergency Humanitarian Action (EHA) unit, National Park Road, Chak Shahzad, Islamabad, Pakistan. For More Information, please contact: Dr. Ahmed Farah Shadoul , Chief of Operations, EHA , WHO, Pakistan; [email protected] Dr. Fazal Qayyum, Director Health Services, Department of Health NWFP, Pakistan Dr. Musa Rahim Khan, Senior Public Health Officer (DEWS Coordinator), WHO,EHA , Pakistan; [email protected]
1. Alert & outbreak investigations and response:
During the epidemiological week 27 of 2009, two alerts of acute watery diarrhoea (AWD) were reported and DEWS teams investigated the alerts and identified as cases of acute diarrhoea.
1.1. On 28th June a 15 year old female, resident of village Charcha, district Mardan was admitted to DHQ hospital Mardan with Diarrhoea, vomiting and severe dehydration. Stool sample was taken and sent for laboratory testing. The Laboratory test results from NIH reported the stool sample negative for AWD pathogen. A DEWS team conducted field investigations in the locality of the patient, and found no other patients with in the locality.
1.2. On 29th June 2009, a 7 year old male patient from Palosa‐II IDP camp with Diarrhoea, vomiting and severe dehydration was treated at the Relief International health facility in the camp and was notified as an alert for AWD. A Field investigation was conducted on 30th June 2009 and stool sample collected and sent for laboratory test at NIH. From the field investigation findings and laboratory results it was declared as a case of simple acute diarrhoea.
2. DEWS reporting units and consultations
Table 1: Weekly number of reporting units and total consultations from health facilities in IDP camps and outside camp in IDP hosting districts of NWFP from week 24 to 27, 2009
Week 24 Week 25 Week 26 Week 27
District consultations consultations consultations consultations Rep. Rep. Rep. Rep. Units Outside Units Outside Units Outside Units Outside Camp Camp Camp Camp Camp Camp Camp Camp
Charrsada 32 2063 5844 35 810 6487 30 1202 5020 42 382 4265
Swabi 4 2527 74 11 3791 1342 10 3634 4877 8 1074 338
Mardan 54 7291 19425 56 7095 23061 52 5761 25490 59 6948 20682
Nowshera 28 4180 6796 25 5240 5465 29 6970 5285 30 11491 4021
Peshawar 62 5714 10879 59 2727 10440 58 8081 11362 59 7593 10636
Total 180 21775 43018 186 19663 46795 179 25648 52034 198 27488 39942
The weekly number of DEWS reporting sites remained fluctuating during the last four to six weeks but the weekly reporting is gradually improving. In general, the overall reporting has improved in most of the districts except Swabi where the number of weekly DEWS reporting is still far behind than it is expected. A total of 67,430 consultations have been reported in week 27 reflecting a decrease of consultations by 10,252 (13%) as compared to the previous week. Drop in the number of consultations was particularly observed outside the IDP camps in district Mardan and Swabi during this week. The detailed analysis confirmed that the drop was due to low reporting from some of the health facilities and mobile clinics in the host districts.
Table 2: Total population and weekly total consultations in IDP camps by district, from week 24 to 27 Consultations District IDP camp Population Week 24 Week 25 Week 26 Week 27 Charrsada Palosa 1 & 2 6778 356 636 798 320 Charrsada Sugar Mill 3756 1707 174 404 62 Swabi Shah Mansoor 21104 ‐ 376 ‐ ‐ Yar Hussain 1 & 2 27468 2527 3415 3634 1074 Mardan Jalala 7239 1443 1495 1642 2174 Mazdoorabad 4786 998 ‐ ‐ 312 Sheikh Shahzad 8153 1751 2191 1527 1701 Sheikh Yaseen 10226 3099 3409 2592 2761 Nowshera Benazir Complex 2550 336 277 339 338 Jalozai 1, 2, 3, 4,5 108308 3844 4963 6631 11153 Peshawar Kacha Garhi 1 & 2 15346 2593 2727 5150 5397 Larama 4934 3121 ‐ 2931 2196 Total 220648 24924 21775 19663 27488
Amongst the health facilities in the IDP camps Shah Mansoor (managed by ICRC) in district Swabi did not report to the DEWS during week 27. Compared to week 26 an increase in the number of total patient consultations by 7,825 (28%) in the health facilities of the IDP camps were reported (particularly from Jalozai because weekly reports from all the partners were received this week).
3. Weekly Morbidity pattern of the seven most common diseases in the IDP hosting Districts NWFP, during week 27 of 2009:
Figure 1: Weekly morbidity pattern of the seven most common diseases reported in the IDP hosting districts, NWFP as number of consultations during week 27, 2009
5000 URTI 4500 AD
s 4000 SCB 3500 UF 3000 LRTI consultation 2500
of MAL
2000 BD 1500 Number 1000 500 0 Mardan Peshawar Nowshera Charsadda Swabi
Incidence rate and morbidity rates are good indicators to determine the morbidity trends. To calculate these rates the actual population under risk is needed but, during complex emergencies, it is difficult to get actual population under risk. Because of this reason it has been decided to simply compare the number of consultations to get an idea about currently prevailing most common diseases in the IDP hosting districts.
During the epidemiological week 27 of 2009; Upper Respiratory Tract Infection (URTI) was the most common disease (18%) among all the consultations reported and it was the leading cause of morbidity in the IDP camps as well as outside the camps in all the hosting districts (Figure 1).
Acute Diarrhoea (AD) was the second common disease (8%) with high incidence in Mardan district followed by scabies (SCB) 5% with high incidence in Swabi, unexplained fever (UF) 3% with high incidence in Mardan, and Lower Respiratory tract Infection (LRTI) 3% with high incidence in Mardan. Malaria was reported in 4642 (2%) of the cases of the total consultations and the incidence is high in Mardan as compared to the other districts.
4. Morbidity pattern of the five most common diseases by number of consultations in the IDP camps of NWFP during week 27 of 2009
Figure 2: Pattern of five most common diseases in the IDP camps NWFP, week 27, 2009
800 URTI 700 AD s 600 LRTI
500 SCB UF consultation
400 of
300
200 Number 100
0 I I V II ‐ II ‐ III ‐ IV ‐ ‐ ‐ ‐ Mill
Jalala Palosa Yaseen Larama
Shahzad Jalozai
Jalozai Jalozai Jalozai Jalozai Sugar B.Complex YarHussain KachaGarhi KachaGarhi Mazdoorabad Shiekh Shiekh
During week 27 URTI was the leading cause of consultation in most of the IDP camps, except Jalozai‐IV, Jalozai‐I, Larama and Mazdoorabad. In these camps, Acute Diarrhoea was the leading cause of morbidity. Most of the Acute Diarrhoea patients present with mild to moderate signs and symptoms of loose motions and vomiting without dehydration. The DEWS teams in collaboration with the Health partners are investigating the cause of this increased number of Acute Diarrhoea in these IDP camps.
5. Weekly Trends of the five Most common diseases in the IDP hosting districts NWFP:
Figure 3: Weekly morbidity pattern of five most common reported diseases by number of cases per 1000 consultations in IDP hosting districts of NWFP from 1st to 27th week of 2009:
350 URTI AD LRTI UF SCB 300
250
200
150
100
50
Number of cases consultations per 1000 0 3 5 7 9 11 13 15 17 19 21 23 25 27
1-09
The morbidity trend has been proximally represented by number of consultation of each disease per 1000 consultations during each week. Generally the Upper Respiratory Tract Infection (URTI) is the leading cause of consultation and depicting fluctuation but decreasing trend similarly the LRTI. Acute Diarrhoea was depicting an increasing trend from week 10 to 16 after that it remained steady till week 23 than started showing some decline in the recent weeks. The rest of the commonly reported diseases (Unexplained Fever and Scabies) are showing a steady trend with a little weekly fluctuation.
6. Weekly morbidity pattern of Acute Diarrhea and LRTI among <5yrs population of IDP hosting districts of NWFP from 1st to 27th week of 2009
Figure 4: Weekly morbidity pattern of Acute Diarrhea and LRTI among <5yrs population as per 1000 consultations in the age group, in the IDP hosting districts of NWFP from 1 to 27 week (1st January to 3rd July) 2009
300 AD <5 LRTI <5 250
200
150
100
50
Number of casesNumber per consultations 1000 0 3 5 7 9 11 13 15 17 19 21 23 25 27
1-09
Acute Diarrhea (AD) and Lower Respiratory Tract Infections (LRTI) are known as the common cause of morbidity and leading causes of deaths among children under the five years age. During week 27 there were total 14,635 consultations reported in children Under Five, out of them, 2261 (15%) were Acute Diarrhea and 681 (5%) were LRTI.
When analyzed the weekly trends of both the diseases among the children Under Five, in IDP hosting districts of NWFP; the overall trend of acute diarrheal cases are settling down during the last few weeks and LRTI shows a steady trend for the last two weeks. The declining trend for acute diarrhea among children less than five year is a temporary event and increase in the Diarrhoea is expected in the coming days with the start of Monsoon.
7. Outstanding epidemiological challenges and related activities:
The sporadic AD cases were contained in the locality and preparedness activities were strengthened by establishing two more DTCs in Jalozai and Kacha Garhi with necessary supplies.
8. Water & Sanitation:
Regular water and sanitation monitoring and evaluations are being done by WHO Environmental Health engineers in all the IDP camps routinely and in the host community from where alert or outbreaks for the waterborne disease are reported. During the outbreak response activities; the teams train the male heads of the affected families on how to use chlorine, Aqua tabs and antiseptic soaps. Hygiene promotion activities through health education messages on prevention of waterborne diseases by practicing hand washing , drinking safe water and maintain personal hygiene etc were conducted by the implementing agencies and LHWs.
The findings of water sample test results from Mardan district during week 27 is summarized in Table 3.
Table 3: Summary of water sample tests done during week 27 (27th June to 3rd July 2009) Source Type location Date Coliform Residual PH Turbidity Remarks Action Taken (100 ml) Chlorine
Advised not to use the House Hold Mansaf Village Unfit for water for drinking Bore Well 1 Mardan 1/7/09 0 CFU - 7.4 15 NTU drinking purpose House Hold Mansaf Village 1/7/09 Fit for Bore Well 2 Mardan 0 CFU - 7.5 <5NTU drinking Masjid Bore Mansaf Village 1/7/09 Fit for Well Mardan 0 CFU - 7.4 <5NTU drinking Mansaf Village 1/7/09 Aqua tabs distributed House Hold Mardan 3 CFU Unfit for with relevant Mug - 7.8 <5NTU drinking instructions HH cooler 1/7/09 Aqua tabs distributed Tent- Sheikh Yasin Unfit for with relevant 21,Sector-G2 camp 75 CFU 7.8 <5NTU drinking instructions RID Storage Sheikh 2/7/09 Fit for 0 CFU tank sector A Shehzad camp 0.24 7.8 <5NTU drinking RID Storage Sheikh 2/7/09 Fit for 0 CFU tank sector C Shehzad camp 0.23 - <5NTU drinking Sheikh 2/7/09 Fit for 0 CFU HH Sector G Shehzad camp 0.2 8 <5NTU drinking Merlin Health Sheikh 2/7/09 Fit for 0 CFU post Shehzad camp - 7.8 <5NTU drinking Sheikh 2/7/09 Fit for 0 CFU RID tanker Shehzad camp - 7.8 <5NTU drinking CDWA Water Sheikh 2/7/09 Fit for 0 CFU Filtration Plant Shehzad camp - 7.8 <5NTU drinking TMA storage Sheikh 2/7/09 Fit for 0 CFU tank sector B Shehzad camp - 8 <5NTU drinking 2/7/09 Aqua tabs distributed Sheikh 0 CFU Unfit for with relevant HH Sector G Shehzad camp - 8 <5NTU drinking instructions Sheikh 2/7/09 <5NTU Fit for 0 CFU HH Sector E Shehzad camp - - drinking 2/7/09 <5NTU Aqua tabs distributed Sheikh 3 CFU Unfit for with relevant HH Sector F Shehzad camp - 7.8 drinking instructions
9. Population movement:
According to the http://helpidp.org website; 587 families (2637 individuals) have returned to their place of origin in Buner, Swat and Lower Dir as of 7th July 2009.
10. Number of Reporting/non‐Reporting Health Facilities by Type and Department (Week 27, 2009):
Number of DEWS Reporting Health Health Facility Implemented Health Percentage Department Facilities Facilities PPHI BHU 215 124 58 % RHC 28 7 25 % DHQ 4 1 25 % Dept. Of Health THQ 1 0 0 % IDP Camps 20 19 95 % Mobile, CD and CH 88 47 53 % Total 356 198 56%
During week 27; 56% of all the assigned DEWS reporting sites reported to the system, it shows 5.6% increase of reporting sites. Steps to improve the quality and sensitivity of DEWS have been placed in action by building the capacity of available human resource and providing logistical and transport supports.