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 48, Wednesday 5 December 2012

Highlights Figure‐1: 88 districts reported to DEWS in week 48, 2012

Epidemiological week no. 48 (25 Nov to 1 Dec 2012)

• Measles: 122 alerts investigated this week, responding to 31 outbreaks involving 397 measles cases. Vitamin A was provided to cases and EDOs‐H took action to improve vaccination in af‐ fected areas (Page 7)

• AWD: 4 alerts investigated this week, involving 9 cases. Alerts/Outbreaks were responded timely and appropri‐ ate measures were taken on case man‐ agement and infection control (Page 7)

• 88 districts have reported to DEWS in week 48, 2012. 2,517 health facilities have shared weekly data to the Disease Early Warning System (DEWS) in this Priority diseases Cumulative number of selected health events reported in week under surveillance Epi‐week 1 to 48, 2012 (1 Jan ‐ 1 Dec 2012) in DEWS

Pneumonia Disease # of Cases Percentage • 868,251 patients’ consultations were Acute Watery Diarrhoea Bloody diarrhoea Acute diarrhoea 2,988,251 8% reported in week 48 compared to Other Acute Diarrhoea 762,234 consultations reported in Suspected Enteric/Typhoid Fever Bloody diarrhoea 163,653 0.5% week 47, 2012. Suspected Malaria Suspected Meningitis Suspected Dengue fever ARI 6,683,257 19% Suspected Viral Hemorrhagic Fever Suspected Measles S. Malaria 1,878,776 5% • Altogether 204 alerts were investigated Suspected Diphtheria Suspected Pertussis and response were provided to 35 Suspected Acute Viral Hepatitis Skin Diseases 1,628,384 5% outbreaks. Neonatal Tetanus Acute Flaccid Paralysis Unexplained fever 1,277,383 4% Scabies Cutaneous Leishmaniasis Total (All consultations) 35,702,258

Major health events reported during the Figure‐2: Weekly trend of Acute diarrhoea in Pakistan; Week‐1, 2011 to week‐48, 2012. Epi‐week ‐ 48 (25 Nov ‐ 1 Dec 2012)

20 Disease # of Cases Percentage 2011 2012 Acute diarrhoea 58,501 7% 15 Bloody diarrhoea 3,004 <1%

10 ARI 213,731 25%

Percentage S. Malaria 47,789 6%

5 Skin Diseases 33696 4%

Unexplained fever 28,807 3% 0 1 3 5 7 9 111315171921232527293133353739414345474951 Epi‐week Total (All consultations) 868,251

• The graph (Figure‐2) shows the comparison of weekly trend of Acute diarrhoea as proportional morbidity (percentage of cases out of total consultations) reported to DEWS each week in year 2011 and 2012. • Overall weekly trend of acute diarrhoea is stable in all provinces. Districts in Sindh and Khyber Pakhtunkhwa are investigat‐ ing alerts for acute watery diarrhoea/suspected cholera.

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 Weekly Bulletin: DEWS, Pakistan, Week no. 48 (25 Nov to 1 Dec 2012) Current week's (48/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken Alert for 2 suspected Measles cases were reported from DHQ Hospital Dir Lower, all the cases were from village Village Matakoo Mattako Marongay, UC Gardai, Bajour agency. WHO team investigated the cases and 3 more cases found. The first Bajaur Marongay, UC 30‐Nov Measles FATA 1 2 2 0 suspected case 3 years old female developed fever followed by rash. BCG Scar was not present on 5 out of 5 children Agency Gardai Qazafay and measles vaccination was missed by all children. Blood samples were collected and sent to NIH. Information was Tehsil Utman Khel shared with DHO. Village Andher Measles alert was reported from CD Pindi Lalma. During active surveillance 5 more cases were found in the affected Khyber sher,UC Pindi 26‐Nov Measles FATA 5 0 1 0 area. Blood sample was taken and sent to NIH. Vitamin A was given to suspected measles cases. Health education Agency Lalma,Tehsil Mu‐ imparted and outreach measles vaccination done in the area. Report shared with Agency surgeon and FSMO. lagori

village Tangi Shah, Alert for 4 suspected Measles cases were reported from DHQ Hospital Dir Lower belong to village Tangi Shah, UC Khyber UC Mayar and Tehsil Mayar. WHO team investigated the alert. BCG Scar was present on 1 out of 6 children and measles vaccination was 29‐Nov Measles Lower Dir 1 0 2 3 Pakhtunkhwa Samarbagh, Dir missed in all children. Blood sample was collected and sent to NIH. Information shared with EDO‐H, Coordinator LHWs, Lower coordinator EPI and requested outreach campaign in the affected area.

Village Taimer, UC Alert for 3 suspected Measles cases reported from DHQ Hospital Dir Lower from village Taimer, UC Taimergara. WHO Khyber Taimergara and team investigated the alert. Blood Sample was collected and sent to NIH. BCG Scar was present on 6 out of 6 children 30‐Nov Measles Lower Dir 2 3 1 0 Pakhtunkhwa Tehsil Taimergara, but measles vaccination was missed. Alert was shared with EDO‐H, Coordinator LHWs, coordinator EPI and requested Dir Lower to conduct mop up campaign in affected area.

Alerts for suspected Measles case, given 1st dose of Vitamin‐A while 2nd dose was handed over. During active surveil‐ lance neighboring 10 house holds were visited and found 8 more cases. During survey, among 12 children of age 9 Basti Koreeja, UC months – 5 years, 8 were having BCG scar and 8 had received single shot of Measles vaccine. While among 15 children Muzaffar‐ 29‐Nov Measles Punjab Utra Sandhila, 3 2 0 3 among age group 5‐15 years, 10 had BCG scar. DOH, DDOH MZG, DSC, MO BHU Utra Sandhila and staff were also given garh Muzaffargarh briefing on the situation. DOH instructed vaccinator to ensure 100% completion of routine EPI to due defaulters and to administer Measles booster to all children under 10 years of age (not covered during last Measles Campaign), within this week. Blood sample of a patient was drawn and sent to NIH. Health education given in households visited.

Diphtheria case was notified from PMCH Nawabshah. Case was investigated and found unvaccinated. Only OPV drops Shaheed UC Ismail Khan 28‐Nov Diphtheria Sindh 0 0 0 1 were verified by parents. ADS (Anti Diphtheria Serum) was provided from WHO office and Tab erythrosine was given to Benazir Abad Brohi, taluka Daur contacts. One throat swab taken for culture and sensitivity. DHMT Informed.

BHU Kot Arbab Mir Alert for suspected Malaria cases, 3 times more then previous 3 weeks average at BHU Level. Total 307 cases were 24‐Nov Malaria Sindh Tharparkar Muhammad, taluka 21 144 14 128 found positive from 866 cases (SPR=35%). Out of them Positive FP=97(36%), Vivax210(68%). Health education was Diplo imparted regarding prevention of Mosquito bite. Informed DHO office and requested to take measures to control

Suspected measles case was reported from THQ Mehar. During field investigation total 8 cases were found from the Dahar Muhalla, same area. Vaccination status revealed that for 16 children who were checked, BCG=11(68%), Penta1=7(43%), Pen‐ 26‐Nov Measles Sindh Dadu Gulshan colony, city 3 3 1 1 ta2=5(31%), Penta3=4(25%), Measles‐1=8(50%), Measles‐2=6(37%). One Blood sample collected from reported case. and taluka Mehar Vitamin (A) dose given to all cases. Health education was given on importance of immunization. EDOH informed about the cases. Suspected measles case was reported from THQ Mehar and it has complete sign and symptoms of Measles. During field investigation 7 more cases were found from same area. Out of them 5 were BCG +ve, 3 were Measles‐1 and 2 were Village Mahesar, Measles‐2 vaccinated. Vitamin (A) dose given to all cases, blood sample was collected and send to NIH. Health educa‐ 26‐Nov Measles Sindh Dadu near city Mehar, 2 0 4 2 tion was given on importance of immunization. Vaccination status was taken from area where total 21 children were taluka Mehar checked. BCG=14(66%), Penta1=10(47%), Penta2=7(33%), Penta3=5(23%), Measles‐1=11(52%), Measles‐2=8(38%). EDOH informed about the cases.

Suspected measles case was reported from THQ Mehar. During field investigation total 11 cases were found from the Village Qazi Arif, UC same area, whereas out of them 7 were BCG +ve, 4 were Measles‐1 and 2 were Measles‐2 vaccinated. Vitamin (A) dose 26‐Nov Measles Sindh Dadu Qazi Arif, taluka 3 2 4 2 given to all cases and one blood sample collected from reported case. Health education was given on the importance of Mehar immunization. Vaccination status was taken from area where total 29 children were checked. BCG=22(75%), Penta1=15 (51%), Penta2=10(34%), Penta3=7(24%), Measles‐1=17(58%), Measles‐2=12(41%) and EDOH informed about the cases.

Suspected measles case was reported from THQ K.N Shah. Case has cough, coryza, conjuctivitis, rashes and high grade fever from past 4 days. During active surveilliance, 8 more cases were found and out of them 5 were BCG +ve, 3 were Village Mado, UC Measles‐1 and 2 were Measles‐2 vaccinated. Vitamin (A) dose given to all cases. Health education given on importance 27‐Nov Measles Sindh Dadu Chorr Qambar, 4 0 3 2 of immunization. Vaccination status was taken from the area where total 24 children were assessed, BCG=16(66%), taluka K.N Shah Penta1=11(45%), Penta2=8(33%), Penta3=7(29%), Measles‐1=10(41%), Measles‐2=8(33%). EDOH informed about the cases and 2 Blood samples collected. One Death due to Measles was reported from city Dadu. Case had symptoms of cough, coryza, rashes, high grade fever and difficulty in breathing. Case also had chest in drawing and unable to pass stool, before death neither was vacci‐ nated for any antigen. During active surveillance 7 more cases were found. Out of them 4 cases were BCG +ve, 3 were Village Timo Lund, 29‐Nov Measles Sindh Dadu 2 2 3 1 Measles‐1 and 2 Were Measles‐2 vaccinated. Vitamin (A) dose given to all cases and health education given on impor‐ taluka Dadu tance of immunization. Vaccination status was taken from area where total 30 children were checked given as, BCG=19 (63%), Penta1=17(56%), Penta2=11(36%), Penta3=8(26%), Measles‐1=14(46%), Measles‐2=10(33%). EDOH informed about the cases and 2 blood samples collected. Alert for 3 suspected cases of Measles admitted at MCH centre from same family, during field investigation 3 more Village Sardar Ghoto cases were found. Vitamin A was given to all cases and two blood samples were collected and sent to NIH. Health 28‐Nov Measles Sindh Ghotki UC Muhammad 0 0 3 3 education imparted regarding importance of routine immunization and information was shared with DHMT with Khan Ghoto request for vaccination in the area. One death due to measles complication was reported from community. On field investigation total 10 suspected Village Peer bux measles cases were found including one death due to measles in the area and all were line listed. Blood sample was Hyderani UC Garhi 29‐Nov Measles Sindh Ghotki 4 3 2 1 collected and Vitamin A was provided to all suspected measles cases. EPI cluster was taken and among 10 children 3 Chakar Taluka were found with BCG scar. All information was shared with DHMT and requested for outreach vaccination activity Mirpur mathelo improving routine immunization. Suspected measles case reported from DGH Qasimabad. Case was investigated along with DSC, DSV and FP‐ Measles. Kachi abadi band, Case was not vaccinated against Measles. During field investigation 5 more cases were found from same location. Out 28‐Nov Measles Sindh Hyderabad Sheedi Goth, UC‐1, 2 2 1 1 of them only 2 cases were vaccinated against Measles. Vitamin (A) dose given and Health education imparted. Vaccina‐ phase‐2, Qasimabad tion status of the area was taken from 10 children given as Measles‐1=3(30%), Measles‐2=(0%). Information shared with DHO authorities and 3 Blood samples collected. Measles alert was reported by Media. During field investigation 2 deaths in nearby villages and total 9 cases were Village Malhoo found. One blood sample was collected and Vitamin (A) drops were given to cases. Health education imparted on 26‐Nov Measles Sindh kashmore Bhutto, UC Badani, 4 2 4 1 importance of routine immunization. EPI status of 16 children were assessed given as BCG=4(25%). Information shared taluka Kashmore with DHMT for mop up the area.

Alert of suspected measles cases was reported from DTHO Kingri. During investigation total 15 cases were found in the Salar Mohalla city & area. All children were belonging to one family and no child was found with BCG scar, as this family was refusal to 28‐Nov Measles Sindh Khairpur UC Pir jo goth taluka 5 2 6 2 routine immunization. All information was shared with DHMT and a session regarding routine immunization was Kingri imparted along with DHCSO. 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 Weekly Bulletin: DEWS, Pakistan, Week no. 48 (25 Nov to 1 Dec 2012) Cont’d current week's (48/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken 2 suspected cases were reported from Children hospital Larkana. During active search found 13 more cases and 3 Village Razi Khan deaths were confirmed from village. Vitamin (A) doses given to all cases. 5 blood samples were collected and health 26‐Nov Measles Sindh Larkana Jagirani, UC Fateh 5 1 8 4 education was imparted. Vaccination status was taken from 8 children given as, BCG=4(50%), Penta‐1=2(25%), Penta‐ Pur 2=2(25%), Penta‐3=(0%), Measles ‐1=3(38%), Measles ‐2=(0%). Outreach vaccination was conducted. Two hundred and sixteen children were vaccinated for Measles. DHO informed about the cases. Suspected measles case was notified from a private clinic. During active surveillance found 5 more cases. Vitamin‐A Village Masoodero, dose given, 2 blood samples collected. Symptomatic treatment assured for cases and health education was imparted. 27‐Nov Measles Sindh Larkana 2 0 4 0 Rind Muhalla Routine cluster was taken from 12 children given as BCG=6(50%), Penta‐1=5(41%), Penta‐2=3(25%), Penta‐3=3(25%), Mealses‐1=5(41%). Information shared with DHO. Suspected measles case was cross‐notified by SO DEWS Qamber. During active search found 4 more cases. Vitamin (A) given and parents sensitized for isolation of patients. Symptomatic treatment assured for all cases. Villagers were Village Kakh Wara 28‐Nov Measles Sindh Larkana 4 0 1 0 sensitized about routine immunization. Routine cluster was taken from 9 children given as BCG=4(44%), Penta‐1=3 Tunia (27%), Penta‐2=(0%), Penta‐3=(0%), Mealses‐1=4(44%). Mealses‐2=(0%). DHO informed about the cases and 2 Blood samples collected. One Death due to Measles was cross‐notified by SO DEWS Qamber. Active surveillance was done and found 1 more death from village and 10 more suspected cases. Vitamin (A) given and community sensitized for isolation of patients. Village Magsi, UC 28‐Nov Measles Sindh Larkana 6 2 4 0 Proper treatment was given and villagers were sensitized about routine immunization. Routine immunization cluster Ratokot was taken from 12 children. BCG=5(45%), Penta‐1=2(16%), Penta‐2=3(25%), Mealses‐1=4(33%). 4 blood samples col‐ lected and DHO informed and requested for outreach vaccination in the area. 2 suspected cases of measles were cross‐notified by SO DEWS Larkana. Upon field investigation, found 6 more cases whereas 5(62%) children having BCG scar out of 8, and parents were not sure about other antigens. Vitamin A (2 doses) Qambar Dafar, UC Boohar, 26‐Nov Measles Sindh 3 0 0 5 were given and blood sample was collected and sent to NIH, health education imparted. Routine immunization was Shahdadkot taluka Qambar checked given as, T.T‐1=4, T.T‐2=3, Penat‐1=7, Penta‐2=5, Penta‐3=3, Measles‐1=67. Informed DHMT for vaccination in the area. Suspected cases of Measles were notified by a private clinic. Upon field investigation, found 7 more cases. 4 children Hoat Khan Marfani, Qambar were having BCG scars and parents were not sure about other antigens. Vitamin A (2 doses) were given and 1 Blood 26‐Nov Measles Sindh UC Kalar, taluka 5 0 0 4 Shahdadkot sample was collected and sent to NIH. Health education imparted regarding Importance of routine immunization. Qambar Information shared with DHMT. Alert for 2 suspected cases were cross‐notified by SO DEWS Larkana. Upon field investigation, found 7 more cases, out of them 5(55%) were found with BCG scar and parents were not sure about other antigens. Vitamin A (2 doses) were Qambar Laktia, UC Boohar, 26‐Nov Measles Sindh 4 1 0 4 given and three Blood samples were collected and sent to NIH, health education imparted. Routine immunization Shahdadkot taluka Qambar checked, given as T.T‐1=4, T.T‐2=3, Penta‐1=7 and Penta‐2=5, Penta‐3=3, Measles‐1=67. Information shared with DHMT and requested for outreach vaccination. Alert for 2 suspected cases of Measles were notified by a private clinic. During field investigation found 3 more sus‐ Bacho Mugheri, UC Qambar pected Measles cases. 2 children were having BCG scar +ve but parents were not sure about other antigens. Vitamin A 27‐Nov Measles Sindh Khairpur Juso, taluka 2 0 0 3 Shahdadkot (2 doses) were given and blood sample was collected and sent to NIH. Health education imparted. Routine Immuniza‐ Qambar tion done by DHMT as follows (Penta‐1=10, Penta‐2=7, Penta‐3=30, Measles‐1=31 and Measles‐2=107). Alert for suspected case of Measles was notified from BHU Mohammad Ali Goarmani. Upon field investigation found 7 more cases from same family. 4 children were having BCG +ve, parents were not sure about other antigens. Vitamin (A) Qambar Khur Magasi, UC 28‐Nov Measles Sindh 4 0 0 4 2 doses were given and 1 blood sample was collected and sent to NIH. Health education imparted regarding importance Shahdadkot Dostli, taluka Qambar of routine immunization. Information shared with DHMT and routine immunization was done as follow. BCG=19, OPV‐6, Penta‐1=15, Penta‐2=4, Penta‐3=13, Measles‐1=68 and Measles‐2=88. 2 suspected cases were reported, upon field investigation found 3 more cases. All children were having BCG scar. Qambar Abad , UC abad , Vitamin‐A (2 doses) were given and blood sample was collected and sent to NIH. Health education imparted regarding 29‐Nov Measles Sindh 2 0 0 3 Shahdadkot Taulka Warah importance of routine immunization. Informed DHMT for vaccination in the area and routine immunization activity was done. Alert for suspected Measles case, during field investigation along with vaccinator, 5 more suspected cases were found. Sheikh Muhalla 2 doses of vitamin (A) were given to all cases and blood sample collected. Health education imparted to cases and village Dribh tanweri 29‐Nov Measles Sindh Shikarpur 3 0 3 0 contacts on importance of routine immunization. 4 children had BCG scar and all 6 cases were found not vaccinated for UC Bhirkan Talluka Measles vaccine. Cluster of routine immunization was checked given as, 5 children BCG=(80%), Measles‐1‐2=(0%). All Lakhi Information was shared. Alert for suspected Measles case, during field investigation along with vaccinator, 1 death due to Measles complications was found in the community. Total 8 cases were line listed. Two doses of vitamin (A) given to cases and blood sample Village Dal UC 29‐Nov Measles Sindh Shikarpur 5 0 3 0 collected. Health education imparted to families of cases and contacts on the importance of routine immunization. Out Bhirkan of 8 children only 1 child had no BCG scar and all were not vaccinated for Measles. Cluster of routine immunization checked given as, out of 9 children BCG=(100%), Measles‐1‐2=(0%). All Information was shared. Alert for suspected Measles case was reported, during field investigation along with vaccinator and UNICEF Social Mobilizer, 6 more suspected cases were found. Two doses of vitamin (A) given and one blood sample collected. Health Nusrat Colony No:2, education imparted to case and contacts on importance of routine immunization. Out of 7 children only 1 child had no 27‐Nov Measles Sindh Sukkur UC Sheikh Sheenh 3 1 2 1 BCG scar and only 2 children had received single dose of Measles vaccine. Cluster of routine immunization was checked talluka Sukkur city from 8 children given as, BCG=(100%), Measles‐1=(0%), Measles‐2=(0%) according to parents history. All Information shared with DHO and DHMT. Alert for suspected case of Measles was identified from BHU Shaikh Birkhio. Case investigated along with DSV, WHO Village Kudad Sha‐ EHE and EM team. Case was found unvaccinated and during house to house surveillance, 1 Death and 6 more cases Tando Muham‐ 28‐Nov Measles Sindh hani, UC Shaikh 1 1 2 3 were found. Vaccinated status was taken from 5 children and found BCG=1(20%), Penta‐1=1(20%) and other were not mad Khan Birkhio vaccinated. Vitamin (A) given to all cases and health education imparted. Information shared with DHO office and 1 blood sample collected. Alert for 3 cases of Measles were reported from GD Ismail Nohri. During active surveillance 2 more cases were found. Village Duodaryo, UC Vitamin (A) doses given to all cases and health education given on importance of immunization, 5 blood samples col‐ 27‐Nov Measles Sindh Umer Kot Khokhrapar, taluka 1 1 2 1 lected. Vaccination status of 34 children were assessed given as BCG=(35%), Penta1=(29%), Penta2=(23%), Penta3= Umerkot (17%), Measles‐1=(11%), Measles‐2=(5%). During investigation vaccination was done by vaccinator of the area as OPV‐1, Penta=9, Measles=43, T.T=3. DSC informed about the cases. Alert for 3 cases of Measles were reported from BHU Faqir Abdullah. During house to house survey 2 more cases were Village Haji Hoato found. All cases were found unimmunized. Vitamin (A) dose given to cases and health education imparted. Vaccination kahn Babar, UC Faqir 28‐Nov Measles Sindh Umer Kot 2 0 2 1 status collected from area where total 32 children were checked, BCG=(37%), Penta1=(31%), Penta2=(25%), Penta3= AbdullaH, taluka (18%), Measles‐1=(12%), Measles‐2=(6%). Information shared with DHO and requested for mop up, 5 blood samples Umerkot collected and sent to NIH.

Village Ismail Rajar During the investigation of death reported in the media, 6 cases of probable Pertussis were found. Erythromycin were 29‐Nov Pertussis Sindh Sanghar UC Faiz Muhammad 0 1 5 0 provided to all cases. 1 nasopharyngeal swab was taken and sent to NIH. Health education imparted to the community Rajar Taluka Khipro regarding the importance of routine immunization. Information shared and requested DHMT for vaccination in the area.

Village Saleem Rajar Alert for 13 cases of probable Pertussis were reported. Complete dose of erythromycin were provided to all cases. 2 29‐Nov Pertussis Sindh Sanghar UC Faiz Muhammad 3 4 4 2 nasopharyngeal swabs were taken and sent to NIH, health education imparted to the community regarding the impor‐ Rajar Taluka Khipro tance of routine immunization. Information shared with DHMT and requested for vaccination in the area.

250000 50 130 104 92 94 200000 40 Measles

Leishmaniasis 150000 30 Typhoid ale rts consultations

of of

100000

AWD # # 20 Malaria 50000 Pertussis 10 CCHF 0 < 1 yr 1‐4 yr 5‐14 yr 15‐50 yr 50 + yr 0 Male 29779 73534 94299 142518 61365 Wk‐45 Wk‐46 Wk‐47 Wk‐48 Female 28798 68269 97098 204628 67963 Province Khyber Pakhtunkhwa: 471 health facilities from 17 districts of Khyber Pakhtunkhwa sent reports to DEWS with a total of 133,483 patients consultations reported in week 48, 2012. Total 23 alerts were received and appropriate measures were taken. Altogether 16 alerts for Measles; 4 for Leishmaniasis; while 1 each for ARI, Typhoid and H1N1. Acute diarrhoea trend showing minor increase as compared with last week.

Figure-5: Trend of acute diarrhoea diseases, province Khyber Pakhtunkhwa Figure-6: Number of alerts received and responded week 45 - 48, 2012, province KPK

20 50

15 40 Measles

30 Leishmaniasis 10 ale rts

Typhoid

of 20

Percentage # CCHF 5 10 AWD 2011 2012 0 0 Wk‐45 Wk‐46 Wk‐47 Wk‐48 1 3 5 7 9 111315171921232527293133353739414345474951 Province Sindh: 959 health facilities from 23 districts in Sindh province reported to DEWS with a total of 415,755 patients consultations in week 48, 2012. Total 100 alerts received while 30 outbreaks were identified and appropriate measures were taken. Altogether 84 alerts for Measles; 3 each for AWD, Leishmaniasis and NNT; 2 for Pertussis; while 1 each for AD, DF, Diphtheria, Malaria and Typhoid. Acute Diarrhoea shows minor decreasing as compared with last week.

Figure-7: Trend of trend of acute diarrhoea, province Sindh Figure-8: Number of alerts received and responded week 45 - 48, 2012, province Sindh

20 2011 50 84 Measles 2012 50 59 50 15 40 AWD

Pertussis 30 10 Typhoid ale rts 20 Percentage of

# Leishmaniasis 5 10 Malaria 0 0 CCHF 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 Wk‐45 Wk‐46 Wk‐47 Wk‐48

Province Punjab: 434 health facilities from 9 districts in province Punjab reported to DEWS with a total of 204,273 patients consultations in week 48, 2012. Total 42 alerts were received and appropriate measures were taken. Altogether 14 alerts for ARI; 10 for Measles; 7 for Typhoid; 4 for AD; 2 each for BD and Leishmaniasis; while 1 each for AJS, AWD and Scabies. AD shows decreasing as compare with last few weeks.

Figure-9: Trend of acute diarrhoea, province Punjab Figure-10: Number of alerts received and responded week 45 - 48, 2012, province Punjab

20 2011 50 2012 15 40 Measles

Typhoid 30 10

ale rts Leishmaniasis 20 of Percentage

# Malaria 5 10 AWD 0 0 13579111315171921232527293133353739414345474951 Wk‐45 Wk‐46 Wk‐47 Wk‐48

Figure-11: Trend of acute diarrhoea, province Balochistan Figure-12: Number of alerts received and responded week 45 - 48, 2012, Balochistan

20 2011 50 2012 Leishmaniasis 15 40 Measles 30 10 Malaria alerts

Percentage 20 Typhoid #

5 10 Pertussis

CCHF 0 0 Wk‐45 Wk‐46 Wk‐47 Wk‐48 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 Province Gilgit Baltistan: 28 health facilities from 5 districts in Gilgit Baltistan reported to DEWS with a total of 12,326 patients consultations in week 48, 2012. No alert for any disease was reported in week 48, 2012. AD showing decrease as compared with last week.

Figure-13: Trend of acute diarrhoea, province Gilgit Baltistan Figure-14: Number of alerts received and responded week 45 - 48, 2012, Gilgit Baltistan

20 2011 50 2012 15 40

30 10

ale rts Typhoid 20 of

Percentage 5 10

0 0 Wk‐45 Wk‐46 Wk‐47 Wk‐48 13579111315171921232527293133353739414345474951

FATA: 52 health facilities from 3 agencies in FATA reported to DEWS with a total of 11,874 patients consultations in week 48, 2012. 12 alerts; 7 for Measles; 3 for NNT; while 2 for Leishmaniasis were reported in week 48, 2012 and appropriate measures were taken. AD showing a fluctuating trend from last few weeks.

Figure-15: Trend of acute diarrhoea, FATA Figure-16: Number of alerts received and responded week 45 - 48, 2012, FATA

20 2011 50 2012 15 40

30 Measles

10 alerts

Percentage of

20 Leishmaniasis #

5 10

0 0 Wk‐45 Wk‐46 Wk‐47 Wk‐48 13579111315171921232527293133353739414345474951 State of Azad Jammu and Kashmir: 127 health facilities from 9 districts in AJ&K reported to DEWS with a total of 27,323 patients consultations in week 48, 2012. 4 alerts for Measles were reported in week 48, 2012. While AD showing a minor increasing as compared with last week.

Figure-17: Trend of acute diarrhoea, AJ&K Figure-18: Number of alerts received and responded week 45 - 48, 2012, AJ&K

20 2011 50 2012 15 40

30 Measles

10 alerts

Percentage 20 Leishmaniasis #

5 10

0 0 Wk‐45 Wk‐46 Wk‐47 Wk‐48 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

Measles 1708 110 5191 585 130 31 5321 616

Pertussis 286 81 359 143 3 2 362 145 NNT + tetanus 398 0 516 0 7 0 523 0 Malaria 132 88 133 67 2 1 135 68 Leishmaniasis 298 33 814 71 20 0 834 71 Others 587 63 1400 58 33 0 1433 58 Total 5750 1082 9563 1207 204 35 9767 1242

Distribution of Wild Polio Virus cases Pakistan 2011 and 2012

• In week 48, 2012, no new polio case was reported from any of the district. • As of 1 December 2012, Pakistan has reported a total of 56 polio cases including 53 type‐1, 2 type‐3 and 1 mixture type‐1 and 3 polio cases from 28 districts/tribal agencies.

Cases 2011 Cases 2012 Province P1 P3 P1 P3 P1+P3 Punjab 9 ‐ 2 ‐ ‐ Sindh 33 ‐ 4 ‐ ‐ Khyber Pakhtunkhwa 23 ‐ 25 ‐ ‐ FATA 57 2 17 2 1 Balochistan 73 ‐ 4 ‐ ‐ AJ&K ‐ ‐ ‐ ‐ ‐ Gilgit‐Baltistan 1 ‐ 1 ‐ ‐ Islamabad ‐ ‐ ‐ ‐ ‐ Total 196 2 53 2 1

Follow up of CCHF, Measles and Dengue

CCHF: CCHF is a serious viral hemorrhagic fever with up to 50% case fatality rate, caused by an RNA virus of family Bunyaviridae, genus Nairovirus, carried by Hyalomma species of ticks. Human beings become infected by tick bites or crushing the ticks, which are usually found on sheep, cattle, goats or camels, and their slaughtered skins. They may also be exposed to the virus in blood or tissues of a viremic animal during its slaughter and butchering; or by contact with infected blood or secretions of acute human cases in home or hospital setting.

Number of CCHF cases (week 1 to 48, 2012), Pakistan In week 48, 2012, no new CCHF case was re‐ 10 Suspeceted Positive Deaths ported from Balochistan. In 2012, So for a total of 61 sus‐ 8 pected cases have been reported throughout the country 6 cases with 42 confirmed to date and 17 deaths; (CFR is 40.48%).

of 4

24 confirmed cases have been reported from Balochistan; # 7 from Sindh; 6 from Khyber Pakhtunkhwa and 5 from 2 Punjab. Chart at right illustrates current situation of CCHF 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 cases in 2012. Epi‐week

Approximately all the cases have contact history with animal trading/handling, tick bite, contact with patient, tannery worker, butcher/animals slaughtering, a traditional practice of wearing fresh animal skin (posti) to treatment ailment. These animals and their skins have continuous movement!intra Pakistan and between neighboring countries (Afghanistan and Iran). Any contact of a CCHF patient should monitor his/her temperature for 14 days and see a doctor if fever develops. The anti viral medicine Ribavirin has been effective in saving lives of patients who report early to the health facility.

Table‐1 2012 (Week 1 ‐ 48) Table‐2 Epi ‐ week 48, 2012

Province # of Alerts # of Outbreaks # of Cases # of Deaths Province # of Alerts # of Outbreaks # of Cases # of Deaths

AJ&K 160 5 254 0 AJ&K 4 0 7 0

Balochistan 401 107 1651 25 Balochistan 8 0 23 0

FATA 205 31 552 13 FATA 7 2 20 0

Gilgit Baltistan 0 0 0 0 Gilgit Baltistan 26 0 30 0 ICT 24 2 59 0 ICT 1 0 1 0

Khyber Pakhtunkhwa 1907 101 3391 35 Khyber Pakhtunkhwa 16 2 34 0

Punjab 756 35 1235 15 Punjab 10 1 20 0

Sindh 84 26 315 15 Sindh 1834 335 5340 120

Total 5313 616 12512 208 Total 122 31 397 15

As it is shown in the above table that majority of the measles cases have been reported from Sindh and Khyber Pakhtunkhwa provinces. Both of these provinces have announced the EPI facilities will be providing measles vaccine twice a week for all children under age 5.

Dengue: Weekly trend of positive Dengue cases reported from Sindh and Punjab, week 1 to 48, 2012 Punjab Sindh 100 The chart at right showing the weekly number of confirmed Dengue cases reported by surveillance focal points from the Depart‐ 80 ments of Health in Sindh and Punjab in 2012. Total number of con‐ 60 cases

firmed dengue cases to date in 2012 is 622 in Sindh and 353 in Pun‐ # jab. Month of peak incidence in 2010 was November while peak inci‐ 20 dence in 2011 was in September and October. 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

Malaria slide positivity and falciparum ratio, week 48, 2012 Malaria: 80

The chart at right shows the Malaria slide positivity and 60 Falciparum ratio reported in week 48, 2012. Total number of malaria 40 cases tested in this week is 13,495, out of which 1813 were found Percentage 20 positive; 1009 for P. Vivax; 627 for P. Falciparum; while 177 for 0 Mixed (SPR = 13.43%; F. R = 44.35%). Balochistan Sindh FATA KPK Punjab GB AJK ICT SPR 17.55 13.63 18.4 6.74 9.49 0 0 0 FR 61.81 50.68 15.13 12.5 13.99 0 0 0

AWD: • The surveillance definition for a case of “Acute Watery Diar‐ AWD Week 45 ‐ 48, 2012 rhoea” (AWD) or suspected cholera in an endemic area, is any Outbreaks with Province # of Alerts # of Outbreaks # of Cases # of Deaths case over age 2 years with severe dehydration or death due to confirmed diarrhoea of 3 or more stools in 24 hours. V. cholera

• An AWD outbreak is defined as a cluster of 6 or more cases of AJ&K 0 0 0 0 0 AWD or any number of cases with at least one confirmed case Balochistan 0 0 0 0 0 of Vibrio cholera. • The table at right summarizes the situation of AWD in last four FATA 0 0 0 0 0 weeks, 4 November to 1 December 2012. During the period, a Gilgit Baltistan 0 0 0 0 0 total of 26 AWD alerts were reported and 1 confirmed AWD ICT 0 0 0 0 0 out breaks were identified and were responded very efficiently Khyber and in systematic manner. 2 0 0 3 0 Pakhtunkhwa • The Surveillance Officers in the districts with the close coordi‐ nation of trained rapid response teams from Department of Punjab 2 0 0 4 0 Health and partners address the outbreaks. Sindh 22 2 1 56 1

Total 26 2 1 63 1