Epidemiological Week No. 40 (30 Sept - 6 Oct 2006) 11 Oct 06/ Vol. 46/ DEWS 2006-40

Reporting Units...... 2 Total number of consultations ...... 2 DEWS Data, Epidemiological Week N0 40 2006...... 3 DEWS Data, Monthly Summary (Epidemiological Weeks N0 37-40) ...... 4 Acute Watery Diarrhoea ...... 5 Bloody Diarrhoea...... 6 Acute Jaundice Syndrome...... 6 Malaria ...... 7 Measles ...... 7 Acute Respiratory Infection ...... 8 Other Reportable Diseases and Conditions ...... 8 Outbreak Alert and Response ...... 9 Number of reported cases and deaths per District, AJK ...... 10 Number of reported cases and deaths per District, NWFP ...... 11 : Picture by Shahzad Alam Khan

ƒ In the past month (Epidemiological ƒ In this week 40, There were two deaths weeks 37-40 inclusive), 159,831 health from acute respiratory infection events under surveillance were reported reported from district including 77 deaths ƒ Fourteen suspected cases of measles ƒ This week, there were 309 reporting reported this week, Six cases from units contributing to the report Mansehra and Five cases reported from district ƒ In this week 40, Total 96,166 ƒ Malaria cases increased by 6% over the consultations were reported, with 21 number in week 39 deaths

The Weekly Morbidity and Mortality Report (WMMR) is published by the Ministry of Health of (MOH) and the World Health Organization (WHO). The WMMR is built on surveillance data that health service providers and NGOs transmit on a weekly basis from health facilities and hospitals in those areas affected by the earthquake that struck Pakistan on 8 October 2005.

The WMMR objectives are to monitor the trend of health conditions over a period of time and provide vital information to all health partners. The WMMR is only a snapshot of the health conditions in those facilities where events are registered and data collected and does not necessarily reflect the situation from other health facilities. The WMMR is a publication that has been developed for emergencies and previously used in other areas such as the Darfur Crisis.

The WMMR is published by the World Health Organization (WHO), Health Emergency Operation Centre, House #6, Street #20, F-7/2, , Pakistan For More Information, please contact: Dorcas Taylor, Epidemiologist, WHO/EHA/Pakistan; [email protected] or Dr. Birjees Mazher Kazi, Chief, Public Health Laboratories Division, NIH MOH; [email protected] or WHO Webpage: http://www.whopak.org/disaster WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

Reporting Units

The number of sites able to report increased by 4 this week and the reporting timeliness of the DEWS system has increased by 1% compared with week 39. See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. Reporting Health Facilities 23 – 29 30 Sept – Area Population 9 – 15 Sept 16 – 22 Sept Sept 6 Oct Week 37 Week 38 Week 39 Week 40 Muzaffarabad 894,364 97 107 102 105 Bagh 452,532 33 35 35 34 Poonch 633,712 51 56 59 66 Mansehra / 1,154,804 67 69 69 65 Battagram / Shangla 592,256 40 40 40 39 Total 3,727,668 288 (89%) 307 (94%) 305 (94%) 309 (95%)

Total number of consultations

In week 40, there was an increase in the number of reporting sites, and a corresponding increase in consultations, to 96,166. The highest number of consultations by district was in Muzaffarabad, with 32,808, and the lowest was in Battagram, at 7,757. The average number of consultations per facility now stands at 318, increased from 306 in week 39. The maximum number of consultations in a facility was 5,563, in Muzaffarabad, and the minimum was 15, also in Muzaffarabad.

No. Unit Reporting Units and Consultations No. Consult. 200000 300 Reporting Unit Consultation 250 150000 200

150 100000

100 50000 50

0 0 W42 W43 W44 W45 W46 W47 W48 W49 W50 W51 W52 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40

Week

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 – 6 Oct 2006.

2 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

DEWS Data, Epidemiological Week No. 40, 2006

Between 30 Sept to 6 Oct 2006, 96,166 consultations were reported through DEWS. Overall, 20% (19,564) were due to Acute Respiratory Infections (ARI), 9% (8,228) due to Acute Watery Diarrhoea (AWD), 7% (6,423) due to Fever of Unknown Origin (FUO), and 5% (4,746) due to Injuries (INJ). ARI accounted for 28% and 18% of consultations in the less than 5 years old and 5 or more years old respectively. All other reportable conditions each represented less than 1% of the total consultations in week 40.

AWD ARI AWD ARI 9% AWD 7% 20% 14% ARI 18% 28% FUO FUO 6% 7%

INJ FUO 5% INJ OTH* 9% 5% OTH* 42% OTH* INJ 62% 57% 4% ≥ 5yrs (n=73,527) < 5yrs (n=22,639) All Ages (n=96,166) Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 30 Sept - 6 Oct 2006. *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

DEWS Data, Epidemiological Week No. 40, 2006: Consultations by age

ARI is the most common reason for consultations among the diseases under surveillance. It is more common in patients under 5 years of age, and the fluctuations in ARI as a percent of all consultations in this age group are greater than in the older patients. After declining in the warmer months, ARI is once again increasing, and increasing more quickly in patients under five. See figure 3.

45.0 40.0 35.0 30.0 25.0 <5 20.0 >=5 15.0 10.0

ARIa percent as of all 5.0

consultations within group consultations age 0.0 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Week

Figure 3: Trend in ARI as a percent of all consultations within age groups, Earthquake Affected Areas, Pakistan 15 Oct 2005 – 6 Oct 2006

3 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

DEWS Data, Monthly Summary (Epidemiological Weeks No. 37-40)

In the past four weeks, between 9 Sept to 6 October (Epidemiological weeks 37-40 inclusive), 159,831 consultations for health conditions under surveillance were reported, out of a total 374,164 consultations. 20% (75,324) of consultations were due to acute respiratory infection (ARI), 10% (35,949) acute watery diarrhoea (AWD), 6% (23,543) unexplained fever (FUO) and 5% (18,956) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. Week WEEK 37 WEEK 38 WEEK 39 WEEK 40 TOTAL CFR% Event C D C D C D C D C D AWD 9507 1 9577 1 8637 1 8228 0 35949 3 0.008 BD 654 1 664 0 516 0 594 0 2428 1 0.041 AFP 1 0 0 0 1 0 1 0 3 0 0.000 MAL 876 0 765 0 760 0 806 0 3207 0 0.000 ARI 18025 1 19085 2 18650 3 19564 2 75324 8 0.011 MES 10 0 1 0 5 0 14 0 30 0 0.000 MEN 7 0 6 0 3 1 3 0 19 1 0.000 JAU 86 0 102 1 80 0 101 0 369 1 0.000 TET 0 0 0 0 1 0 2 0 3 0 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 5558 0 6034 0 5528 0 6423 0 23543 0 0.000 INJ 4543 0 4964 0 4703 0 4746 0 18956 0 0.000 OTH 50711 9 58858 23 49080 12 55684 19 214333 63 0.029 TOTAL 89978 12 100056 27 87964 17 96166 21 374164 77 RU 287 303 290 309

C – Cases, D – Deaths, AWD - Acute Diarrhoea, BD - Bloody Diarrhoea, AFP - Acute Flaccid Paralysis, MAL – Malaria, ARI - Acute Respiratory Infection, MES – Measles, Men - Meningitis, JAU - Acute Jaundice Syndrome, TET - Neonatal Tetanus, AHF Acute Hemorrhagic Fever, FUO –Unexplained fever, INJ – Injuries, OTH – Others, RU – Reporting Units. Please note data from late reporting in previous weeks has been updated. During the same reporting period, 91,267 consultations were reported in the less than 5 years old group, (24% of the total consultations), of which 26% (24,032) were due to ARI, 15% (13,749) due to AWD, 8% (7,236) due to FUO and 4% (3,750) were reported as injuries (INJ).

Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 9 Sept - 6 Oct 2006. Week WEEK 37 WEEK 38 WEEK 39 WEEK 40 TOTAL CFR% Event C D C D C D C D C D AWD 3605 0 3759 1 3226 1 3159 0 13749 2 0.015 BD 201 0 169 0 177 0 208 0 755 0 0.000 AFP 1 0 0 0 1 0 1 0 3 0 0.000 MAL 164 0 115 0 133 0 152 0 564 0 0.000 ARI 5785 1 5977 0 6031 2 6239 2 24032 5 0.021 MES 6 0 1 0 0 0 7 0 14 0 0.000 MEN 3 0 2 0 2 1 0 0 7 1 0.000 JAU 23 0 29 1 16 0 28 0 96 1 0.000 TET 0 0 0 0 0 0 1 0 1 0 0.000 AHF 0 0 0 0 0 0 0 0 0 0 0.000 FUO 1598 0 1910 0 1750 0 1978 0 7236 0 0.000 INJ 891 0 1013 0 1000 0 846 0 3750 0 0.000 OTH 9557 4 11746 9 9737 6 10020 6 41060 25 0.061 TOTAL 21834 5 24721 11 22073 10 22639 8 91267 34 RU 287 303 290 309

4 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

In the current week, there was a decrease in the number of cases of AWD with 8,637 last week and 8,228 this week. In the current week, ARI increased in the total number of cases as compared with the previous week, (18,650 last week and 19,564 this week). The weekly proportion of ARI and AWD is shown in figure 4.

% Consultation ARI and AWD percent of total consultations 40 ARI AWD 35 30 25 20 15 10 5 0 W45 W46 W47 W48 W49 W50 W51 W52 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40

Week

Figure 4. Weekly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 5 November - 6 October 2006.

Acute Watery Diarrhoea

In week 40, there were 8,228 cases of AWD reported, with no associated deaths. The rate of AWD varies considerably by district, from a high of 13.6% of all consultations, in Rawalakot, to a low of 2.8% of all consultations, in Dhirkot. See Figure 5.

16.0 14.0 12.0 10.0 8.0 6.0 4.0 consultations 2.0 0.0 AWD as a percent of all all as a percent of AWD OGHI BAGH ALLAI DASSU HAJIRA PATTAN HATTIAN DHIRKOT KHAUTTA BALAKOT SHANGLA MANSERA ABBASPUR ATHMUQAM BATTAGRAM RAWALAKOT MUZAFFARABAD BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH District

Figure 5: AWD as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 30 Sept – 6 Oct 2006

5 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

Bloody Diarrhoea

In week 40, there were 594 cases of bloody diarrhoea reported, an increase over week 39, though still lower than the numbers seen in weeks 37 and 38. There were no associated deaths. After some initial fluctuations, bloody diarrhoea has settled to a relatively constant percent of all diarrhoea cases, with some small increases during the monsoon. See figure 6

25.0

20.0

15.0

10.0 all diarrhea all 5.0

0.0 Bloody diarrhea as a percent of of percent a as diarrhea Bloody 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Week

Figure 6: Trend in bloody diarrhoea as a percent of all diarrhoea consultations, Earthquake Affected Areas, Pakistan,15 Oct 2005 – 6 Oct 2006

Acute Jaundice Syndrome

The number of cases of suspected hepatitis increased in week 40 to 101 cases. There were no associated deaths. Despite being a waterborne disease, the rate of suspected hepatitis did not experience a large increase in the monsoon (with the exception of week 32, which saw a significant rise), and remains relatively steady. See figure 7.

0.70 180 0.60 160 140 0.50 120 0.40 100 Cases/reporting site 0.30 80 Cases counts 60 0.20

per reporting site 40 0.10 20 Suspected hepatitis case Suspected hepatitis cases 0.00 0 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Week

Figure 7: Suspected hepatitis cases and cases per reporting site, Earthquake Affected Areas, Pakistan, June 30 – Oct 6 2006

6 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

Malaria

In week 40, there were 806 malaria cases reported, with no associated deaths, an increase from week 39, where there were 760 cases reported. The trend in malaria cases varies by district, with Bagh, Muzaffarabad, and Poonch showing an increase in week 40, while Battagram and Mansehra have decreased. (See figure 8).

6.0

5.0 BAGH 4.0 BATTA GRAM 3.0 MA NSERA MUZA FFA RABAD 2.0 POONCH 1.0 Cases per reportingCases site 0.0 37 38 39 40 Week

Figure 8: Trend in malaria cases per reporting site by district, Earthquake Affected Areas, Pakistan, August 8 – 6 Oct, 2006

Measles

14 cases of suspected measles were reported in week 40, a near tripling in cases from week 39. The rate of measles, as represented by cases per reporting site, differs by district, and is very uneven, with periodic small outbreaks earlier in 2006, and a settling to a low background level since the beginning of the summer, 2006. See figure 9.

1.40

1.20

1.00 BAGH 0.80 BATTAGRAM MA NSERA 0.60 MUZAFFARABAD 0.40 POONCH

0.20

Measles per cases reportingsite 0.00 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

Week

Figure 9: Trend in measles cases by district, Earthquake Affected Areas, Pakistan, 30 Dec 2005 – 6 Oct 2006.

7 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

Acute Respiratory Infection

In week 40 there were 19,564 consultations for ARI, an increase over the number of cases in week 39. There were 2 associated deaths, both in patients under five years of age in Mansehra. ARI continues its general climb as a percent of all consultations, though for most districts week 40 has seen a levelling out of the rate, and even a decrease in some districts. See figure 10 25.00

20.00

15.00

10.00 consultations 5.00 ARI percent as od all

0.00 33 34 35 36 37 38 39 40 BAGH BATTAGRAM MA NSERA MUZAFFARABAD Weeks POONCH

Figure 10: Trend in ARI as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, August 13 – 6 Oct, 2006

Other Reportable Diseases and Conditions

There were 3 cases of suspected meningitis in week 39, 2 from Muzaffarabad, one from Poonch. There were 2 cases of tetanus reported from Mansehra, and one case of acute flaccid paralysis also from Mansehra. There were 6,423 cases of fever of unknown origin, a 16% increase over week 39. There were 4, 746 cases of injuries.

Though there were a significant number of tetanus cases directly after the earthquake, as a result of injuries, it is now a rare disease, and months have passed with no cases. Week 40 is unusual for having two reported cases (see outbreak and alert page).

8 7 6 POONCH 5 MUZAFFARABAD 4 MA NSERA 3 BATTAGRAM BAGH Tetanus cases 2 1 0 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Weel

Figure 11: Tetanus cases, by district, Earthquake Affected Areas, Pakistan, 15 October 2005 – 6 Oct 2006.

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Outbreak Alert and Response1

Measles Battagram Five cases of measles were reported from Battagram, 4 from the Kohistan district, and one from NCHD Field Clinic Hutal Batkul, Allai. The Kohistan cases were not accessible, but Hutal Batkul was visited to look for further cases and determine vaccination status. The case, a 6 year old female, had moved to another village 5 km away. All of the children in the surrounding houses were already vaccinated. No members of her family were affected. A sample was taken for confirmation. Mansehra Five measles cases were reported from Saudi Field Hospital Mansehra. On investigation, there were no patients still present, and no addresses available for the patients who had been seen. The director and all doctors of the field hospital were briefed on the importance of proper record keeping.

Tetanus Mansehra Two cases of tetanus were reported from DHQ hospital, Mansehra. One was in a four year old female from Chanja Hungrai, Tehsil Balakot. According to her father, she had not been vaccinated. The second was an 8 year old male resident of . His vaccination history was not known.

Acute Flaccid Paralysis (AFP): Mansehra An 18 month old male child from , district Mansehra, visited Saudi Field Hospital for lower right limb weakness, and was referred to DHQ hospital Mansehra. The polio surveillance team was notified, and samples were taken. The case was clinically diagnosed as septic arthritis.

1 Outbreak Investigation and response of Suspected Viral Hepatitis, Malaria, and Bloody Diarrhoea and Watery Diarrhoea would only take place when a cluster of cases is identified or there is an increase in the incidence of the disease. (Note: Single death due to Diarrhoea and single case of reported severe dehydration among >5 years would be investigated)

9 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46/ DEWS 2006 -40

Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, Bagh District, Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 37 592 0 33 0 0 0 33 0 2465 0 1 0 0 0 16 0 0 0 0 0 192 0 630 0 8047 0 38 619 0 36 0 0 0 24 0 2800 0 0 0 0 0 12 0 0 0 0 0 221 0 736 0 8397 0 39 543 0 35 0 0 0 27 0 2759 0 0 0 0 0 9 0 0 0 0 0 238 0 736 0 7275 0 40 432 0 53 0 0 0 46 0 2612 0 1 0 0 0 23 0 0 0 0 0 300 0 523 0 9510 0 Total 2186 0 157 0 0 0 130 0 10636 0 2 0 0 0 60 0 0 0 0 0 951 0 2625 0 33229 0

Table 7. Number of reported cases and deaths, Poonch District, Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 37 1713 0 20 0 0 0 256 0 2791 0 0 0 1 0 3 0 0 0 0 0 1912 0 758 0 6341 3 38 1932 0 24 0 0 0 206 0 3044 0 0 0 0 0 0 0 0 0 0 0 2193 0 726 0 7794 4 39 1961 0 25 0 1 0 209 0 3723 0 0 0 0 0 6 0 0 0 0 0 2356 0 766 0 7395 5 40 1661 0 39 0 0 0 264 0 3247 0 0 0 1 0 3 0 0 0 0 0 2281 0 788 0 7219 10 Total 7267 0 108 0 1 0 935 0 12805 0 0 0 2 0 12 0 0 0 0 0 8742 0 3038 0 28749 22

Table 8. Number of reported cases and deaths, , Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 37 4083 1 393 0 0 0 266 0 6476 0 0 0 5 0 17 0 0 0 0 0 1170 0 2047 0 16698 3 38 3668 1 388 0 0 0 225 0 7222 1 0 0 6 0 24 1 0 0 0 0 1305 0 2191 0 19306 15 39 3681 1 338 0 0 0 202 0 6272 1 3 0 3 1 18 0 1 0 0 0 1093 0 2080 0 14821 5 40 3362 0 326 0 0 0 314 0 6993 0 2 0 2 0 24 0 0 0 0 0 1430 0 2290 0 18065 6 Total 14794 3 1445 0 0 0 1007 0 26963 2 5 0 16 1 83 1 1 0 0 0 4998 0 8608 0 68890 29

10 WMMR Weekly Morbidity and Mortality Report Pakistan 11 Oct 2006 / Vol. 46 DEWS 2006 -40

Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 37 922 0 93 0 0 0 95 0 1304 0 5 0 0 0 13 0 0 0 0 0 563 0 236 0 4676 0 38 962 0 107 0 0 0 92 0 1484 0 0 0 0 0 18 0 0 0 0 0 600 0 342 0 4711 2 39 732 0 50 0 0 0 99 0 1198 0 2 0 0 0 14 0 0 0 0 0 491 0 315 0 3055 0 40 792 0 69 0 0 0 65 0 1646 0 6 0 0 0 15 0 0 0 0 0 687 0 334 0 4143 0 Total 3408 0 319 0 0 0 351 0 5632 0 13 0 0 0 60 0 0 0 0 0 2341 0 1227 0 16585 2

Table 10. Number of reported cases and deaths, *, Earthquake Affected Areas, Pakistan, 9 Sept - 6 Oct 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 37 2197 0 115 1 1 0 226 0 4989 1 4 0 1 0 37 0 0 0 0 0 1721 0 872 0 14949 3 38 2396 0 109 0 0 0 218 0 4535 1 1 0 0 0 48 0 0 0 0 0 1715 0 969 0 18650 2 39 1720 0 68 0 0 0 223 0 4698 2 0 0 0 0 33 0 0 0 0 0 1350 0 806 0 16534 2 40 1981 0 107 0 1 0 117 0 5066 2 5 0 0 0 36 0 2 0 0 0 1725 0 811 0 16747 3 Total 8294 0 399 1 2 0 784 0 19288 6 10 0 1 0 154 0 2 0 0 0 6511 0 3458 0 66880 10 *Data from were merged with the data from Mansehra district.

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