DISEASES EARLY WARNING SYSTEM WER-42(6Th Year) DEWS WEEKLY EPIDEMIOLOGICAL REPORT

October22, 2012 DISEASES EARLY WARNING SYSTEM WER-42(6th Year)

DEWS WEEKLY EPIDEMIOLOGICAL REPORT EPREPORT SUMMARY:

This report includes surveillance data from 13th to 19th October 2012. Out of 318 functional Sentinel sites(SS), all 318 (100%) have sent their reports in Week-42 of 2012; Out of total 274,496 Consultations recorded in week-42 of 2012, 86,316 (31.4%) consultations were reported due to

DEWS target diseases.

Main causes of consultations this week are Acute Respiratory Infections/ARI (20%) and Acute Diarrheal

Diseases/ADD (10.2%) from total clients in a continuing trend from the week before. 34 deaths caused due to Pneumonia, Diarrheal diseases and Meningitis/Severely ill children, so that 22 deaths due to pneumonia, 7 deaths due to diarrheal diseases and 5 deaths reported due to Meningitis and Severely Ill Children. In this reporting week, two measles outbreaks have been reported from Paktika and Zabul provinces, and one suspected post vaccine encephalopathy case reported from Charkh district of Logar province.

REPORTS RECEIVED FROM REPORTING SITES: As of October 19, 2012, 318 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of Afghanistan. In this reporting week, all 318 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-42, 2012

Central Central East Central West North North East West South East South East Total No. of Expected Reports from 53 30 49 39 34 41 38 34 318 Sentinel Sites No. of Reports Received in this 53 30 49 39 34 41 38 34 318 week

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DEWS Sentinel Sites: Figure-1(Map) shows the distribution of DEWS sentinel sites, already Table-2: DEWS Epidemiological Regions and types of Sentinel Sites in

established in the relevant Week-42, 2012

regions/provinces by October 19,

Type of 2012 by type of health facilities. Data

alEast Centr al West North North East West South East South East Total on15 DEWS target diseases are being Centr collected from these sentinel sites CHC/BHC 25 19 34 28 20 32 28 26 212 (SS).The symbols on the map show DH 12 7 10 7 9 4 7 4 60 the number of sentinel sites in each PH/RH/SH 14 4 5 4 4 5 3 4 43 region/province, and do not indicating the GPS of the SS locations. Poly Clinic 2 0 0 0 1 0 0 0 3 DEWS Data in Epidemiological Total 53 30 49 39 34 41 38 34 318 Week-42 of 2012 CHC=Comprehensive Health Center, DH=District hospital, PH=provincial Ut of total 274,496 clients hospital, RH= Regional hospital, SH= specialized hospital recorded in week-42 of 2012, 17.2% (47344) of O consultations were reported due to cough and cold Fig-2: Percentages of DEWS Target Diseases and 2.8% (7658) of consultations was reported due to 30.0% by age Group in W42 of 2012 pneumonia. In the same reporting period, 10.2% or 28,030 25.0% events were reported due to diarrheal illnesses (7.7% due 20.0% to Acute Watery Diarrhea, 1.9% due to Bloody Diarrhea 15.0% and 0.6% due to acute watery diarrhea with dehydration). 10.0% In comparison with previous week (W41 of 2012) the 5.0% percentage of ARI diseases has increased by 0.1% 0.0% to20.0%, whereas the percentage of Acute Diarrheal ARI Men/ AVHe Malari TyphF ARI Pn AwD BD AwDw diseases decreased by 0.7% to 10.2%. These variations C&C SIC p a ev could be occurred due to changes in temperature /weather U5% 25.6% 6.0% 15.9% 2.9% 1.2% 0.1% 0.1% 0.6% 0.3% during the reporting week.Figure-2 above shows the O5% 13.4% 1.3% 3.9% 1.5% 0.3% 0.0% 0.1% 0.5% 0.6% percentages of DEWS target diseases by age groups in Tot% 17.2% 2.8% 7.7% 1.9% 0.6% 0.0% 0.1% 0.5% 0.5% week-42 of 2012.

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Percentage of ARI by weeks and by Age Groups In the epidemiological week-42, a total of 55,002 events of ARI were reported.25.6 % of total clients less than 5 years of age were cough & Cold patients and 13.4% among the age group 5 years and over. The percentage of C&C (<5 years) Table-3: Percentages of ARI Diseases during 11 recent weeks by age groups and by weeks Disease Age Week Week Week Week Week Week Week Week Week Week Week 32-12 33-12 34-12 35-12 36-12 37-12 38-12 39-12 40-12 41-12 42-12 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 Yr. 16.4 16.9 16.2 18.3 18.4 21.5 21.6 21.7 23.1 24.2 25.6 5+ 9.7 10.2 7.5 10.1 11.0 10.9 11.8 12.6 13.3 13.6 13.4 ARI- <5 Yr. 3.7 3.8 4.6 4.0 4.3 4.7 4.8 4.9 5.5 6.2 6.0 Pneumonia >=5 Yr 0.8 1.0 1.1 0.9 1.0 1.1 1.0 1.2 1.2 1.5 1.3 consultations in week-32,in comparison with the percentage of C&C in week-42 of 2012, increased by 9.2%, whereas in case of 5 years and above increased by 3.7% to 13.4% in this reporting week. The trend of ARI diseases in last 11 weeks can be read in table-3.The percentages of consultations on Pneumonia cases of age group less than 5 years increased by 2.3% in last 11 weeks, whereas the percentage of age group 5 years and over shows an increase of 0.5% in last 11 weeks. n the reporting week-42 of 2012, the highest percentage of Cough & Cold has been recorded in Paktika and Nuristan provinces with 36% and 29% respectively, whereas the lowest percentages of C&C were reported from Farah I province with 7% . The highest percentages of Pneumonia cases reported from Sar-pul and Baghlan provinces with 8% and 7%, whereas the lowest percentage of Pneumonia cases was recorded in Uruzgan province with less than one percent. (Fig-3) 40% Fig-3: Percentages of ARI from Total Clients in week-42 of 2012

20%

0% BD BA DA GH HE JO KA KH LO NA PK PA SA WA KA BD GH KA PA NI UR KN LA NU BAL FYB HEL KDZ PIA SARTAK ZAB BGL FRA S M Y A R W N O G N A R M R B G O P N M U R G R Pneumonia 2% 4% 6% 2% 3% 1% 2% 1% 7% 1% 2% 3% 3% 3% 1% 2% 2% 4% 8% 3% 4% 1% 3% 7% 1% 1% 2% 2% 2% 1% 0% 2% 4% 6% Cough&Cold 17%20%20%20%19%14%15%18%14%15%22%17%22%21%36%20%12%20%19%14%18%13%14%18%17% 7% 13%21%18%12%11%25%17%29%

Percentages of Diarrheal Diseases by weeks and by Age Groups The table-4 below shows the percentages of diarrheal diseases (Acute watery Diarrhea, Bloody Diarrhea and Acute watery Table-4: Percentages of Diarrheal Diseases from Total Clients during 11 recent weeks by age groups. Disease Age Week Week Week Week Week Week Week Week Week Week Week 32-12 33-12 34-12 35-12 36-12 37-12 38-12 39-12 40-12 41-12 42-12 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 27.2 25.0 28.9 24.0 21.6 20.9 20.5 19.2 18.5 16.6 15.9 Diarrhea >= 5 Years 6.9 6.8 8.4 6.6 6.3 6.4 5.2 5.0 4.5 4.2 3.9 Bloody Diarrhea <5 Years 4.1 4.1 2.9 3.8 3.8 3.7 3.4 3.3 3.5 3.1 2.9 >=5 Years 2.0 1.9 1.8 1.9 1.8 1.9 1.7 1.7 1.7 1.5 1.5 Acute W. Diarrhea <5 Years 3.1 3.1 3.4 2.5 2.3 2.1 2.0 1.9 1.5 1.6 1.2 with Dehydration ≥5 Years 0.8 0.7 1.0 0.6 0.6 0.6 0.5 0.5 0.4 0.4 0.3 diarrhea with dehydration) from week-32 to week-42 of 2012, from total clients. Acute watery diarrhea among children less than five years of age has been decreased from 27.2% in week-32 to 15.9% in the reporting week, whereas acute watery diarrhea among age group 5 years and above has been decreased by 3% to 3.9%.(Please refer to Table-4, above).Bloody diarrhea, in age group less than 5 years decreased by 1.2% in last 11 weeks, while in case of age group 5 years and above decreased by 0.5%. Acute watery diarrhea with dehydration in age group less than 5 years decreased by 1.9% and in case of five years and above decreased by 0.5% in last 11 weeks.

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20% Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-42 of 2012 AWDwD BD AWD 15%

10%

PIA

FYB

HEL

BAL

BGL

FRA

SAR

ZAB

TAK

KDZ

BDS

LAG

HER

PKA KAP

PAR

KAB

LOG

DAY

KNR

PAN

NIM

KAN

BDG

KHO

URU

GHA NUR

JOW

NAN

GHO

SAM

BAM WAR

Percentages of suspected Meningitis/SIC, Malaria and Typhoid Fever by Region: n the epidemiologic week-42 of 2012, a total of 2.5% Fig -5: Percentages of Men/SIC Malaria & Typhoid Fever 128 suspected cases of Meningitis/Sever Ill Child from Total Clients in Week-42 of 2012 by Region I were reported from all regions and the highest 2.0% percentage was recorded in Central East region. In the same reporting week, from all regions 1477 1.5% consultations were reported by Sentinel Sites to be malaria and the highest percentages of Malaria cases 1.0% were reported from East and South East regions with 0.5% 2.1% and 1.1% respectively. Out of the total clients, 1418 cases or 0.5% in national level were reported to 0.0% be suspected Typhoid Fever and the highest NER NR CWR WR CER SR ER SER percentages of Typhoid Fever were reported from Men/SIC 0.1% 0.1% 0.0% 0.0% 0.1% 0.0% 0.0% 0.1% South east and South regions with 1.2% and 0.9% Malaria 0.2% 0.2% 0.1% 0.1% 0.1% 0.3% 2.1% 1.1% respectively. Typhoid Fev 0.4% 0.4% 0.4% 0.3% 0.2% 0.9% 0.8% 1.2% Vaccine Preventable Diseases In DEWS target diseases (priority diseases) seven vaccine preventable diseases are included, so that their occurrences are changing by seasonal variations. Among these diseases Meningitis/severely ill child is being reported mostly from North region; in this Table-5: Suspected Cases of Vaccine Preventable week out of total 128 cases in country Diseases in W42 of 2012 by Region

level, 34 cases have been reported from

Central East region, 24 cases from North

East and 23 cases were reported from Regions North region.

In general the highest number of cases of Viral

Meningitis/ Ill Sever Child Hepatitis Measles Pertussis Diphtheria Tetanus Natal /New Tetanus Acute Flaccid Paralysis Acute viral hepatitis being reported from North East 24 12 0 0 0 0 1 East and south East regions, so that in the reporting week out of total 171 cases, 74 North 23 12 5 1 0 0 4 cases reported from Central-East, 28 from Central West 6 1 2 0 0 0 0 East, and 23 cases from South East region West 11 10 0 0 0 1 2 were reported. From total 70 Measles cases Central East 34 74 13 0 0 0 3 reported in the reporting week 28 cases South 14 11 19 1 0 3 2 were recorded in East and 19 cases were East 4 28 28 0 0 0 0 reported from South region. South East 12 23 3 0 0 0 0 Total 128 171 70 2 0 4 12

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Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks(from W22 of 2011 to W42 of 2012) mong the DEWS target diseases, Acute Respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) as 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-22 of 2011 to week-42 of A 2012(more than one complete cycle).In week-22 of 2011, the ARI and ADD curves crossed each other, so that ARI started decreasing and ADD changed its course to increase. By the end of Summer season in 2011, these curves crossed one another again in week-37and from that time to week-6 of 2012, the percentage of ARI was increasing, while the percentages of ADD were falling /decreasing, but week-09 of 2012 was a turning point for both categories of ARI and Diarrheal diseases i.e. ARI started decreasing, while ADD started increasing. Comparing this week data with previous week-41, ARI increased by 0.1% to 20%, while the percentage of ADD decreased by 0.7% to 10.2%. As the line-chart shows in week-36 once again the ARI and ADD curves crossed each other and it is expected to continue their courses at least to end of January 2013 i.e. the percentages of ADD will decrease, while the percentages of ARI increases further.

Fig.-6: Trend of ARI/ADD as Propotion of Total Clients From Week-22 of 2011 to Week-42 of 2012 35

30 ARI 31.2 30.5 31.530.8 30.5 29.529.9 29.9 ADD 29.328.9 P 28.128 26.926.8 e 25 26.1 25.7 25.3 r 24.4 23.2 22.4 18.9 21.8 22 22.5 c 20 21.521.7 18.1 17.7 17.6 17.1 20.7 20.9 17.3 15.7 16.8 20 20.1 16.816.8 16.5 16.8 20.0 e 16.215.8 16.1 1615.9 16.2 15.8 16.1 15.8 19.919.5 17.115.7 19.9 15.315.5 15 18.8 15.7 19.0 14.1 17.617.9 16.3 14.4 17.8 n 15 13.5 13.3 13.317.1 12.416.3 15.316.4 12.6 15.4 15.2 t 14.9 11.1 11.4 14.714.6 14.7 12.0 14.3 10.610.7 14.0 14.0 14.3 14.5 10.9 13.813.9 13.4 13.6 13.8 13.4 10.110.1 13.613.7 13.913.6 13 13.212.9 12.8 12.8 12.8 9.2 12.9 13.5 10.2 a 12.4 8.5 8.5 8.6 9.0 12.6 10 11.5 8.2 7 7.3 7.2 g 6.6 6.2 6.3 5.7 5.5 5.5 5.6 4.9 4.9 4.9 e 4.6 4.7 4.5 4.3 4.4 4.2 4.4 4.7 5 4.0 s

Weeks of the Year

All cases of suspected measles, pertussis, diphtheria, meningitis, or cholera, and unusual increases in incidence of any disease, and animal outbreaks of avian influenza, anthrax, brucellosis or other zoonoses should be reported immediately to the DEWS team in the relevant province or the national focal point – "Director Surveillance" 0700290955 or the WHO CSR/DEWS Technical Officer, 0708811856,[email protected]

ARI Dis & ADD from Week-21 to Week-38 of 2008

18 16.8 ARI 16.4 16.4 16.316.1 Dis 16 15.3 16.716.9 16.6 16.5 ADD 16.2 14.4 13.9 14.9 13.713.613.3 14 14.8 1312.8 14.2 12.2 14 12.1 13.5 11.3 11.2 12 10.9 11.2 10.7 10.810.9 10.7 11.8 10.7 10 10.6

8 Percentages

Reporting Weeks

Mortality: Among DEWS target diseases Pneumonia, Table-6: Deaths by Main Causes of Mortality and by Region in W42 of 2012

Diarrheal diseases Main Causes

and Meningitis/

of Deaths

Severely Ill Children

East North Central West West Central East South East South East Total (SIC) are main North causes of mortality Pneumonia which make in 1 5 5 3 2 4 1 1 22 general more than Diarrheal 95% of total deaths Diseases 4 0 2 1 0 0 0 0 7 of surveillance target Meningitis/SIC diseases. Usually 0 2 1 1 1 0 0 0 5 deaths due to Total diarrheal diseases 5 7 8 5 3 4 1 1 34 increases during summer season, while the number of deaths due to Pneumonia increases during cold period/Winter Season. In this week out of 34 deaths reported from all regions, 22 deaths caused by Pneumonia, 7 deaths caused by diarrheal diseases and 5 deaths were caused by Meningitis/severely ill children.(Table-6). In this reporting week the highest number of deaths was reported from sentinel sites of Central and North regions.

Number of Outbreaks investigated in 2012 with details of W41/W42 Reported outbreaks since first week of 2012 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 24 3 21 Avian/Swine Flu 1 1 ARI 7 7 Measles 186 7 179 Diarrhea 5 1 4 Meningitis Hepatitis 3 3 Malaria Typhoid 1 1 CCHF 18 18 Bl. Diarrhea 2 2 Chickenpox 1 1 Other 50 2 48 Total 299 14 285 Epidemiological week-41  Suspected Acute Viral Hepatitis: reported from Bondakhila Village, Tani District of Khost province, on Oct 07.2012 and investigated on the following day, and the health team investigated the affected area and they find 14 cases with no deaths, the team collected the specimen and sent to CPHL, and the patients treated and health education and hygiene session conducted for villagers, outbreak is under control,

 CCHF outbreak: : reported from Center of Khostiha mosque of Aybak city of Samangan province on Oct 07 /2012, the team investigated the area on the following day and during the investigation there was one suspected CCHF case He was the citizen of Scotland after his stay in motherland he left to Scotland and within few days hospitalization , they collected the specimens ,the result was positive for CCHF and although the patient treated but died there ,the team collected sample of close relative of him and send them to CPHL the team is investigating for further cases at area .  Suspected Rabies Outbreak: reported from Center of Khulm district of Balkh province on Oct 10 /2012, the team investigated the area on the following day and during the investigation there were 2 suspected Rabies cases with no deaths, , the cases treated and the vaccine recommended to them , the team is investigating for further cases. Epidemiological week-42  Suspected post vaccine encephalopathy : reported from Argan Village, Charkh District of Logar province, on Oct 14.2012 and investigated on the same day, and the health team investigated the affected area and they find 3 cases with two deaths, the team checked the cold chain system and vaccine status , and follow up of those who have received vaccine recently and health education session regarding conducted for villagers, outbreak is under control,  Suspected Measles Outbreak: reported from Faqir kala village of Mata khan district of Paktika province on Oct 17 /2012, the team investigated the area on the following day and during the investigation there were 6 suspected measles cases with no deaths , the team collected the specimens and send it to CPHL , the cases treated and the vaccination campaign conducted in surrounding villages, the team is investigating for further cases  Suspected Measles Outbreak: reported from Shedara village of Qalat district of Zabul province on Oct 16 /2012, the team investigated the area on the following day and during the investigation there were 9 suspected measles cases with no deaths , the team collected the specimens and send it to CPHL , the cases treated and the vaccination campaign conducted in surrounding villages, the team is investigating for further cases

ANNEX: Mapping of Percentages/Cases of Selected Diseases in Week-42 of 2012 by Province