June 9, 2014 DISEASE EARLY WARNING SYSTEM WER-22 (8th Yr) WEEKLY EPIDEMIOLOGICAL REPORT

Summary:

 The surveillance data collected for this weekly report is from 31 May – 6 June 2014.  Out of 386 functional Sentinel sites (SS), 383 (99.4%) have submitted reports for Week-22 of 2014.  Out of a total of 377,209 consultations (161,179 male, 216,030 female) recorded in Week-22 of 2014, 33.7% or 127,137 (62,009 male, 65,128 female) consultations were reported due to DEWS targeted diseases.  Main causes of consultations this week were Acute Respiratory Infections (ARI) (17.8%) and Acute Diarrheal Diseases (ADD) (14.7%) from total clients in a continuing trend from the week before.  A total of 46 deaths reported due to DEWS targeted Diseases, which includes 25 deaths (10 male, 15 female) caused by Pneumonia, 10 deaths (4 male, 6 female) caused by Diarrheal Diseases, 10 deaths (5 male, 5 female) caused by Meningitis/Severely Ill Children and 1 death (0 male, 1 female) caused by Malaria.  In this reporting week, a Scabies Outbreak reported from Nimroz province and two Suspected CCHF Outbreaks and a Suspected Measles Outbreak reported from .

Reports Received From Reporting Sites:

As of June 6, 2014, 386 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of . In this reporting week, 383 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-22, 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 52 49 45 386 Sentinel Sites No. of Reports Received in this 55 33 58 52 40 51 48 45 383 week

Figure-1 DEWS Sentinel Sites: Table-2: DEWS Epidemiological Regions and Figure-1(Map) shows the Sentinel Sites by type in Week- 22, 2014 distribution of DEWS sentinel

sites established in the

regions/provinces by June 6,

Type of SS

2014. Table-2 shows the SS

East Central West North North East West South East South East Total distribution by type of health Central facility. Data on 15 DEWS target CHC/BHC 28 20 43 43 26 42 39 37 278 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 52 49 45 386 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-22 of 2014: Out of a total of 377,209 clients recorded in week-22 Fig-2: Percentages of DEWS Target Diseases by of 2014, 15.4% (57,919) of consultations were Gender in W22-14 reported due to Cough and Cold and 2.4% (9,224) of 18.00 16.00 consultations was reported due to Pneumonia. In the 14.00 same reporting period, 14.7% or 55,671 events were 12.00 10.00 reported due to diarrheal illnesses (11.1% due to 8.00

Acute Watery Diarrhea, 2.8% due to Bloody Diarrhea Percentage 6.00 and 0.8% due to Acute Watery Diarrhea with 4.00 2.00 Dehydration). In comparison with the previous week 0.00 ARI Men/SI (W21 of 2014) the percentage of ARI disease has ARI Pn AwD BD AwDw AVHep Measle Malaria C&C C decreased by 1.1% to 17.8%, and the percentage of Male Acute Diarrheal Disease has increased by 0.5% to 17.03 2.95 12.97 3.27 0.99 0.07 0.07 0.05 0.49 14.7%. These variations could be due to changes in Female 14.10 2.07 9.73 2.51 0.68 0.05 0.04 0.03 0.40 temperature /weather during the reporting week. Total 15.35 2.45 11.11 2.84 0.81 0.06 0.05 0.04 0.44 Figure-2 (right) shows the percentages of DEWS target diseases by gender in week-22 of 2014. Percentage of ARI by Weeks and by Age Groups: In the epidemiological week-22 a total of 67,143 events of ARI were reported. 21.8 % of total clients less than 5 years of age were Cough & Cold patients and 12.4% were among the age group 5 years and over. The percentage of C&C (<5 years) consultations in week-13, in comparison with the percentage of C&C in week-22 of 2014, decreased by 9.2%, whereas in case of 5 years and above decreased by 5.2% to 12.4% 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 4.5% in last 10 weeks, whereas the percentage of age group 5 years and over decreased by 0.8% 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- 13-14 14-14 15-14 16-14 17-14 18-14 19-14 20-14 21-14 22-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 31 30.2 28.2 28.3 26.2 25.1 24.2 22.9 23.5 21.8 Years ≥5 17.6 16.2 15.8 15.6 14.8 13.9 13.9 13.4 13 12.4 Years ARI- <5 9.6 8.6 7.5 6.8 6.6 6.6 5.9 5.9 5.5 5.1 Pneumonia Years ≥5 2 1.8 1.7 1.6 1.5 1.5 1.4 1.5 1.2 1.2 Years

In the reporting week-22 of 2014, the highest percentages of Cough & Cold were recorded in Parwan, Kapisa and Nuristan provinces with 26.7%, 26% and 23.5%, whereas the lowest percentages of C&C were reported from Farah, Nimroz and Zabul provinces with 5.5%, 5.6% and 8% respectively. The highest percentages of Pneumonia cases were reported from Bamyan, Saripul and provinces with 6.9%, 5.6% and 4.9% respectively, whereas the lowest percentages of Pneumonia cases were recorded in Zabul, Urozgan and Herat provinces with 0.3% and 0.4% respectively. (Fig-3)

35 Fig-3: Percentages of ARI from Total Clients in Week-22 of 2014 30 25 20

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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)

30 Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-22 of 2014

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10 Percentage Percentage

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BAM WAR Provinces AWD BD AWDwD

From week-13 to week-22 of 2014 from total clients, Acute Watery Diarrhea among children less than five years of age has increased from 9.2% in week-13 to 21.5% in the reporting week, whereas Acute Watery Diarrhea among age group 5 years and above has been increased by 3.4% to 6.3% (Table-4). Bloody Diarrhea in age group less than 5 years increased by 1.9% in last 10 weeks, while in case of age group 5 years and above has been increased by 0.9%. Acute Watery Diarrhea with Dehydration in age group less than 5 years show an increase by 1 % in last 10 weeks, while in case of five years and above AWDwD increased by 0.3% 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 13-14 14-14 15-14 16-14 17-14 18-14 19-14 20-14 21-14 22-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 9.2 10.4 11.1 12.4 14.7 16.7 18 17.6 20.6 21.5 Diarrhea ≥5 Years 2.9 3.1 3.5 3.8 4.5 4.6 5.3 5.3 5.9 6.3 <5 Years 2.4 2.6 2.8 3.1 3.4 3.6 3.7 3.9 3.9 4.3 Bloody Diarrhea ≥5 Years 1.3 1.4 1.5 1.6 1.6 1.7 1.9 2.1 2 2.2 Acute Watery <5 Years 0.6 0.8 1 0.8 1.2 1.4 1.3 1.6 2 1.6 Diarrhea with ≥5 Years 0.2 0.2 0.3 0.3 0.4 0.5 0.5 0.5 0.7 0.5 Dehydration

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

In the epidemiologic week-22 of 2014, a total of 225 suspected Fig-5: Percentages of Meningitis, Malaria & Typhoid Fever from Total cases of Meningitis/Severely Ill Clients in W22-14 Child were reported from all 1 regions and the highest percentage was recorded in North, 0.8 North East and Central East regions. In the same reporting 0.6

week, from all regions, 1663 Percentage Malaria consultations were 0.4 reported by Sentinel Sites and the highest percentages of Malaria cases were reported from East, 0.2 South and South East regions with 1.63%, 0.62% and 0.61% 0 SR CER CWR WR ER NR NER SER respectively. Out of the total clients, 2069 cases or 0.5% at the Men/SIC 0.05 0.04 0.00 0.05 0.00 0.20 0.05 0.02 national level were reported to be Malaria 0.62 0.07 0.10 0.05 1.63 0.17 0.09 0.61 suspected Typhoid Fever and the Typhoid Fev 0.90 0.20 0.52 0.33 0.91 0.58 0.37 0.74 highest percentages of Typhoid Fever cases were reported from East, South and South East regions with 0.91%, 0.90% and 0.74% 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 225 cases in country level, 122 cases have been reported from North region, 31 cases from the Central East region and 22 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 194 cases, 98 cases reported from Central East region, 20 cases were reported from South East and 19 cases were reported from South regions. From a total of 152 Measles cases reported in the reporting week, 42 cases were recorded in South, 40 cases were reported from East and 36 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- 22 of 2014 by Region Meningitis/ Acute Viral Acute Flaccid Total Regions Severely Ill Measles Pertussis Diphtheria Tetanus Hepatitis Paralysis Children 19 19 42 4 0 1 2 87 SR 31 98 21 0 0 0 2 152 CER 1 10 7 0 0 0 1 19 CWR 22 15 2 0 0 0 0 39 WR 3 15 40 0 0 0 1 59 ER 122 6 36 0 0 0 2 166 NR 21 11 3 0 0 0 3 38 NER 6 20 1 0 0 0 0 27 SER 225 194 152 4 0 1 11 587 Total

Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks (trend from W24 of 2013 to W22 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-22 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-21 of 2014, ARI decreased by 1.1% to 17.8%, while ADD increased by 0.5% to 14.7% (Fig-6).

40.0 Fig-6: Trend of ARI/ADD as Propotion of Total Clients From Week-24 of 2013 to Week-22 of 2014

35.0 ARI ADD

30.0

25.0

20.0

15.0 Percentages

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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 46 deaths reported due to DEWS targeted Diseases, which includes 25 deaths (10 male, 15 female) caused by Pneumonia, 10 deaths (4 male, 6 female) caused by Diarrheal Diseases, 10 deaths (5 male, 5 female) caused by Meningitis/Severely Ill Children and 1 death (0 male, 1 female) caused by Malaria . (Fig-7)

Fig-7: Deaths due to DEWS targeted diseases in week-22 of 2014

12.44% 4.98% 4.98% 0.50%

Pn

77.11% Diarrheal Disease Men/SIC

Malaria

Other

Report of Outbreaks: Last 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 provincesand in this reporting week a , a Scabies Outbreak reported from Nimroz province and two Suspected CCHF Outbreaks and a Suspected Measles Outbreak reported from Herat province.Table-7 (below) shows the number of outbreaks investigated in 2014 with details of week-21 and week-22 of 2014.

Table-7: Reported outbreaks since first week of 2014 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 3 3 Avian/Swine Flu 1 1 ARI 4 2 2 Measles 64 1 63 Diarrhea Meningitis Hepatitis Malaria Typhoid CCHF 8 8 Bl. Diarrhea Chickenpox 6 6 Other 12 1 11 Total 98 4 94 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 , 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, Herat Province 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. Epidemiological week- 22

 Scabies Outbreak: Reported from Prison of Zaranj city of Nimroz Province on June 02/2014, the team investigated the area on the same day, During the investigation there were 60 scabies cases ,it was clinical confirm outbreak . The cases treated and health education session conducted in the prison, the active surveillance has been established for investigation of further cases.  Suspected CCHF Outbreak: Reported from Sargangal village of Guzara of Herat Province on June 01/2014, the team investigated the case at regional hospital on the same day, During the investigation there was one suspected CCHF cases , the patient is 65 years old young man who had contact with animal ,it was clinical confirm outbreak . 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 Charchah village of of Herat Province on June 1/2014, the team investigated the case at regional hospital on the same day, During the investigation there was one suspected CCHF cases, the patient is 35 years old man and had slaughtered an animal 10 days ago and also had contact with animal, due to insecurity field investigation was not done .it was clinical confirm outbreak. The team collected lab samples and send them to CPHL, the case was treated, health education session conducted to his caretakers, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Area 3 of Herat city, Herat Province on June 01 /2014, the team investigated the area on the following day, Vaccination coverage is 100%. During the investigation there were 11 suspected measles cases ,it was clinical confirm outbreak , There were no cases of under five years old but 11 cases of over five years old .Based on sex, there was 6 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, 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 region.  High incidence of Pneumonia overall up to 2.4% and 5.1% 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 and CCHF in West region 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-22 of 2014 by Province 8 Density Cases of Pneumonia in Week-22 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 Pn Helmand Kandahar Nimruz 16 - 34 35 - 128 129 - 311 312 - 799 800 - 2139

8 Density Cases of Typhoid Fever in Week-22 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 TF Helmand Kandahar Nimruz 2 - 20 21 - 44 45 - 70 71 - 132 133 - 210

8 Density Cases of Malaria in Week-22 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 Mal Helmand Kandahar Nimruz 0 - 21 22 - 74 75 - 193 194 - 378 379 - 572

8 Density Cases of Acute Viral Hepatitis in Week-22 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 AVH Helmand Kandahar Nimruz 0 - 1 2 - 4 5 - 9 10 - 13 14 - 97