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 13, Wednesday 4 April 2012

Highlights Priority diseases under surveillance Epidemiological week no. 13 (25 to 31 March 2012) in DEWS

Acute (Upper) Respiratory Infection • In week 13, 2012, total 87 districts including 3 agencies provided surveillance data to the Pneumonia DEWS on weekly basis from around 1,881 health facilities. Data from mobile teams is reported Suspected Diphtheria through sponsoring BHU or RHC. Suspected Pertussis Acute Watery Diarrhoea Bloody diarrhoea • A total of 755,137 consultations were reported through DEWS of which 20% were acute Other Acute Diarrhoea respiratory infections (ARI); 7% were acute diarrhoea; 4% were suspected malaria; while 4% were Suspected Enteric/Typhoid Fever Skin disease. Suspected Malaria Suspected Meningitis Suspected Dengue fever • A total of 164 alerts with 17 outbreaks were reported/identified in week 13, 2012: Alto‐ Suspected Viral Hemorrhagic Fever gether 93 alerts for Measles; 22 for Leishmaniasis; 13 for Typhoid; 9 for ARI; 6 for NNT; 5 for Per‐ Pyrexia of Unknown Origin tussis; 4 for AWD; 2 each for Acute diarrhoea, Bloody diarrhoea, AJS, Scabies and Chicken Pox; Suspected Measles Suspected Acute Viral Hepatitis while 1 each for Diphtheria and Dengue Fever. Chronic Viral Hepatitis

Neonatal Tetanus • In this week no new polio cases was reported. As of 2 April 2012, the total number of polio Acute Flaccid Paralysis cases confirmed by the laboratory is 15 from 10 districts/towns/tribal agencies and areas. Scabies Cutaneous Leishmaniasis Others

Figure‐1: Weekly trend of Acute diarrhoea, Bloody diarrhoea, ARI and Suspected malaria in Pakistan, Week‐1, 2011 to week‐13, 2012.

50 AD BD ARI S. Malaria 45

25 Percentage 20

0 1 3 5 7 9 1 3 5 7 9

11 13 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

Table 1: Most common communicable diseases syndromes reported weekly

Disease Wk-6 Wk-7 Wk-8 Wk-9 Wk-10 Wk-11 Wk-12 Wk-13

Acute respiratory infection 141,503 (25%) 159,074 (26%) 153,111 (24%) 157,828 (23%) 155,186 (23%) 158,872 (23%) 141,713 (21%) 150,480 (20%)

Skin diseases 27,267 (5%) 29,199 (5%) 28,820 (4%) 29,430 (4%) 30,909 (4%) 31,383 (4%) 28,391 (4%) 31,018 (4%)

Acute diarrhoea 29,359 (5%) 30,607 (5%) 31,623 (5%) 34,918 (5%) 38,427 (6%) 40,328 (6%) 40,810 (6%) 49,875 (7%)

Bloody diarrhoea 2,681 (0.48%) 2,730 (0.45%) 2,765 (0.43%) 3,094 (0.45%) 2,874 (0.42%) 3,627 (0.51%) 2,853 (0.43%) 3,410 (0.45%)

Suspected malaria 21,813 (4%) 22,883 (4%) 23,483 (4%) 28,265 (4%) 29,599 (4%) 30,498 (4%) 29,445 (4%) 32,290 (4%)

Total consultation 557,926 605,633 650,423 680,221 688,813 705,715 669,876 755,137

• The above graph shows the weekly trend of ARI; Acute diarrhoea; Bloody diarrhoea and Suspected malaria as proportional morbidity (percentage of cases out of total consultations) reported to DEWS on weekly basis.

• The above table provides the total consultations for each of the last 8 weeks proportional morbidity of five disease syn‐ drome. Proportional morbidity of ARI is highest in Sindh, KP and FATA while acute diarrhoea is highest in Balochistan and Sindh (please see the graphs for every province in page 6 and 7).

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 Special Bulletin: DEWS, Pakistan, Week no. 13 (25 to 31 March 2012) Previous week's (12/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken 2 suspected cases of Leishmaniasis were reported from RHC Lakhra and 5 more cases found Village Dovina, Tehsil during active surveillance. Patients having no travel history. Inj Glucantime was advised and 19‐Mar Leishmaniasis Balochistan Lasbela 1 2 1 3 Lakhra guided to take regular treatment. Information was shared with DHMT and requested to take intervention as cases were received on regular basis.

Goth Yar Muhammad 6 suspected cases for Measles investigated and Vit‐A was administered, while 3 samples were 19‐Mar Measles Balochistan Nasirabad 0 0 0 0 Pindarani, UC Quba taken and sent to NIH. DHMT was informed. 6 AWD cases from one family at Village Jattgram, Tehsil Wari, Dir Upper reported from RHC Wari . One stool sample collected and sent to NIH but found negative for Cholera. Unpro‐ tected spring water was the suspected source. Line list of cases maintained and shared with Village Jattgram, UC EDO‐H, In charge RHC Wari and health authorities. WHO provided 1430 Aqua tabs, 100 ORS, 19‐Mar AWD KPK Upper Dir 2 2 1 1 Nihagdarra, Tehsil Wari 7 Hygiene kits, 10 jerry cans, 144 soaps and 2 straw filters to the affected families, while EHE chlorinated the main source; Shock chlorination of springs, water storage tanks. On job train‐ ing of community on disinfection of water sources, clothes and utensils and emphasis was given on use of boiling water for drinking. IEC material provided to the villagers. An alert for measles 5 cases reported from two different locations (CD KTS3 and CH Khalabut). 31 houses were assessed in 2 both locations 37 children between 9 months to 5 years were Khalabut Township UC assessed. 16 children had measles 1 and 25 children with measles 2 vaccine. 9 children were 19‐Mar Measles KPK Haripur 2 1 1 1 Khalabut below 9 months. EPI coordinator and EDO Health were informed. Measles campaign is planned in 5 UC of District Haripur adjoining Afghan Refugee camp. Health session was con‐ ducted on prevention and spread for the affected families An alert of suspected measles case was reported from BHU Sikandarpur. Active surveillance was carried out and 78 more cases were identified. Vit A given to the cases. Vaccination status was assessed in the surrounding out of seven houses that were assessed, found 15 children Makhan Colony UC 19‐Mar Measles KPK Haripur 1 2 2 3 with no vaccination history of any sort. No BCG scar was seen in any of the children. EPI Sikandarpur coordinator and EDO Health were informed. Immediate mop up campaign was launched in the area for measles, Pentavalent and OPV. Blood samples were taken and set to NIH. Follow‐ up is planned. During routine visit to SGTH WHO Swat team found three cases of Suspected Measles belong‐ ing to the same village. Detailed histories were taken from the patients and Blood Samples Village Sar Sardarey Bar were collected, while Vitamin A doses provided. WHO along with a team from DoH went to 18‐Mar Measles KPK Swat Jabar, UC Aka Maruf 8 1 0 1 Bamikhel, Tehsil Babuzai area for active surveillance and eight more cases were found in the village. Outreach vaccina‐ tion was conducted in the area in which 347 children were vaccinated. Health education session was conducted in the community regarding the importance of routine immunization.

Sethaar verho Village Suspected case of measles was reported from GD Boriri, during active surveillance Vit(A) dose 24‐Mar Measles Sindh Shikarpur borriri UC taib taluka 2 0 1 2 was given, immunization status was not good, health education was imparted, EDOH in‐ lakhi formed and 4 Blood samples were collected and sent to NIH.

Probable Pertussis cases was found by SO DEWS Sukkur, during active surveillance found 14 village Ulra Jageer taluka cases in 5 houses where only 4 children were found vaccinated, index case has been taken to 24‐Mar Pertussis Sindh Khairpur 3 5 4 2 Kingri Agha khan hospital karachi, health education was imparted, health promotion activity planned with EPI vaccinator and LHWs.

Probable Pertussis case was investigated at village haji Achar Chandio; During active surveil‐ Shaheed village haji Achar Chandio lance 7 more cases found. Only one child was fully vaccinated found among 10 children under 24‐Mar Pertussis Sindh 0 0 2 6 Benazirabad taluka Qazi Ahmed 2 years of age, while 3 cases were admitted in hospital. Syrup Erythromycin provided to all the suspects. EDO‐H informed.

Current week's (13/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken 6 cases of suspected measles were reported from wapda colony. Vit A and supportive treat‐ wapda colony, UC Sadar‐ ment was given to all patients. DHO was informed and started responding to community 28‐Mar Measles Balochistan Kharan 0 3 0 3 ran town about immunization. No sample was collected as parents refused. On the house hold survey 67 children were checked for routine vaccines. 49% were found vaccinated. Alert of 3 suspected measles cases were reported from AHQ Landikotal.On active surveillance Village Musalyan,UC Khyber 4 more cases were found in the area. 1 blood sample collected and Vit (A)drops provided. 28‐Mar Measles FATA Sheikh Mal Khel Mirdad 3 0 4 0 Agency Khel, Tehsil Landikotal mopup activity conducted and vaccinated 75 children. Health education imparted and the details were shared with Agency Surgeon and FSMO. Alert of 3 suspected measles cases were reported from CD Pindi Lalma. According to MT the 3 cases were brought to the CD with complaints of fever and cough and there parents informed Village Nawaz killi,UC Khyber them of more cases in the area. On active surveillance visit, found 12 more cases including 18 30‐Mar Measles FATA Pindi Lalma,Tehsil Mu‐ 2 3 7 3 Agency lagori years old girl. Vit A drops provided. Health education imparted. Due to security issue, 3 chil‐ dren found fully unvaccinated and no outreach activity been done in their area. 54 children were get vaccinated by the team.

3 cases of Suspected Measles were reported from THQ Samar Bagh with fever & rashes but during response WHO team found that all 3 patients had suspected DHF with history of Se‐ vere headache, fever, body aches, diarrhoea with rashes on their face and upper extrimities, 2 Khyber patients passed blood in stool, 1 patient also complains of bleeding from their nose. 1 other Village Khanakai, Lal Qilla 30‐Mar DHF Pakhtunk‐ Lower Dir 0 3 0 1 patient at their family also suffering from same complications, all the patients were investi‐ ‐Maidan hwa gated, blood samples were taken and sent to NIH for DF/DHF antibodies confirmation,The patients then referred to the DHQ Hospital Timargara for further investigation (CBC, Mp, Typhidot etc) and emergency treatment. ITN's were provided, EDO‐H, RBM focal person were informed.

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 Special Bulletin: DEWS, Pakistan, Week no. 13 (25 to 31 March 2012) Current week's (13/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken During Monitoring visit to the HF of AR Taimar Camp, 2 cases of CL were identified in the OPD register and were under treatment from same HF. During Active surveillance 7 more cases Khyber were identified in the area and 4 patients recieved 2 doses of Inj Glucantime. On job training Village Baroon, UC 27‐Mar Leishmaniasis Pakhtunk‐ Lower Dir 0 7 0 2 of AR health staff was conducted for Intralesional adminstration of Inj Glucantine. Health & Munjai, Tehsil Balmbat hwa Hygiene sessions conducted, Camp Incharge/RBM was informed and requested for residual spray before the favorable season for vector breeding and transmission. EDO Health and focal person was informed .

8 cases of suspected measles were found during the follow up survey of the area. Vitamin (A) drops given. Total 50 children were assessed for their routine immunization, 60% found unvaccinated. Information shared with the district EPI staff. Mopup activity conducted and 50 Khyber Village Nagrai bazaar children were vaccinated on the same day. In addition, residents were requested to bring rest 28‐Mar Measles Pakhtunk‐ Buner near CD Amazai tehsil 1 3 3 1 hwa Mandan of their children to CD Amazai and RHC Nagrai for vaccination. Health education session conducted with the elders and advocate them to vaccinate all their children in future.

6 cases of suspected measles were found on active surveillance. Vitamin A drops provided.12 Khyber Village pariwal near BHU children were assessed for their routine immunization coverage, out of which 4 children 28‐Mar Measles Pakhtunk‐ Buner 2 3 1 0 Langow tehsil Mandan hwa found unvaccinated. Health and hygiene education imparted. Line list shared with EPI staff for mopup activity.

Alert of one suspected measles case was generated by BHU Tofkian. Vitamin (A) provided, Health education imparted, on active surveilliance found 4 more cases of post Measles & prodermal phase, Two blood samples collected & sent to NIH, routine immunization of the Khyber Village Gakhra, UC area was checked and found 4 children had no measles vaccine, 6 children were missing 26‐Mar Measles Pakhtunk‐ Haripur 2 1 1 1 Tofkian hwa measles‐2 vaccine, 2 children had no BCG scar, 1 child was missing penta 3 and 1 child was totally unvaccinated. Missed children were referred to BHU Tofkian for completion of vacci‐ nation. Follow‐up was done and found no more cases. EDO H and EPI coordinator were in‐ formed.

Alert of 2 suspected cases of Measles were reported from BMC Swabi. During investigation 6 Khyber more cases found iin the same locality. Vit.A given,health education sessions conducted,EDO 29‐Mar Measles Pakhtunk‐ Swabi BMC Swabi, Punjpir 1 4 2 1 hwa H and EPI coordinator Informed, Measles Mopup Vaccination done in the Relevant Village. WHO EHA and PPHI provided the essential medicines to the relevant Health Facilities. 9 Suspected cases of measles reported by DSC . All cases were Nomades. On active Surveil‐ Nomades near Railway lance 3 more cases were found. Alltogether 51 Children were checked for vaccination( BCG+ 26‐Mar Measles Punjab Bhakkar Crossing, Behal Road,UC 7 0 5 0 Measles) and 100% of children were found unvaccinated. mopup activity conducted on the Bhakkar Urban II same day. Vit A drops given, health and hygiene education imparted. 3 blood samples col‐ lected.DHMT informed about the situation. Five suspected cases found on active surveillance, vitamin (A) drops was given, 1 blood sam‐ Street 4 near Xblock ple collected and sent to NIH. On field investigation only 43% children found vaccinated. 28‐Mar Measles Punjab D. G. Khan 1 0 0 4 Model TOWN uc urban 6 Health education session conducted. Mop up activity planned for community after informing DDOH and DSV of the District .

Alert was received through automated SMS from eDEWS alert generation system, 07 cases of TF reported from RHC. Line list was obtained. 4 cases were reported from Khanbela Town. On further investigation, 1 more suspected case was identified and refered to RHC. 2 of the cases had a history of travelling to District Kashmore and on the way ate street food. Widal Test was Rahim Yar Khanbela, Tehsil Liaqat‐ 28‐Mar Typhoid Punjab 0 4 1 2 positive for both cases. All the patients were prescribed with oral antibiotics. Aqua Tabs and Khan pur Jerry cans were distributed among community, Health facility and LHWs for further distribu‐ tion. 02 Health Education sessions were conducted with the community. 03 LHWs were mobi‐ lized to conduct further health education sessions on Safe drinking water, safe food handling and hygiene.

5 suspected cases of measles were found on active surveilliance visit, vitamin(A) drops pro‐ Fazal abad colony, UC vided, house to house immunization status was checked and found 12 childrens, all were 29‐Mar Measles Sindh Badin 1 2 1 1 Mati, taluka matli, vaccinated, health education regarding importance of vaccination was imparted, EDOH in‐ formed and 1 Blood sample collected. Alert of one suspected measles case was reported from private clinic, on active surveilliance Shahee bazar, Thakur das found 4 more cases,On house to house survey, 9 children were assessed but only 3 childrens 30‐Mar Measles Sindh Hyderabad 2 0 2 1 gali, taluka Hyderabad were found vaccinated, Vitamin(A) drops given, health education imparted, DHO, DSC, DSV and FP‐Measles was informed and 2 Blood sample collected for lab confirmation. Alert of one Suspected case was admitted in NIH, active surveilliance of the area was done, Vitamin(A) dose was given, Immunization status was checked and found(BCG/OPV=71%, Street # 25. Hijrat colony, 28‐Mar Measles Sindh Karachi 3 0 3 0 OPV1/PENTA1=36&, OPV2/PENTA2=36%, OPV3/PENTA3=36%, Measle1=7%, Measles2=0% UC. 9, Saddar town and fully vaccinated=7%), health education and community sensitizing was done, THMT was requested for crush Measles program, THO informed and 1 Blood sample collected. Alert of one Suspected case of Measles from Private GP, During active surveilliance found 9 Drib Mohalla , UC ‐2 Qambar more suspected cases, Vitamin (A) was given, Immunization status was assessed and found 25‐Mar Measles Sindh Shahdadkot , Taulka 3 1 3 3 Shahdadkot Shahdadkot (BCG 40%, Measles‐1 30%, Measles‐2 15%), DHMT were informed for implementation of Measles Vaccination and 8 blood samples collected.Health and Hygiene education imparted. Alert of one suspected measles case was reported from THQ Sakiro, active search was done Village Achar Khaskhali and found 9 more suspected cases, house to house cluster was taken and assessed 30 chil‐ 30‐Mar Measles Sindh Thatta UC Udasi taluka Ghara‐ 2 2 2 4 drens out of which only 10 childrens were found vaccinated , health education imparted, bari Vitamin(A) drops provided, EDOH informed and 5 Blood samples collected for lab confirma‐ tion.

Distribution of Wild Polio Virus cases Pakistan 2011 and 2012

As of 2 April 2012, the total number of polio cases confirmed by the labora‐ tory is 15 from 10 districts/towns/tribal agencies and areas.

Cases 2011 Cases 2012 Province P1 P3 P1 P3 P1+P3 Punjab 9 ‐ 1 ‐ ‐ Sindh 33 ‐ 2 ‐ ‐ Khyber Pakhtunkhwa 23 ‐ 4 ‐ ‐ FATA 57 2 4 1 1 Balochistan 73 ‐ 2 ‐ ‐ AJ&K ‐ ‐ ‐ ‐ ‐ Gilgit‐Baltistan 1 ‐ ‐ ‐ ‐ Islamabad ‐ ‐ ‐ ‐ ‐ Total 196 2 13 1 1

Number o alerts by province, week 12, 2012 Province Khyber Pakhtunkhwa Province Punjab Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 30‐Mar DHF Lower Dir Village Khanakai, Lal Qilla‐Maidan 0 3 0 1 28‐Mar AD R Y Khan Pacca Laran, Tehsil Khanpur 6 11 5 9 26‐Mar Diphtheria Shangla Village Banjar Dherai 0 0 0 1 28‐Mar AJS Lahore Cantonment 1 1 0 1 27‐Mar Leishmaniasis Bannu Village Darmakhel Suraye 1 0 0 0 26‐Mar AJS Mianwali THQ Hospital Kalabagh 2 1 1 2 27‐Mar Leishmaniasis Haripur Afghan Camp Bassu Mera 1 4 0 0 27‐Mar ARI Bhakkar BHU Litten, UC Litten, Tehsil Mankera. 24 32 27 28 27‐Mar Leishmaniasis Lower Dir Village Baroon, UC Munjai 0 7 0 2 28‐Mar Leishmaniasis Lower Dir Village Malakand Payeen‐Sorikandao 0 2 0 1 27‐Mar ARI Mianwali THQ Piplan 14 2 18 1 27‐Mar Measles Buner malak pur tehsil dagar 1 0 0 0 26‐Mar ARI Multan Ali Pur Saddat 9 24 6 15 27‐Mar Measles Buner Village bajkata tehsil gagra 0 0 1 0 26‐Mar ARI Multan Nawabpur 11 42 7 49 27‐Mar Measles Buner Village churano danakol 1 0 0 0 27‐Mar ARI Multan Makhdoom Rasheed 15 158 9 107 27‐Mar Measles Buner Village thithwalan 0 0 0 1 29‐Mar ARI RY Khan RHC Mianwali Qureshian 10 6 14 12 28‐Mar Measles Buner Village Nagrai bazaar 1 3 3 1 30‐Mar ARI RY Khan Rohti Sharif, Tehsil Rahim Yar Khan 19 11 28 21 28‐Mar Measles Buner Village pariwal near BHU Langow 2 3 1 0 28‐Mar BD RY Khan Aminabad, Tehsil Liaqatpur 1 1 2 1 27‐Mar Measles Charsadda Para Jranda 0 0 0 1 27‐Mar Leishmaniasis Rajanpur Basti Ali Murad Jhullan, UC Rojhan Urban 0 0 0 1 28‐Mar Measles Charsadda Khat Koroona 0 1 0 0 26‐Mar Measles Bhakkar Nomades near Railway Crossing 7 0 5 0 28‐Mar Measles Charsadda Manikhel 0 0 0 1 26‐Mar Measles D. I. Khan Gandi Ashiq, Tehsil Kulachi 1 0 0 0 28‐Mar Measles D. G. Khan near Bambani Mosque 2 0 1 0 26‐Mar Measles D. I. Khan Kirri Shamozai, Tehsil Paroa 1 0 0 0 28‐Mar Measles D. G. Khan Oj street Bhutta colony uc urban6 0 0 1 0 26‐Mar Measles D. I. Khan Lunda Shareef, UC Naiwela, Paroa 1 0 0 0 28‐Mar Measles D. G. Khan Opp purana thana uc urban 1 0 0 0 1 29‐Mar Measles D. I. Khan Pahar Pur Urban, Tehsil Pahar Pur 0 0 1 0 28‐Mar Measles D. G. Khan Street 4 near Xblock Model TOWN 1 0 0 4 29‐Mar Measles D. I. Khan Shor Kot 0 1 0 0 29‐Mar Measles D. G. Khan Basti Thata Leghari uc Kot Qaisrani 0 0 1 0 30‐Mar Measles D. I. Khan Maddi, Tehsil Kulachi 1 0 0 0 25‐Mar Measles Lahore Cantonement 2 0 0 0 30‐Mar Measles D. I. Khan New Chungi, City 2 0 0 1 0 26‐Mar Measles Lahore Allama Iqbal Town 1 0 1 0 30‐Mar Measles D. I. Khan Noshera Morr, Bilot Shareef 1 0 0 0 26‐Mar Measles Lahore Data gunj baksh town 1 0 0 0 30‐Mar Measles D. I. Khan Village Rodi Khel, Tehsil Kulachi 1 0 0 0 26‐Mar Measles Lahore Gulberg Town 0 0 1 0 28‐Mar Measles Hangu Village Aliabad, UC Ganjiano Kalay 1 0 0 0 27‐Mar Measles Multan Babar town, near Ahsan petrol pump 1 2 0 1 28‐Mar Measles Hangu Village Nazir Baba, UC KhanBari 0 0 1 0 26‐Mar Measles Haripur Village Gakhra, UC Tofkian 2 1 1 1 26‐Mar Measles Muzaffargarh Basti Sheikhan, UC KP Bagga Sher 1 0 0 0 27‐Mar Measles Kohat UC Raisaan 1 0 0 0 26‐Mar Measles Muzaffargarh Basti Talai, Wadda Khoo, UC Basira 1 0 0 0 27‐Mar Measles Kohat Village Kraapa, Tehsil and UC Laachi 0 0 0 1 26‐Mar Measles Muzaffargarh C/O Dr. Shagufta Rao, UC Lutkeran 0 1 0 0 29‐Mar Measles Lower Dir Village Garkor, UC Khall 0 1 0 0 29‐Mar Measles Muzaffargarh Basti Chacha, Moza Sadey Wahin 0 1 0 0 30‐Mar Measles Lower Dir Village Sorai Ghondai 0 0 0 1 29‐Mar Measles Muzaffargarh Mohallah Qazi Wala, Gali Rajpoot 1 0 0 0 27‐Mar Measles Malakand Dheri 0 0 0 1 30‐Mar Measles RY Khan Basti Malik Budh Darigh 0 0 1 0 28‐Mar Measles Malakand Haryankot 1 1 0 1 26‐Mar Measles Rajanpur Moza Rusool Pur, UC Allah Abad 0 0 1 0 26‐Mar Measles Shangla Village Basi Kele 1 0 0 1 27‐Mar NNT Multan Basti Jhoke lashkar pur 1 0 0 0 27‐Mar Measles Swabi BHU Kalabat, Kotta 0 1 0 0 28‐Mar Scabies Layyah BHU Bait Wasawa Shumali 4 27 11 40 28‐Mar Measles Swabi BMC Swabi, Bamkhel 0 0 1 0 29‐Mar Measles Swabi BMC Swabi, Punjpir 1 4 2 1 27‐Mar Typhoid Layyah BHU Garay wala, UC Garay wala 0 2 0 2 26‐Mar Measles Swat Village Khkata Shahi Bagh 0 1 0 0 27‐Mar Typhoid Layyah BHU Jherkal, UC Samtia, Tehsil Karoor 1 1 0 2 26‐Mar Measles Swat Village Tooth Banai 2 1 0 0 28‐Mar Typhoid Layyah RHC Chowk Azam, UC Chowk Azam City 0 1 0 2 26‐Mar Measles Swat Village Usman Abad Gumbad Mera 1 0 1 1 28‐Mar Typhoid Mianwali RHC Kammar machani 2 6 3 7 28‐Mar Measles Swat Village and UC Qambar, Tehsil Babuzai 0 0 1 0 25‐Mar Typhoid Multan Muzaferabad 0 7 0 2 28‐Mar Measles Swat Village Aqba Saidu Sharif 1 0 0 0 27‐Mar Typhoid Muzaffargarh DHQ Muzaffargarh 1 3 0 2 29‐Mar Measles Swat Village Chuprial, UC Chuprial 1 0 0 0 27‐Mar Typhoid Muzaffargarh RHC Khangarh, Tehsil MZG 1 3 0 1 29‐Mar Measles Swat Village Kokarai Gul Kah 1 0 0 0 28‐Mar Typhoid Muzaffargarh BHU Pattal Kotaddu, Tehsil Kotaddu 0 2 0 0 29‐Mar Measles Tank Kot Nawaz 0 1 1 0 28‐Mar Typhoid Muzaffargarh RHC Daira Deen Panah, Tehsil Kotaddu 0 2 0 1 27‐Mar NNT Bannu Village Dogar Omerzai 1 0 0 0 28‐Mar Pertussis Shangla Village Buneerwal 0 0 0 1 28‐Mar Typhoid Muzaffargarh RHC Sinanwan, Tehsil Kotaddu 0 1 0 1 28‐Mar Typhoid Haripur Khalabut Township Sector 4 0 1 0 1 28‐Mar Typhoid Muzaffargarh THQ Kotaddu 1 0 0 1 29‐Mar Chicken Pox Hangu Sector ‐ B, Togh Saray IDP Camp 0 0 2 0 28‐Mar Typhoid RY Khan Khanbela, Tehsil Liaqatpur 0 4 1 2 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]. 04 Special Bulletin: DEWS, Pakistan, Week no. 13 (25 to 31 March 2012) Province Sindh Province Balochistan Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 30‐Mar AWD Tando Allah Yar Aik Minar wali Masjid 0 0 0 1 27‐Mar AD Bolan RHC Haji Shehr 0 0 0 0 30‐Mar AWD Tando Allah Yar Shah Latif Naseerabad colony, UC# 3 0 0 1 0 27‐Mar ARI Bolan RHC Haji Shehr 0 0 0 0 25‐Mar AWD Tharparkar Village Dad Jarwar 1 1 0 1 26‐Mar ARI Ziarat Village Kawas sharki, UC Kawas 0 0 0 0 29‐Mar AWD Tharparkar Village Laplo, UC Chachro 1 2 0 1 26‐Mar BD Harnai Village Khidrani, UC Harnai Urban 0 0 0 0 29‐Mar Measles Badin Fazal abad colony, UC Mati 1 2 1 1 30‐Mar Chicken Pox Lasbela Hindu mohalla, Tehsil Hub 1 2 1 0 28‐Mar Measles Hyderabad Near Pakland Banglows, Qasimabad 0 0 1 0 29‐Mar Leishmaniasis Bolan Village Bagh 0 1 0 0 30‐Mar Measles Hyderabad Shahee bazar, Thakur das gali 2 0 2 1 26‐Mar Leishmaniasis Jhal Magsi Village and UC Gandawah 2 1 0 0 30‐Mar Measles Jamshoro Fanty Charach, UC H.M Shoro 0 1 0 0 29‐Mar Leishmaniasis Kech Village Koshkalat, Tehsil Turbat 0 0 1 0 30‐Mar Measles Jamshoro Khushk Muhalla Akro, UC Petro 1 0 0 0 28‐Mar Measles Karachi Street # 25. Hijrat colony 3 0 3 0 29‐Mar Leishmaniasis Kech Village Sahlalabazar, UC Absar 0 1 0 0 30‐Mar Measles Larkana Mumtaz colony UC‐4 0 1 1 0 30‐Mar Leishmaniasis Kech Village Sarikhan, UC Satikhan 0 1 0 0 28‐Mar Measles Matiari Bughio Muhalla, Musafirabad Bhit 0 0 1 0 28‐Mar Leishmaniasis Lasbela UC Winder,Tehsil Uthal 1 3 1 2 28‐Mar Measles Matiari Latif colony Bhit shah city, taluka Hala 0 0 1 0 26‐Mar Leishmaniasis Nasirabad Ghot Siva & Punal Khan 0 0 0 2 25‐Mar Measles Q Shahdadkot Drib Mohalla , UC ‐2 Shahdadkot 3 1 3 3 27‐Mar Leishmaniasis Nasirabad Ghot Mir Hassan, Tehsil Tamboo 0 1 0 1 30‐Mar Measles Q Shahdadkot village by Pass Chandia , UC Kambar‐2 1 0 0 0 28‐Mar Leishmaniasis Nasirabad Irregation Colony 0 1 0 1 30‐Mar Measles Q Shahdadkot Village Chundia , UC Ber Sharif 1 0 0 1 30‐Mar Leishmaniasis Nasirabad Ghot Farid Khan Umrani 0 1 0 0 28‐Mar Measles Sanghar Village Mureed Akbar Sangrasi 2 0 0 0 30‐Mar Leishmaniasis Nasirabad Ghot Noor Muhammad Mengal 1 0 0 0 28‐Mar Measles Sanghar Village Nou Goth 3 0 1 0 28‐Mar Leishmaniasis Panjgur Village Kalla Kore 0 1 0 0 28‐Mar Measles S Benazirabad OMCH 0 0 1 0 26‐Mar Leishmaniasis Quetta BHU Kaichi bag 0 1 0 1 28‐Mar Measles S Benazirabad village qaim sahito bucheri Nawabshah 0 0 1 0 30‐Mar Leishmaniasis Sibi DHQ hospital 0 2 0 1 30‐Mar Measles Sukkur GMCH (Peer Murad shah colony) 1 1 0 0 26‐Mar Leishmaniasis Ziarat Village Koshkai, UC Ziarat 0 1 0 0 28‐Mar Measles Thatta Village Misan Near Floor Mill Thatta 1 0 1 0 29‐Mar Measles Jhal Magsi Goth Bunglani, UC Hathyari 0 0 1 0 30‐Mar Measles Thatta Mallah Mohalla 1 1 0 0 28‐Mar Measles Kech Village Aftoobazar, UC Ginnah 2 1 0 1 30‐Mar Measles Thatta Village Achar Khaskhali 2 2 2 4 28‐Mar Measles Umer Kot Ward # 311, UC 1 Chania Muhalla 0 0 0 1 28‐Mar Measles Kharan wapda colony, UC Sadarran town 0 3 0 3 29‐Mar NNT Ghotki Village Haji Pnuhoo chachar Wari Daro 1 0 0 0 30‐Mar Measles Lasbela Akram colony UC Beroot 0 0 1 0 30‐Mar NNT Q Shahdadkot Village Mehal , Near Dostli Pul 1 0 0 0 30‐Mar Measles Nasirabad Ghot Hamal Khan Pethafi 1 0 0 0 29‐Mar Pertussis Thatta Shah Kamal Mohalla Thatta 0 1 0 0 28‐Mar Measles Panjgur Villagea Gareeb Abad UC 1 0 1 1 30‐Mar Scabies Q Shahdadkot Bitio , UC Ghogharo 3 5 6 6 30‐Mar Measles Ziarat Killi ghowazh, UC Zindra, Tehsil Ziarat 2 1 1 0

Focus on: Measles In the previous week 12, 2012, DEWS team successfully responded to 17 outbreaks out of which 14 outbreaks were only of measles. In addition, 93 alerts of measles and 5 outbreaks have also been detected and responded this week 13, 2012. In‐ crease in the number of measles cases this year compared to last year indicates that the children are not vaccinated against measles and no such campaigns have been planned this year. However, last year, the measles immunization follow up cam‐ paign was organized in Feb 2011 which had reduced the number of cases. Measles is a killer childhood disease. One in 15 people have complications with measles, and one in 1000 will die of it, but two doses of measles vaccine will protect people against the disease. WHO has set the target for measles elimination for 2015 which would require that more than 95% of the world’s children are covered by two doses of measles vaccine.

Proper case management during outbreaks: It is imperative that during outbreak situations proper case management is ensured in order to minimize measles related deaths and measles related complications. The treatment of measles patients with 2 doses of Vitamin A will dramatically re‐ duce their risk of death. Two doses of Vitamin A will be given to all identified cases (active and old) during house‐to‐house investigation, unless it was already received as part of the treatment in the health facility. One dose to be given by the health worker on the day of investigation and the 2nd dose to the parents advising to give on next day. The therapy will be given re‐ gardless of previous vitamin A prophylaxis. If the investigation team observes measles complications, the patient should be referred to the nearest health facility for spe‐ cific treatment of these complications.

Measles Prevention: Routine measles vaccination for children, combined with mass immunization campaigns in countries with high case and death rates, is a key public health strategy to reduce global measles mortality rates. The measles vaccine has been in use for over 40 years. It is safe, effective and inexpensive. It costs less than one US dollar to immunize a child against measles. Measles vaccine is provided by the Pakistan EPI programme to children at 9 months and 15 months. Children who are vacci‐ nated against measles before 9 months of age must receive a 2nd measles vaccination at 9 months age ensuring a gap of one month between both vaccinations. Moreover, any child who receives measles vaccine should also receive OPV. In outreach situation, priority should be placed to immunize children 6 months to 5 years old, regardless of vaccination status or history of disease. Auto destructible syringes and safety boxes are recommended and safe disposal of used sharps and safety of injection during immunization should be ensured. Let’s remind all our neighbours, friends and colleagues to be sure their children are immunized against measles.

Skin diseases 6,349,885 (10%) 150000

Acute diarrhoea 5,739,522 (9%) 100000 Percentage Bloody diarrhoea 503,297 (<1%) 50000

Suspected malaria 3,868,511 (6%) 0 < 1 yr 1‐4 yr 5‐14 yr 15‐50 yr 50 + yr Unexplained fever 2,432,579 (4%) Male 25450 59071 76992 118712 56204 Female 25315 55736 83080 191870 62707 Total consultations 64,921,678 Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response 2010 2011 2012 (up till week 13) Total Disease A O A O A O A O Acute watery diarrhoea 209 85 1350 543 78 3 1637 631 Acute jaundice syndrome 5 2 51 17 38 2 94 21 Bloody diarrhoea 10 1 98 20 35 3 143 24 Dengue fever 81 32 785 111 19 1 885 144 Measles 48 6 1710 91 904 40 2662 137 Pertussis 1 0 287 81 166 55 454 136 NNT + tetanus 5 0 399 0 178 582 0 Malaria 12 7 131 88 18 7 161 102 Leishmaniasis 1 0 298 33 251 25 550 58 Others 75 11 643 69 369 43 1087 123 Total 447 144 5752 1053 2056 179 8255 1376 Province Khyber Pakhtunkhwa: Figure-3: Trend of priority communicable diseases, province KPK • 491 health facilities from 19 districts of Khyber 50 Pakhtunkhwa reported to DEWS on weekly basis with AD BD ARI S. Malaria a total of 133,981 patients consultations in week 13, 45 2012. 40 35 • 49 alerts were reported in week 13; Altogether 39 for 30 Measles; 4 for Leishmaniasis; while 1 each for DF, 25 Diphtheria, NNT, Pertussis, Typhoid and Chicken- Percentage 20 pox. 15 10 • 5 outbreaks, 4 for Measles; while 1 for Leishmaniasis 5 were identified and appropriate measure were taken. 0 1 3 5 7 9 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 11 13

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk Province Sindh: Figure-4: Trend of priority communicable diseases, province Sindh • 473 health facilities from 23 districts in Sindh reported on weekly basis to DEWS with a total of 279,967 patient 50 AD BD ARI S. Malaria consultations in week 13, 2012. 45 40 • 29 alerts were reported; Altogether 21 for Measles; 4 for 35 AWD; 2 for NNT; while 1 each for Pertussis and Sca- 30 25 bies. Percentage 20 15 • 5 outbreaks for Measles were identified and appropri- 10 ate measures were taken. 5 0 1 3 5 7 9 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 11 13

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

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]. 06 Special Bulletin: DEWS, Pakistan, Week no. 13 (25 to 31 March 2012) Province Punjab: Figure-5: Trend of priority communicable diseases, province Punjab • 408 health facilities from 8 districts reported data to 50 DEWS in Punjab with a total of 212,059 patient con- AD BD ARI S. Malaria sultations. 45 40 • A total of 44 alerts were reported in in this week; Alto- 35 gether 18 for Measles; 12 for Typhoid; 7 for ARI; 2 for 30 AJS; while 1 each for AD, BD, Leishmaniasis, NNT 25 and Scabies. Percentage 20 15 • 3 outbreaks, 2 for Measles; while 1 for Scabies were 10 identified and appropriate measures were taken. 5 0 1 3 5 7 9 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 11 13

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk Province Balochistan: Figure-6: Trend of priority communicable diseases, province Balochistan

• 434 health facilities from 20 districts in Balochistan 50 reported to DEWS, with a total of 72,987 patient con- AD BD ARI S. Malaria 45 sultations. 40 • 27 alerts were reported in week 12 from Balochistan; 35 Altogether 15 for Leishmaniasis; 7 for Measles; 2 for 30 25 ARI; while 1 each for AD, BD and Chicken Pox. Percentage 20 • 1 outbreak for Leishmaniasis was identified and appro- 15 priate measures were taken. 10 5

0 1 3 5 7 9 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 11 51 13

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk

Province Gilgit Baltistan:

Figure-7: Trend of priority communicable diseases, Gilgit Baltistan

50 AD BD ARI S. Malaria • 27 health facilities from 4 districts in Gilgit Baltistan 45 reported to DEWS in week 13, with a total of 13,743 40 patient consultations. 35 30 • 2 alerts, 1 each for Leishmaniasis and Pertussis were 25 received and appropriate measures were taken. Percentage 20 15 10 5 0 1 2 3 4 5 6 7 8 9

48 49 50 51 52 10 11 12 13 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

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk State of Azad Jammu and Kashmir: FATA:

• 146 health facilities from 10 districts reported to DEWS in this • 51 health facilities from 3 agencies reported from FATA in week with a total of 28,654 patient consultations. this week, with a total of 13,746 patient consultations.

• 6 alerts, 3 for Measles; 2 for Pertussis; while 1 for Leishmani- • 7 alerts, 5 for Measles, while2 for NNT were received and asis were received and appropriated measures were taken. appropriate measures were taken.

50 50 AD BD ARI S. Malaria AD BD ARI S. Malaria 40 40

30 30

20 20 Percentage Percentage 10 10

0 0 2 4 6 8 6 8 2 4 6 8

10 12 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk wk