HEALTH CLUSTER Crisis in NWFP

WEEKLY BULLETIN No 12 9 September 2009

HIGHLIGHTS

• The IDP return process continues. Health Cluster partners are moving forward with health interventions in the districts of , Buner, Lower Dir and Upper Dir while continuing to support IDPs who remain in the camps. To date, a total of 235 159 families have returned to their respective districts. (Source: PDMA/PaRRSA.)

• The latest data from the National Database Registration Authority (NADRA) show there has been an influx of returnees in . A total of 17 375 families, including 8281 in D.I. Khan District and 2756 in , have registered. Maternal, neonatal and and child health remains a priority among health interventions in NWFP • An assessment of health facilities in D.I. Khan was completed on 28 August. The report is being finalized and will be shared shortly. An assessment of health facilities in will begin on 13 September.

• Between 22 and 28 August, a total of 69 892 consultations were reported from 226 disease surveillance sentinel sites in NWFP. This represents a 7% decrease compared to the number of consultations registered the previous week.

• Seventeen DEWS sites reported 546 antenatal visits between 22 and 28 August. Data from UNFPA’s seven maternal, neonatal and child health (MNCH) care service delivery points in Lower Dir, Nowshera, Charsadda and districts showed an overall 16% increase in patient consultations in government and in-camp health facilities. However, postnatal consultations decreased from 48 to 35, and deliveries dropped from 18 to 10 at MNCH clinics. These variations in caseload are due to people returning to their home districts during Ramadan and to the increasing number of returnees.

• Eleven out of 34 water samples taken from IDP-hosting districts of Swabi, Mardan, and Nowshera tested positive for faecal coliform contamination. Eighteen out of a second batch of 27 samples tested positive for residual chlorine. The Health Cluster took remedial action, together with WASH partners.

ASSESSMENT • In Swat District, 17 out of 75 health facilities are non-functional as a result of the conflict. These include 13 BHUs, 3 CDs and 1 RHC. Five health facilities are completely destroyed and 21 are partially damaged. (Source: EDO Health.)

MNCH/RH/FP • Seventeen DEWS sites reported 546 antenatal visits between 22 and 28 August. Data from UNFPA’s seven maternal, neonatal and child health (MNCH) care service delivery points in Lower Dir, Nowshera, Charsadda and Mardan districts showed an overall 16% increase in patient consultations in government and in-camp health facilities. However, postnatal consultations decreased from 48 to 35, and deliveries dropped from 18 to 10 at MNCH clinics. These variations in caseload are due to people returning to their home districts during Ramadan and to the increasing number of returnees.

Disease surveillance • Between 22 and 28 August, a total of 69 892 consultations were reported from 226 disease surveillance sentinel sites in NWFP. The number of consultations dropped by 4868, representing a decrease of 7% compared to the number of consultations registered the previous week. As the return programme continues, a decrease in the number of consultations in camps is expected. Consultations included 546 visits for antenatal care, 707 consultations for chronic noncommunicable diseases and 227 consultations for injuries.

The table below shows the type of patient, number of consultations and percentages recorded between 22 and 28 August 2009:

Type of patient Number of consultations Percentage Female 40 277 58% Male 29 615 42% Children under 5 15 808 23%

• The table below shows the leading causes of morbidity among IDPs inside and outside camps. Health facilities in IDP camps reported upper respiratory tract infections as the leading cause of consultations and acute diarrhoea as the second most common cause. Only Benazir Complex IDP camp in Nowshera reported acute diarrhoea as the leading cause of consultation.

Disease surveillance Most common conditions Percentage Acute Respiratory Tract Infection (ARI) • Acute Upper Respiratory tract Infection (URTI) 18% • Acute Lower Respiratory Infection (LRTI) 4% Acute Diarrhoea (AD) 9% Unexplained fever (UF) 4% Scabies (SCB) 5% Suspected malaria (MAL) 2% Bloody diarrhoea (BD) 1%

• Surveillance officers are monitoring reports from health facilities closely. The necessary medical supplies have been prepositioned.

The graph below presents the weekly morbidity pattern of the seven most common communicable diseases reported in IDP-hosting districts in NWFP between 15 and 21 August 2009.

450 URTI LRTI AD SCB MAL UF BD 400 s 350 300

250 consultation

of 200 150

Number 100 50 0 Jalozai ‐3 Jalozai ‐4 Jalozai ‐2 Jalozai ‐1KG‐II KG‐I Karapa Jalala B.Complex Palosa

• Over the last four weeks, the common causes of morbidity and leading causes of death among children under five living in IDP camps were acute diarrhoea and lower respiratory tract infections. There were 15 808 consultations of children under five, of whom 2402 (15%) had acute diarrhoea and 796 (5%) had lower respiratory tract infection. Alerts and outbreaks

• On 5 September, an alert for a suspected H1N1 case was reported from Khyber Teaching Hospital in Peshawar. The 22-year old patient suffered from lower respiratory infection while in Dubai on 26 August and was treated with antibiotics and oseltamivir. The patient was deported from Dubai on 2 September and admitted to the hospital on arrival in Pakistan. Investigations are underway; a nasal swab sample has been sent to NIH for laboratory confirmation. • An increasing number of consultations for scabies have been reported in most IDP camps. Health facilities have been put on alert to intensify hygiene promotion and water and sanitation interventions for the prevention of waterborne and water-related diseases. • Between 22 and 28 August, one alert of suspected smallpox was reported from Lady Reading hospital in Peshawar. While the alert was investigated, the patient underwent treatment. No other suspected cases were found.

Water and sanitation

• Water and sanitation are regularly monitored and evaluated in all IDP camps. Together with WASH partners, the Health Cluster took remedial action on 11 out of 34 water samples that tested positive for faecal coliform contamination and 18 out of 27 samples that tested positive for residual chlorine. The water samples were taken from IDP-hosting districts of Swabi, Mardan, Peshawar and Nowshera. Actions included: o Disconnecting the handpump source in Mohalla, Sodairwala in . o Providing sodium hypochlorite for water chlorination in Kacha Garhi, Peshawar Camp. o Conducting awareness activities in IDP camps on good hygienic practices. Health promotion activities were also conducted in Khat Kallay, . o Chlorinating 11 water sources in Mardan, Peshawar, Swabi and Nowshera.

COORDINATION

Health Cluster, Peshawar The 55th Provincial Health Cluster meeting was held on 3 September 2009 at the office of the Director General of Health in Peshawar. Main points include: • An assessment of health facilities in D.I. Khan was completed on 28 August. An assessment of health facilities in Swat district will begin on 13 September. • A training course on using health assessment tools will be held for Department of Health staff from 11- 12 September. • Health Cluster partners were asked to verify IDP populations in host areas to allow proper planning of follow-through health activities. • The Director of Health Services asked health partners to avoid duplication of services in urban areas and extend services to remote areas, particularly those in .

Who does what, where? The map "Who Does What, Where", updated as of 9 September, is attached.

FILLING GAPS

Care International continues to operate its mobile medical cllinics in Buner and Mardan. Between 31 August and 6 September, a total of 711 patients were treated in four medical clinics conducted in three Union Councils of Buner (Makhrani, Koga and Elai). In Mardan, a total of 648 patients were treated at mobile medical clinics in three Union Councils (Patbaba, Taker and Tehsil Takbahi).

Cordaid is continuing its primary health care services, referral services and health education campaigns through nine BHUs and one CD in . Between 31 August and 4 September, Cordaid's health teams conducted 10 medical clinics and treated 967 patients.

Community Appraisal and Motivation Programme (CAMP) is supporting the primary health care needs of women and children in Jalozai camp. Four mobile teams are providing primary health care services in all sub- camps of District Peshawar in order to reach out to IDPs in host communities. The mobile health units are equipped with all necessary equipment and medicines to meet the requirements of the IDP population. The CAMP mobile health teams operate around the clock and offer referral services to secondary and tertiary health facilities.

Health Net TPO, in collaboration with the Malaria Control Programme, has completed spraying campaigns in Kacha Ghari 1,2 and Jalozai. Currently, it is conducting malaria prevention awareness-raising activities in Palowsai, Kacha Ghari and Jalozai camps.

USAID-Paiman donated five ambulances to NWFP’s Department of Health on 5 August. The ambulances will be used in Mardan, Charsadda and Buner. The handover ceremony was attended by the Secretary Health of NFWP, the Mission Director of USAID, Dr Nabeela, Chief of Party-PAIMAN, EDO-H Mardan, Charsadda and Buner, and DCO Charsadda.

Church World Service is providing health services and free medicines to IDPs in District Swabi, Mansehra and Abbotabad. Between 31 August and 7 September, CWS provided services to 618 IDPs. CWS's mobile health unit focuses on providing mother and child health services. During the week of 31 August, CWS provided medical services to three antenatal patients and 116 children under five years of age through its mobile health services in Swabi, Mansehra and Abbotabad.

International Media Corps is providing comprehensive primary health care services, including health education, MCH and referral services, in BHUs Ghagra and Cheena, RHC Deewanababa and DHQ Daggar in . In Swat district, IMC is providing health care services in RHC Khazana and BHU Manyar. Two IMC mobile medical units are providing health care to IDPs living with host communities in Charsadda district. Another four IMC mobile medical units are providing services to IDPs living with host families in Swabi District.

Islamic Relief is supporting static and mobile health facilities in five Union Councils of Mardan (Rustum, Machi, Katakhat, Bakshali and Chargulli) through its five mobile health teams. To date, 2595 patients have been treated and provided with the necessary medical supplies.

Malteser International is providing relief assistance to IDPs in Mardan and returnees in Swat district through the donation of comprehensive hygiene kits. Malteser’s aim is to infuse good hygiene practices among IDPs (both returnees and host families). Good hygiene helps prevent risks from major seasonal communicable diseases. So far, 500 IDP and host families in Mardan District have been assisted. Another 3500 hygiene kits are being distributed to returnee families in Swat district.

Malteser International launched its Early Recovery health support project in Swat district on 1 August. The project will initially focus on returnees and the resident population in three Union Councils (Kokarai, Islampur and Nawakalay). Following a decision made during the recent Health Cluster coordination meeting in Swat, Malteser International has also been given responsibility for strengthening health-service delivery in BHU Meragai (Kokarai UC), BHU Islampur and CD Citar/ Chewetar (both in Islampur UC).

Save the Children’s emergency medical teams have treated 5051 patients through a combination of 14 mobile health teams and static health facilities in Swabi, Mardan, Buner, and Swat.

With the continuing return of displaced families to their places of origin, Save the Children is shifting its focus of operations from areas of displacement (Swabi and Mardan) to areas of return (Buner and Swat). Skin infections (particularly scabies), diarrhoea and acute respiratory infections are the most common ailments treated.

UNFPA continues to provide comprehensive reproductive health care services at seven MNCH service delivery points in Lower Dir, Nowshehra, Charsadda and Mardan districts. A total of 1613 patients have consulted at the health centres in three districts (Lower Dir, Mardan and Nowshehra) including three in-camp facilities and four static existing health care facilities. Health care services provided include 10 deliveries, 218 prenatal consultations, 35 postnatal consultations, 67 family planning consultations and 542 consultations for other minor general outpatient services.

WHO is providing continuous support to district health authorities, implementing partners and health partners. Between 31 August and 7 September, WHO donated one mini-emergency health kit (MEHK) to Save the Children's operations in Buner and three MEHKs to Merlin for its Jalozai and Mardan health facilities. In response to the increased number of acute watery diarrhoea cases, WHO donated two cholera kits to Swat and one cholera kit to MS Saidu Sharif hospital. In addition, WHO is procuring 2000 bottles of calamine lotion to help prevent acute skin infections among IDPs in Kacha Gari and Jalozai camps.

On 1 September, WHO trained 14 staff of the Frontier Primary Health Care (FPHC) mobile health teams on DEWS. On 2 September, WHO trained another seven medical staff from IDEA (an implementing partner of Care International) on DEWS. FPHC mobile health teams serve in flood-affected areas in Mardan and at an Afghan refugee camp. IDEA mobile teams provide health services in Takhtbai and Buner.

Urgent needs: To date, there is still a shortage of female health care providers for health facilities in returnees' districts. Tough security conditions remain an obstacle to providing health care services in these districts.

As the number of IDPs accelerate, the DEWS in the districts of return, particularly Swat and Buner, needs to be implemented immediately.

Funding situation As of 8 September, the Health Cluster has received 32% of funds required as presented in the UN Pakistan Humanitarian Response Plan (Revision) document. (Needs identified: US$42 065 870. Funds available: US$13 534 884.) (Source: OCHA Pakistan, 9 September)

Communication and advocacy activities Efforts are being made to raise the visibility of the health response to the crisis through: • Distribution of NWFP crisis intervention brochure • Pakistan health in photos • Production and distribution of Health Cluster bulletins • Packaging of disease surveillance film for distribution • Updating of health cluster website • Production of NWFP crisis slide show

Web links:

WHO HQ: http://www.who.int/hac/crises/pak/en/index.html Health Cluster Pakistan: http://www.whopak.org/idps Provincial Relief Commissionerate: http://www.helpidp.org Pakistan MoH: http://www.health.gov.pk WHO EMRO: http://www.emro.who.int/eha/pakistan Relief Web FTS: http://ocha.unog.ch/fts/pageloader.aspx

Contacts: For further information please contact:

WHO Pakistan Country Office Dr Khalif Bile Mohamud WHO Country Representative to Pakistan e-mail: [email protected]

WHO Regional Office for the Eastern Mediterranean Dr Irshad Shaikh EHA Regional Adviser e-mail: [email protected] tel.: + (202) 2276 5525 mobile: + (201) 01733924 http://www.emro.who.int/eha/

WHO Headquarters Mr Paul Garwood Communications Officer Health Action in Crises e-mail: [email protected] tel. +41 22 791 3462 mobile: +41 79 475 5546 www.who.int/disasters Acronyms

AWD: Acute Watery Diarrhoea ACD: Association for Community Development BHU: Basic Health Unit CD: Civil Dispensary CERD: Centre for Excellence for Rural Development DART: Disaster Assistance Response Team DEWS: Disease Early Warring System DHQ: District Headquarter DTC: Diarrhoea Treatment Centre DSM: District Support Manager EDO: Executive District Officer EMRO: Eastern Mediterranean Regional Office ERU: Emergency Response Unit FP: Family Planning IEHK: Inter-agency Emergency Health Kit HRDS: Human Resource Development Society HTH: High test Hypochlorite INGOs: International Nongovernmental Organizations LHV: Lady Health Visitor LHW: Lady Health Worker LSS: Logistic Support System MCHC: Maternal Child and Health Centre MEHK: Mini Emergency Health Kit MMT: Mobile Medical Team NIH: National Institute of Health MNCH: Maternal, Neonatal and Child Health NWFP: North West Frontier Province MSU: Mobile Service Unit OFDA: Office of Foreign Disaster Assistance ORS: Oral Rehydration Salts ORT: Oral Rehydration Treatment PaRRSA: Provincial Relief, rehabilitation and Settlement Authority PHRP: Pakistan Humanitarian Response Plan PIPOS: Pakistan Institute of Orthotics and Prosthetics Sciences, PPE: Personal Protective Equipment PPHI: People's Primary Healthcare Initiative PRC: Provincial Relief Commissionerate PRCS: Pakistan Red Crescent Society PWDs: Persons With Disabilities RH: Reproductive Health RHC: Rural Health Centre THQ: Tehsil Headquarter WMO: Woman Medical Officer Pakistan: Who is doing What and Where (health sector)- North West Frontier Province

Turkmenistan Tajikistan Tajikistan China F.A.N.A. Q No of persons: 3,604 Kohistan Afghanistan Organizations working: P.A.K. Aksai Chin Samar Bagh N.W.F.P. Al-khidmat Foundation Afghanistan Disputed Area National program, WHO F.A . T. A . Satbar Q Kallay Upper Dir Kohistan China/India No of persons: 3,063 China Organizations working: Batagram Organizations working: PUNJAB UNFPA, National program Timergara No of persons: 4,596 IMC WHO Q Lower Q Dir Organizations working: Munda Q PRCS/ ICRC, National Program Swat Shangla BALOCHISTAN Wali Kandaw Q Al-khidmat Foundation, WHO Iran (Islamic Republic of) India Khungi No of persons: 3,345 SINDH Bajaur Agency Organizations working: National Program, WHO Chitor Maragai Batagram No of persons: 2,970 !(!( !( Organizations working: Islampur No of persons: 2,295 National Program, WHO Batagram Organizations working: National Program, WHO Sr. No. District Name of IDP camp Static Clinics NGOs Working 1 Kacha Garhi 1 2 Merlin, CERD Peshawar 2 Kacha Garhi 2 2 Merlin, CERD 3 Charsadda Palosa1 2 IMC-WHO, DoH 4 Benazir complex risalpur 1 PRCS Nowshera 5 Jalozai 1, 2, 3, 4 4 Merlin, CAMP-WHO Rangmala Piran 6 Mardan Jalala 1 Merlin Q Organizations working: Total 12 IMC Malakand PA No of persons: Data not available Mansehra Organizations working: ICRC, National program, WHO Buner Mohmand Agency Legend

!( Locations of Malteser International Jalala Q No of persons: 1,818 Mardan IDP Camps and origin of IDPs Organizations working: Merlin, UNFPA, WHO Q Bajaur/ Mohmand Charsadda Q Bajaur/ Mohmand/ Swat Q Swat/ Buner/ Dir No of persons: 2,701 Palosa 1 Organizations working: Khyber Agency Q IMC, UNICEF, National program Neighbour country Hashoo Foundation, WHO No of persons: 5,466 Benazir Complex Swabi District boundary Organizations working: Q No of persons: 1,745 Haripur Kacha Garhi 2 Merlin, UNICEF, CERD Other Districts Organizations working: Q National program, EDHI, WHO Kacha Garhi 1 PRCS, UNICEF Q National program, WHO IDP Hosting Districts Peshawar Nowshera Military Operation in process No of persons: 8,850 Jalozai 1, 2, 3 Organizations working: Q No of persons: 91,594 Military Operation in some areas Merlin, UNICEF, CERD Organizations working: National program, EDHI, WHO Khyber Agency Merlin, UNICEF, EDHI, CAMP Attock Military Operation completed National program, WHO

Tribal Area Peshawar Rawalpindi

Produced by: Information Management Unit, WHO-Pakistan Date created: September 14, 2009 WHO Map Num: WHO-Flood-226 04812162 Scale: 1:551,051 Source: HIC, WHO The boundaries, names and the designation used on this map do not imply official endorsement or Population Data Source: Commissionerate Afghan Refugee Kilometers 1 inch equals 14 kilometers acceptance by the United Nations. Dated: September 02, 2009 . World Health Organization, Chak Shehzad, NIH Premises, Park Road, Islamabad. Email: [email protected] Website: http://www.whopak.org