DEWS WEEKLY EPIDEMIOLOGICAL REPORT EPREPORT SUMMARY:  This Report Includes Surveillance Data from 4Th July to 10Th August 2012

August 13, 2012 DISEASES EARLY WARNING SYSTEM WER-32(6th Yr)

DEWS WEEKLY EPIDEMIOLOGICAL REPORT EPREPORT SUMMARY:  This report includes surveillance data from 4th July to 10th August 2012.  Out of 312 functional Sentinel sites(SS), all 312 (100%) have sent their reports in Week-32 of 2012;  Out of total 274,261 Consultations recorded in week-32 of 2012, 90,745 (33.1%) consultations were reported due

to DEWS target diseases.

 Main causes of consultations this week are Acute Respiratory Infections/ARI (13.6%) and Acute Diarrheal Diseases/ADD (17.6%) from total clients in a continuing trend from the week before.  52 deaths caused due to Pneumonia, Diarrheal diseases and Meningitis/Severely ill children, so that 19 deaths due to pneumonia, 20 deaths due to diarrheal diseases and 13 deaths reported due to Meningitis and Severely Ill Children.  In this reporting week, three Measles outbreaks reported and investigated in Laghman, Zabul and Urozgan provinces. No other outbreaks have been reported in this reporting week.

REPORTS RECEIVED FROM REPORTING SITES: As of August 10, 2012, 312 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of Afghanistan . In this reporting week, all 312 sentinel sites have sent their reports on new cases of DEWS target diseases , recorded during the reporting. 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-32, 2012

Central Central East Central West North North East West South East South East Total No. of Expected Reports from 53 30 49 37 34 38 37 34 312 Sentinel Sites No. of Reports Received in this 53 30 49 37 34 38 37 34 312 week

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

of DEWS sentinel sites, already Week-32, 2012

established in the relevant

Type of regions/provinces by August 10, 2012

alEast Centr al West North North East West South East South East Total by type of health facilities. Data on15 Centr DEWS target diseases are being CHC/BHC 25 19 34 26 20 29 27 26 206 collected from these sentinel sites DH 12 7 10 7 9 4 7 4 60 (SS).The symbols on the map show PH/RH/SH 14 4 5 4 4 5 3 4 43 the number of sentinel sites in each region/province, and do not indicating Poly Clinic 2 0 0 0 1 0 0 0 3 the GPS of the SS locations. Total 53 30 49 37 34 38 37 34 312 DEWS Data in Epidemiological CHC=Comprehensive Health Center, DH=District hospital, PH=provincial Week-32 of 2012 hospital, RH= Regional hospital, SH= specialized hospital Ut of total 274,261 clients recorded in week-32 of 2012, 11.9% (32505) of consultations were reported Fig-2: Percentages of DEWS Target O due to cough and cold and 1.8% (4808) of 30.0% Diseases by age Group in W32 of 2012 consultations was reported due to pneumonia. In the same 25.0% reporting period, 17.6% or 48,287 events were reported due to 20.0% diarrheal illnesses (13.4% due to Acute Watery Diarrhea, 2.7% 15.0% due to Bloody Diarrhea and 1.5% due to acute watery diarrhea 10.0% with dehydration). In comparison with previous week (W31 of 5.0% 2012) the percentage of ARI diseases has decreased by 0.3% 0.0% ARI ARI AwD Men AVH Meas Mala Typh to13.6%, whereas the percentage of Acute Diarrheal diseases AwD BD increased by 0.3% to 17.6%. These variations could be C&C Pn w /SIC ep le ria Fev occurred due to changes in temperature /weather during the U5% 16.4% 3.7% 27.2% 4.1% 3.1% 0.1% 0.1% 0.2% 1.0% 0.5% reporting week.Figure-2 above shows the percentages of O5% 9.7% 0.8% 6.9% 2.0% 0.8% 0.0% 0.1% 0.0% 0.8% 0.9% DEWS target diseases by age groups in week-32 of 2012. Tot% 11.9% 1.8% 13.4% 2.7% 1.5% 0.1% 0.1% 0.1% 0.9% 0.8%

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Percentage of ARI by weeks and by Age Groups In the epidemiological week-32, a total of 37,313 events of ARI were reported.16.4 % of total clients less than 5 years of age were cough & Cold patients and 9.7% 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 22-12 23-12 24-12 25-12 26-12 27-12 28-12 29-12 30-12 31-12 32-12 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 Yr. 22.6 20.7 19.8 18 17.4 16.6 16.6 16.5 16.8 17.3 16.4 5+ 12.4 11.9 11.4 10.7 10.3 10.0 9.5 9.6 10.0 9.7 9.7 ARI- <5 Yr. 5.9 5.8 5.0 4.8 4.6 4.1 4.2 4.0 3.9 3.9 3.7 Pneumonia >=5 Yr 1.2 1.1 1.2 1.1 1.0 1.0 1.0 1.0 0.9 0.9 0.8 consultations in week-22,in comparison with the percentage of C&C in week-32 of 2012, decreased by 6.2%, whereas in case of 5 years and above decreased by 2.7% to 9.7% in this reporting week. The trend of ARI diseases in last 11 weeks can be read in table-4.The percentages of consultations on Pneumonia cases of age group less than 5 years decreased by 2.2% in last 11 weeks, whereas the percentage of age group 5 years and over decreased by 0.4% to 0.8% in last 11 weeks. n the reporting week-32 of 2012, the highest percentage of Cough & Cold has been recorded in Kunar and Nuristan provinces with 19% and 18% respectively, whereas the lowest percentages of C&C were reported from Farah and I Uruzgan provinces with 6% and 7% respectively. The highest percentages of Pneumonia cases reported from Jawzjan and Sar-i-pul provinces with 6% and 5%, whereas the lowest percentage of Pneumonia cases was recorded in Zabul and Uruzgan provinces with 0.00%(almost Zero) and 0.3% respectively. (Fig-3) 30% Fig-3: Percentages of ARI from Total Clients in week-32 of 2012

20%

10%

0% BA DA GH HE JO KA KH LO NA SA WA BD GH PA NI UR KN NU BDS BAL FYB HEL KDZ PKA PIA PAR SAR TAK ZABKABBGL FRA KAP LAG M Y A R W N O G N M R G O N M U R R Pneumonia 1% 2% 2% 1% 2% 1% 1% 0% 6% 1% 2% 1% 1% 2% 1% 1% 2% 2% 5% 2% 3% 0% 2% 3% 1% 0% 1% 1% 2% 1% 0% 3% 2% 3% Cough&Cold 10%13%15%14%13% 9% 8% 14%10% 9% 17%14%17%15%13%14% 9% 11%11%11%14% 8% 9% 11%13% 6% 8% 17%13% 9% 7% 19%10%18%

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 22-12 23-12 24-12 25-12 26-12 27-12 28-12 29-12 30-12 31-12 32-12 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 19.2 21.0 23.0 23.8 24.7 25.9 25.9 25.0 27.5 27.1 27.2 Diarrhea >= 5 Years 5.4 5.2 5.7 6.4 6.4 6.7 7.0 6.7 7.4 7.0 6.9 Bloody Diarrhea <5 Years 3.5 3.4 3.9 3.9 3.7 3.9 4.1 3.9 4.1 4.1 4.1 >=5 Years 1.6 1.6 1.9 1.9 1.9 1.9 1.9 2.0 2.0 2.0 2.0 Acute W. Diarrhea <5 Years 2.4 2.8 2.5 3 2.9 3.4 3.2 3.1 2.8 2.9 3.1 with Dehydration ≥5 Years 0.6 0.7 0.6 0.7 0.7 0.8 0.8 0.7 0.7 0.6 0.8 diarrhea with dehydration) from week-22 to week-32 of 2012, from total clients. Acute watery diarrhea among children less than five years has been increased from19.2% in week-22 to 27.2% in the reporting week, whereas acute watery diarrhea among age group 5 years and above has increased by 1.5% to 6.9%.(Please refer to Table-5, above).Bloody diarrhea, in age group less than 5 years increased by 0.6% in last 11 weeks, while in case of age group 5 years and above increased by 0.4% in the same period. Acute watery diarrhea with dehydration in age group less than 5 years increased by 0.7% and in case of five years and above increased by 0.2% in last 11 weeks.

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30% Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-32 of 25% 2012 AWDwD BD AWD 20%

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 3.5%Fig -5: Percentages of Men/SIC Malaria & Typhoid Fever from Total Clients in Week-32 of 2012 by Region Percentages of suspected Meningitis/SIC, 3.0% Malaria and Typhoid Fever by Region: 2.5% n the epidemiologic week-32 of 2012, a total of 2.0% 162 suspected cases of Meningitis/Sever Ill Child 1.5% I were reported from all regions and the highest percentage was recorded in North region. In the same 1.0% reporting week, from all regions 2457 consultations 0.5% were reported by Sentinel Sites to be malaria and the 0.0% highest percentage of Malaria cases were reported NER NR CWR WR CER SR ER SER from East region with 3.1%. Out of the total clients, Men/SIC 0.1% 0.1% 0.1% 0.1% 0.0% 0.0% 0.0% 0.0% 1646 cases or 0.8% in national level were reported to Malaria 0.5% 0.4% 0.3% 0.1% 0.2% 0.7% 3.1% 2.0% be suspected Typhoid Fever and the highest Typhoid Fev 0.7% 0.8% 0.6% 0.4% 0.3% 1.4% 1.0% 1.2% percentage of Typhoid Fever was reported from South region with 1.4% and followed by South East region with 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 Table-5: Suspected Cases of Vaccine Preventable Meningitis/severely ill child is being Diseases in W32 of 2012 by Region

reported mostly from North region; in this

week out of total 162 cases in country level52(32%) cases have been reported Regions

from North region and 25 cases were

Viral

Sever Ill Ill Sever Child Hepatitis Measles Pertussis Diphtheria Tetanus Natal /New Tetanus Acute Flaccid Paralysis recorded in North East region. Meningitis/ In general the highest number of cases of North East 25 16 12 12 0 0 0 Acute viral hepatitis being reported from North 52 9 10 2 0 0 1 East, south East and North east regions, so Central West 11 17 13 0 0 0 1 that in the reporting week out of total 212 West 24 6 0 0 0 0 1 cases, 97 cases reported from East, 37 from Central East, and 19 cases from South East Central East 23 37 60 0 0 0 2 region were reported. From total 217 South 10 11 24 3 0 0 6 Measles cases reported in the reporting East 12 97 64 0 0 0 0 week 60% of cases were recorded in East South East 5 19 34 0 0 0 1 and Central East regions. Total 162 212 217 17 0 0 12

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Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks(from W22 of 2011 to W32 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-32 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 2011these 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-31, ARI slightly decreased by 0.3% to13.6%, while the percentage of ADD increased by 0.3% to 17.6%.

35 Fig-6: Trend of ARI/ADD as Propotion of Total Clients From Week-22 of 2011 to Week-32 of 2012 30 ARI 31.2 30.5 31.530.8 30.5 29.529.9 29.9 P 29.328.9 ADD 28.1 28 25 26.926.8 e 26.1 25.7 25.3 r 24.4 23.2 c 22 22.5 22.4 20 21.8 21.521.7 18.1 17.7 17.6 16.8 17.1 20.7 20.9 16.816.8 17.3 16.2 16.1 16.2 16.1 20 20.1 16.5 e 15.8 16 15.9 15.8 15.8 19.919.5 17.115.7 15.7 15.315.5 15 18.8 14.1 17.9 16.3 n 13.5 13.3 17.6 15 12.416.3 t 14.9 15.4 11.1 11.4 14.715.2 14.3 10.610.7 14.6 13.813.9 13.6 13.8 10.110.1 14.013.6 13.7 14.0 13.9 13.6 a 13.4 13 13.212.9 13.4 9.2 12.9 13.5 12.812.4 12.8 12.8 8.5 8.5 8.6 9.0 10 11.5 8.2 g 7 7.3 7.2 6.6 6.2 6.3 5.7 5.5 5.5 5.6 e 4.9 4.9 4.6 4.7 4.7 4.9 4.5 4.3 4.4 4.2 4.0 4.4 s 5

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 W32 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 3 3 0 2 5 3 2 1 19 general more than Diarrheal 95% of total deaths Diseases 5 7 0 4 3 0 0 1 20 of surveillance target Meningitis/SIC diseases. Usually 2 4 1 2 0 4 0 0 13 deaths due to Total diarrheal diseases 10 14 1 8 8 7 2 2 52 increases during summer season, while the number of deaths due to Pneumonia increases during cold period/Winter Season. In this week out of 52 deaths reported from all regions, 19 deaths caused by Pneumonia, 20 deaths caused by diarrheal diseases and 13 deaths were caused by Meningitis/severely ill children. (Table-7) Number of Outbreaks investigated in 2012 with details of W31/W32

Reported outbreaks since first week of 2012 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 24 3 21 Avian/Swine Flu ARI 7 7 Measles 175 7 168 Diarrhea 4 4 Meningitis Hepatitis 2 2 Malaria Typhoid 1 1 CCHF 11 11 Bl. Diarrhea 2 2 Chickenpox 1 1 Other 43 2 41 Total 271 12 259 Epidemiological week-31  Suspected Measles Outbreak: reported from Zadran village of Sharana district of Paktika province on July 29 /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 cholera Outbreak: reported from Kokjar village of Hazart-i-sultan district of Samangan province on August 01 /2012, the team investigated the area on the same day and during the investigation there were two suspected cholera case with no death , the team collected

the specimens and send it to CPHL , the case treated and the health education session conducted in surrounding villages, the team is investigating for further cases.  Suspected Measles Outbreak: reported from Potai village of Tarinkot district of Urozgan province on July 27 /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  Suspected Measles Outbreak: reported from Nahia chahar of Tarinkot district of Urozgan province on July 28 /2012, the team investigated the area on the following day and during the investigation there were 11 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  CCHF outbreak: : reported from Dara Takht village of Chasht sharif district of Hirat province on July 26 /2012, the team investigated the area on the same day and during the investigation there was one suspected CCHF case , the team collected the specimens and send it to CPHL, the result was positive , the cases treated , the team is investigating for further cases  CCHF outbreak: : reported from Laman village of Qala Naw district of Badghias province on July 26 /2012, the team investigated the area on the same day and during the investigation there was one suspected CCHF case , the team collected the specimens and send it to CPHL ,the result was positive , the cases treated , the team is investigating for further cases Epidemiological week-32  Suspected Measles Outbreak: reported from Haji Qadir village of Qalat district of Zabul province on August 04 /2012, the team investigated the area on the same day and during the investigation there were 11 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 outbreak is controlled .  Suspected Measles Outbreak: reported from Shah Zafar of Tarinkot district of Urozgan province on August 07 /2012, the team investigated the area on the following day and during the investigation there were 17 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 Shahri Naw of Mehthlam city of Laghman province on August 09 /2012, the team investigated the area on the same day and during the investigation there were 7 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-32 of 2012 by Province