Floods in Pakistan Pakistan Health Cluster Bulletin No 7 6 August 2010

Highlights

Sanitary conditions in Nowshera and Charsadda districts are alarming, with thousands of dead animals lying in pools of stagnant water that provide a breeding ground for flies and mosquitoes.

Access to safe drinking water is the biggest health risk. Groundwater sources have been submerged and surface water contaminated by the floodwaters.

WHO with its Health Cluster partners has distributed 144 cholera kits, 129 emergency kits, 3 surgical supply kits, 750 anti snake venom and 1 500 hygiene kits These kits will cover the needs of around 800 000 people for one month.

Daily disease surveillance reports have been received from 114 health facilities in eight flood-affected districts in Khyber Pakhtunkhwa (KPK), Punjab and Baluchistan. An alert for suspected acute watery diarrhoea (AWD) was reported from Civil Hospital Pachakalay in District Buner. A second AWD alert was reported from Chendangari village in FR Peshawar. The total number of cases from Chendangari village has reached 70.

In KPK, the three leading diseases reported through the disease early warning system (DEWS) are acute diarrhoea, scabies and acute respiratory tract infection.

A man looks at damaged homes in an Afghan refugee area in Nowshera district. Photo by H. Ali/WHO

Situation overview and current scope of disaster

According to the United Nations Office for the Coordination of Humanitarian Affairs, over 4 million people have been affected by the flood. The latest National Disaster Management Authority (NDMA) figures show that the number of deaths has reached 1 002. A total of 263 590 houses have been damaged.

An emergency has been declared in Northern Sindh on 6 and 7 August, as huge amounts of water rush through Indus River, particularly between Ghotki and Kashmore districts. Over 350 000 people have been moved to safer places. On 6 August, torrential rains hampered evacuation efforts and the movement of relief supplies. According to the early warning flood telemetry system, more than 8 million cubic metres of water per second will pass through the province in the next 24 hours.

In Punjab, the districts of Muzzafargarh, DG Khan, Layyah, Rajanpur and Rahim Yar Khan are the worst affected districts in the southern part of the province, while the districts of Mianwali and Khushab in the north-west are also badly affected. Water levels in the Indus in southern Punjab are receding but remain critically high. A total of 48 relief camps have been established in the districts of Bhakkar, Dera Ghazi Khan, Khusab and Mianwali.

In Balochistan, people from Trehar and Tehdi were evacuated to Lehri town due to heavy rains. With the exception of Lehri town, the whole of Lehri Tehsil is badly affected.

Health situation/ alerts and outbreak

KPK

On 5August 2010, daily disease surveillance reports were received from 114 health facilities from eight flood-affected districts in KPK. The health facilities reported a total of 31 652 patient consultations through the DEWS. Acute diarrhoea (AD) accounted for 14% of patient visits in all age groups (4589 cases). Scabies accounted for 23% of consultations (7 301 cases). Acute respiratory tract infections (ARI) were the third most common cause of consultations (12% of visits, or 3845 cases). The table below reflects the daily number of cases reported from flood-affected districts in KPK.

Distribution of daily patient visits by priority diseases in the flood affected districts Khyber Pakhtunkhwa

Disease / condition 31 July 2 Aug 3 Aug 4 Aug 5 Aug Total Acute diarrhoea 337 1978 2277 820 4589 10001 Acute jaundice syndrome 9 1 5 15 Bloody diarrhoea 59 22 70 51 112 314 Upper respiratory tract infection 276 737 1528 881 3447 6869 Lower respiratory tract infection 34 179 109 221 398 941 Malaria 28 75 222 49 374 Scabies 150 2603 4130 635 7301 14819 Unexplained Fever 125 945 1122 164 1836 4192 Injuries 71 111 182 Others 1056 7503 8800 2971 13804 34134 Grand Total 2037 14004 18111 6037 31652 71841

DEWS is functional in all flood affected districts in KPK, and acute diarrhoea trends are monitored on a weekly basis. On the onset of floods, acute diarrhoea accounted for between 11% and 13% of total patient visits at health facilities. This weekly trend is used as the baseline to monitor the diarrhoea situation in the flood-affected districts. The figure below shows the weekly trend of acute diarrhoea in 2009 and 2010 (until epidemiological week 29 which ended on 23 July).

Both mobile medical teams and fixed health facilities have begun daily reporting on priority communicable diseases. The daily trend of acute diarrhoea in flood-affected districts fluctuates between 13% and 14% of total patient consultations, as shown in the graph below.

Daily trend of acute diarrhoea flood affected districts KPK

Two alerts for acute watery diarrhoea outbreaks were reported (one from Civil Hospital Pachakalay, District Buner on 3 August and another from Chendangari village of Frontier Peshawar). The total number of cases has reached 70 patients. To date, the area is inaccessible due to security issues. Executive District Officer - Health is responding to the alert.

Weekly pattern of acute diarrhea, IDP crisis and hosting districts, Khayber Pakhtunkhwa (2009-2010) 15 2009 2010 13

11

9

Percentage 7

5

3

1

1 2 3 4 5 6 7 8 9

10 11 12 13 14 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 48 49 50 51 52 Epi-week

Punjab Province Daily disease surveillance has also been initiated in the flood-affected districts of Punjab. Of the total patient visits, 13% were cases of skin diseases and 8% were acute diarrhoea. A total of 28 dog and four snake bites were also reported.

Number of cases by diseases in the affected districts of Punjab, 5 August 2010 Skin Dog Snake Other District RTI Injuries disease POU Bite Bite AWD Diseases Total Bhakkar 512 0 170 0 0 0 103 781 1 566 Gujrat 0 0 0 5 0 0 4 0 9 Hafizabad 0 0 57 19 13 0 22 0 111 Lahore 138 0 40 21 2 0 67 4 272 Mianwali 1 911 1 751 2 604 0 0 0 1 533 3 161 10 960 Muzafargarh 209 2 316 1 291 2 0 612 2 533 4 965 Nankana Sb. 0 0 0 0 10 2 58 0 70 R.Yar Khan 0 0 0 38 0 0 11 139 188 Rajanpur 0 0 0 0 1 2 0 2 597 2 600 Sialkot 0 18 199 16 0 0 72 297 602 Sargoda 1 270 824 1 108 0 0 0 424 2 750 6 376 TOTAL 4 040 2 595 4 494 1 390 28 4 2 906 18 821 34 278 12% 8% 13% 4% 0% 0% 8% 55% Percentage

The graph below shows the distribution of patient visits by disease vis-à-vis the percentage of patient consultations in the flood-affected districts in Punjab (5 August 2010).

RTI 12% RTI

Injuries Injuries 8%

Skin infection

Skin infection POU 13% Dog Bite Others 55% Snake Bite POU 4% AWD

Snake Bite Dog Bite Others 0% AWD 0% 8%

Health impact

The environmental health situation in Nowshera and Charsadda in KPK is very poor, with pools of stagnant water and dead animals everywhere. The following issues were identified during the assessment:

More than 20 000 families living in spontaneous, overcrowded IDP camps need to be relocated to properly planned and sited camps where proper support to meet their basic needs can be provided. Access to safe drinking water is the biggest health risk facing affected communities, since groundwater sources have been submerged and surface water has been contaminated by the floodwater. Most people have no choice but to use flood water for drinking purposes, as all the water supply systems and hand pumps are out of order. The stagnant water provides a breeding ground for flies and mosquitoes. There are very few functional latrines for the affected communities; most latrines are full and/or submerged. There are no pit latrines in IDP areas: most people are defecating in the flood water, and using the same water for drinking and bathing. The floods have swept away pots, pans, kitchen utensils, beds and bedding and other household items, leaving many people with without the basic necessities. The incidence of water-borne diseases and malaria is likely to increase as the floodwaters recede and stagnate.

Most districts assessed have not experienced immediate adverse health effects because of the floods. However, the situation is likely to change once the water recedes and stagnates. Health staff may be overwhelmed by the anticipated increase in disease outbreaks. As of today, people in camps in Nowshera and Charsadda are not able to access health facilities.

The Medical Superintendent of Nowshera district hospital emphasized, during the assessment, that the hospital, which used to provide basic health services to more than one million people, was severely damaged by the floods. He added that, with pledges from health partners, the facility can soon be rehabilitated.

Health cluster response

American Refuge Committee is supporting seven health facilities in Swat district, where 237 people have been treated. In Baluchistan, the organization is supporting five health facilities and has treated 515 patients.

Care International is supporting flood affected people through four health facilities in Upper Swat district and 14 Mobile clinics in the area. Care International has treated 3800 people on 6 August.

CERD conducted 400 consultations in Nowshera district through a mobile team and distributed 400 face wash soaps, 200 laundry soaps and oral rehydration salts.

Church World Service has conducted an average of 500 daily consultations in the last three days in Tehsil kabal, Charbagh and Matta in Swat district. In Mansehra, the organization has conducted 150 consultations in Tehsil Headquarter Hospital Balakaot and treated 175 patients through a mobile clinic.

International Medical Corps (IMC) is supporting a mobile medical unit at Government Higher Secondary School No. 1 in Peshawar City, where 2100 flood affectees are residing. IMC has treated 375 patients and supporting referral services through ambulances.

Johanniter International is supporting Charsadda district through two mobile units. The organization treated 458 patients on 5 August.

Merlin continued its health activities, and has treated 3070 patients through 11 mobile teams in Nowshera, Buner and Swat district of KPK. Merlin is supporting health units in 28 static clinics (12 in Swat, 10 in Buner and six in Jalozai). It is also supporting three mobile teams ( Buner) in 27 static clinics ( 11 in Swat, 10 in Buner and six in Jalozai). It has another 13 mobile teams (six in Swat, three in Buner and four in Nowshera). Merlin mobile medical teams were airlifted to remote areas in upper Swat today.

Pakistan Red Cross Society, with the support of the German Red Cross, is providing health services in four basic health units (BHUs) in district Shangla (BHU Damorai, BHU Olander, BHU Chichloo and BHU Shang) and 3 BHUs in District Kohistan (BHU Doga, BHU Seo and BHU Razika). In District Nowshera, two mobile health units are operating in two areas (Pashtoon Garhi (Pabbi) and Abakhail (Nowshera Kalan)), where they will remain for two months. In Pushtoon Garhi, a total of 138 consultations were recorded (36 females and 102 males). Skin infections, diarrhoea, scabies, and minor injuries were the most common cause of consultation. In Abakhail a total of 232 consultations were held on 5 August (57 females and 175 males).

Save the Children conducted 2 700 consultations at five health facilities in Swat, DI Khan and Buner on 5 August 2010. Two ambulances have been deployed from Buner to Swat district to assist in the relief and rescue efforts.

UNFPA is continuing to support maternal-neonatal child health services through 10 health facilities in Swat, Kohat Hangu, Lower Dir, DI Khan and Tank. UNFPA has deployed a mobile health unit with female medical officers to provide health services in Nowshera District. It has also provided 600 delivery kits, 8 000 sachets of oral rehydration salts and 1 000 scabies treatment solutions to the Department of Health in D.I. Khan and Tank districts of KPK. The organization is now supporting primary and reproductive health care services in seven districts in KPK, two in Sindh and one in Punjab.

On 6 August, the World Health Organization (WHO) air transported three emergency health kits (enough to meet the basic health needs of 18 000 individuals for one month) to the District Coordination Officer in Upper Dir. WHO dispatched another three emergency health kits to the Secretary of Health in Gilgit-Biltistan.

As of 6 August, WHO has distributed a total of 144 cholera kits (72 000 treatments); 129 emergency kits (enough to meet the basic health needs of 780 000 people for one month); four inter-agency emergency health kits (24 000 people for one month); three surgical supply kits (18 000 treatments); 750 vials of anti-snake venom and 1500 hygiene kits.

In Punjab, WHO provided the first tranche of 340 000 oral rehydration salt sachets to the Department of Health, which began distributing them on 6 August.

In Naseerabad district of Baluchistan, three mobile health teams visited the flood-affected areas and provided health care services to the communities.

For further information contact

Dr Hendrikus Raaijmakers Emergency Preparedness and Humanitarian Action Coordinator e-mail: [email protected]

Alfred Dube Health Cluster Coordinator e-mail: [email protected]

Syed Haider Ali Communications Officer mobile: 0092 3004005944 e-mail:[email protected]; [email protected]

Christina Banluta Communications and Advocacy Officer mobile: 0092 3085559639 e-mail: [email protected]