Weekly Epidemiological Bulletin Disease Early Warning System and Response in Pakistan

Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan

Volume 2, Issue 29, Monday 25 July, 2011

Highlights Priority diseases under surveillance Epidemiological week no. 29 (15 - 21 July, 2011) in DEWS • 89 districts and 3 agencies provided surveillance data to the DEWS this week from 3,248 Acute Flaccid Paralysis (AFP) health facilities. Acute Jaundice Syndrome (AJS) • A total of 1,029,167 consultations were reported through DEWS of which 18% were acute respiratory infections (ARI), 12% skin disease, 10% acute diarrhoea, and 6% suspected Acute Respiratory Infections (Upper and Lower) (ARI) Malaria.

Acute Watery Diarrhoea (AWD)/ • Critical situation of diarrhea in Khyber Pakhtunkhwa is surpassing the proportional mor- Suspected Cholera bidity recorded in the 2010 post-Flood period. 12 out of 21 reporting districts in KP have Acute Bloody Diarrhoea (BD) more than 16% diarrhea cases out of total consultations at public health facilities. Other Acute Diarrhoeas (AD) • A total of 127 alerts with 23 outbreaks were reported in week-29, 2011: Altogether 49 Suspected Viral Hemorrhagic alerts were for AWD; 39 for Measles; 6 for Pertussis, 5 each were for Acute diarrhoea, Fever (VHF) Leishmaniasis and Malaria, 4 each were for Neonatal tetanus and Mumps, 3 each were for Suspected Malaria (Mal) Bloody diarrhoea and Chicken pox, 2 for Scabies, while one each for Meningitis and Ty- phoid. Suspected Measles (MS)

Suspected Meningitis (MG) • National Polio Eradication Initiative reported one new confirmed polio case this week from district Pishin in Balochistan. Total 60 (59=type1, and 1=type3) confirmed polio Others cases have been reported in 2011 from 25 districts.

Figure‐1: Three years trend of Acute diarrhoea in Pakistan (2009, 2010, and 2011)

2009 2010 2011

12 Percentage

1 4 7 101316192225283134374043464952

Epi‐week

Disease Wk-22 Wk-23 Wk-24 Wk-25 Wk-26 Wk-27 Wk-28 Wk-29 Other Acute Diarrhoea (Not Watery) 102,005 (10%) 100,753 (10%) 102,217 (10%) 103,978 (10%) 107,924 (10%) 99,777 (10%) 104,139 (10%) 106,851 (10%) Total consultation 995,731 1,009,254 1,028,090 1,019,724 1,087,368 991,853 1,023,160 1,029,167

Since July 29, 2010, approximately 37,391,802 patient consultations have been reported to the DEWS from the five provinces and three agencies and state of AJK. In this week 29, 2011 (15 to 21 July, 2011) reports were received from 3,248 health centers and the major causes for seeking health care by the communities in almost all of the provinces were diarrheal diseases, acute respiratory infections (180,515), skin diseases (122,143) and suspected malaria (60,175). The above graph shows the trend of acute diarrhoea in 2009, 2010 and 2011 up until now.

This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, 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 Epidemiological Bulletin: DEWS, Pakistan, Week no. 29 (15 - 21 July, 2011) Previous week's Outbreaks: Date Disease Province District Area M F Action Taken Alert for 46 cases of Malaria was reported, 12/18 samples found positive for Malaria (P. Falciparum 5, P.Vivax 4, Mixed 3). SPR Balochis‐ CD Baloo Pur, Tehsil 14‐Jul Malaria Jaffarabad 7 19 4 16 67% while Falciparum rate also 67%. Appropriate treatment initiated, DHO informed who requested for distribution of bednets tan Sohbat Pur in the affected location. A case of AWD reported from a private hospital. On field investigation a V.c. Ogawa positive case was found in the locality of 12‐Jul AWD ICT Islamabad Merabadia, F11/1 1 0 0 0 Merabadia opposite to F11‐1 sector. Patient recovered. No other case was found during active search. Water disinfection at household level, ORS and hygiene messages shared. Jhazo Maidan, UC One AWD case was reported by private clinic, case investigated jointly with DoH. Sample collected and sent to NIH and found 10‐Jul AWD KPK Hangu 0 1 0 0 Ganjiano Kale positive for V.c. Ogawa. No other suspected cases found on active surveillance. Preventive measures reinforced in the area. Suspected outbreak of AWD was reported from BHU Kundi from village Baji Sar. Patients presented to BHU with severe dehydra‐ tion and informed the in charge of BHU about other cases in their locality with same sign and symptoms. Investigations showed Village Baji Sar, the cases started on 10th of July after having a lunch at a wedding . Samples sent to NIH were found positive for V. c. Ogawa. 15‐Jul AWD KPK Haripur Union Council 3 15 4 24 Total of 46 cases were found on active case finding . 8 cases were severely dehydrated and 4 out of them were admitted in Kundi, Tehsil Ghazi different health facilities of Ghazi for treatment. Aqua tabs, ORS and soap were distributed and Health and Hygiene session was conducted for the affected community. EDO Health was informed of the outbreak One case of AWD reported. Sample collected and found positive for V.c. Ogawa, active surveillance conducted and 423 diar‐ Mohallah Pirano rhoea cases found in the area. EDO‐H, DSM PPHI, MS DHQH and Coordinator National programme informed and alerted. Health 11‐Jul AWD KPK Mardan Korona, UC Manga, 102 79 108 118 and Hygiene session conducted. LHWs continue house to house survey for diarrhea patients and to provide health and hygiene Charsadda Road education and distribute aqua tabs in the community. District Rapid Response team mobilized to strengthen RHC Manga and staff alerted and trained on diarrhea case management. 1 AWD case was reported from UC Pir Ashab, Tehsil and District Bhakkar, on active surveillance no more cases were found. Stool 13‐Jul AWD Punjab Bhakkar UC Pir Ashab 0 0 0 1 sample collected and found positive for V.c. Ogawa water samples were tested and found contaminated. Health and hygiene session given, ORS use was explained, life straws, jerry cans, aqua tabs and soaps were distributed in the community. UC Zeir Pir Village, Seven cases of AWD were recorded. Reinforce case management, Health education, Aqua tabs, ORS, IEC Material, family filters, 13‐Jul AWD Sindh Matiari Deper Lakha, Near 0 5 1 1 Jerry cans and Zinc Tabs provided, 1 stool sample collected and found positive for V.c. Ogawa, 5 Water samples also collected mansoorah for quality testing , EDO‐H and DOH Informed. Village Rab Rakhio Qambar 1 AWD case reported, stool samples found positive for V.c. Ogawa, 3 drinking water samples also collected for quality testing. 13‐Jul AWD Sindh Lakho, Tehsil 0 0 0 1 Shahdadkot The alert responded along with rapid response team of EDOH. Qambar Current week's Outbreaks: Date Disease Province District Area M F Action Taken Balochis‐ Village Kud Sayan‐UC AWD outbreak comprising of 35 cases. 2 stool sample collected and found positive for V.c. Ogawa, 4 water sample were also 16‐Jul AWD Lasbela 7 9 4 15 tan Kathore, Tehsil Bela collected. Report submitted to provincial office while AWD line list is being shared with provincial office on daily basis. AWD outbreak reported in media. Cases investigated with collaboration with DHO and health authorities staff, house to Balochis‐ Kehn, Barani Bhaint, UC 17‐Jul AWD Khuzdar 6 24 2 21 house survey revealed cases with typical sign and symptoms. Two stool and two water samples were collected and sent to tan Ornach, Tehsil Nall NIH. Health education session conducted, water filters, aqua tabs, hygiene kits were distribute in the community. Union Council Tasp Balochis‐ During NID, AWD alert was reported, area visited, 12 patients found. Early response team meeting was conducted with DHO 21‐Jul AWD Panjgor Sarekalat, Mohalla 5 4 1 2 tan and health authorities. DTC established in BHU Tasp Bazar. Medicine, Health education sessions provided. Johan Dun 43 cases on summing were observed and 14/19 verified positive of Malaria (P. Falciparum 6, P.Vivax 3, mixed 5). The DHO Balochis‐ CD Meher Ali, Tehsil 21‐Jul Malaria Jaffarabad 8 12 4 19 was informed and requested for distribution of bednets to the said location. (SPR=74%, FR=79%). Appropriate treatment tan Sohbat Pur initiated. 63 Suspected cases of Malaria reported from Jam Ghulam Qadir Hospital hub, 11/21 found positive for P. Falciparum, Balochis‐ Jam Ghulam Qadir 21‐Jul Malaria Lasbela 0 0 0 0 Information was shared with EDO Health and MS Jam Ghulam Qadir Hospital Hub for fogging and distribution of Bed net in tan Hospital, Hub the community. Request for RDT Kits was also made for Health Facilities of Lasbela. SPR=52%. 29 cases were observed. 10/17 samples collected were verified positive of Malaria (P.Falciparium 6, P. Vivax 3). The DHO Balochis‐ 21‐Jul Malaria Nasirabad BHU Kot Mengal 4 11 5 9 was informed and requested for distribution of bednets to the said location. SPR= 59%, FR= 60%). Appropriate treatment tan initiated. Zahoor colony, UC Balochis‐ 19‐Jul Typhoid Chagai Saddar, Killi Dilmurad, 0 2 2 1 Five suspected cases were reported. Health education sessions were conducted. DHO and health authorities were informed. tan UCPadag 4 suspected AD cases with moderate dehydration were reported and 23 more found during active surveillance in village Barkot, Haripur. The patients presented with moderate dehydration. Initial epidemiological investigation suggested contami‐ nated water was the source. Stool sample was taken sent to NIH and found positive for V.c. Ogawa. Environmental assess‐ 15‐Jul AWD KPK Haripur Village Bagra, UC Bagra 6 8 2 13 ment was carried out water samples were taken and found contaminated. 6 cases with moderate dehydration were admit‐ ted in different health facilities. Aqua tabs, ORS and soap were distributed. Door to door by LHW during the polio campaign. Health and Hygiene session conducted for the affected community. Water tank was cleaned with the help of local commu‐ nity. EDO Health was informed. AWD alert was reported from DHQ hospital Mardan. The case was investigated and sample taken and found positive for V.c. Mohalla Sharif Abad, Ogawa. EDO Health, DSM of PPHI, MS of DHQ and EPI Coordinator informed. On active surveillance in the area one more 16‐Jul AWD KPK Mardan 0 0 0 0 Takht Bai patient recovered from diarrhea was found. Water samples taken and being tested. Health Education conducted with households and community. IEC material, soap and aqua tabs were distributed.

Hasan Garha UC Mera Two AWD cases were reported form Akora Khattak, Nowshera. 1/2 samples collected was found positive for V.c. Ogawa. 15‐Jul AWD KPK Nowshera Akora Khattak Now‐ 0 1 0 1 Hygiene sessions were conducted, Filters and IEC material distributed. No more cases were found during field surveillance. shera Alert for BD was reported by BHU Muslimabad. 6 cases were reported from a poultry farm in the village. On active case finding 15 more diarrhoea cases were found having abdominal cramps and some with bloody diarrhoea. All these cases are Village Muslimabad, UC resident employees of same poultry farm. Stool sample was taken and sent to NIH. Environmental assessment was carried 16‐Jul BD KPK Haripur 0 21 0 0 Muslimabad out and water samples were taken from 2 sources and 1 found contaminated. Management of the poultry farm were advised to use the safe water source. Health and hygiene session was conducted for the staff. Aqua tabs, soap and ORS were distributed. Follow up visit was made on 20th July. No new cases were reported. EDO health was informed. One AWD case reported from Nishter hospital, sample taken and found positive for V.c. Ogawa, the area was visited jointly by the SO,EHE and DEWS FP. House to house survey conducted no other cases found in the locality. Area was assessed for Mohalla Koharay Wala, 21‐Jul AWD Punjab Multan 0 1 0 0 the WASH. Health education session conducted, health hygiene kits (Aqua tabs, Jerry cans, Multi purpose soap, Antiseptic Ghazia Abad Chowk soap, Buckets and water filter) distributed. LHWs mobilized to conduct HE sessions on hygiene in the other areas of the whole UC. shared the line list with EDO(H). Chah Mithoo Wala, Near by Four AWD cases fron four different locations were reported, 4/4 samples found positive for V.c. Ogawa. In the locality/area Sardar Koorey Khan School; 10 households on each side were interviewed but no more similar case or suspect was found. Health education to family 15‐Jul Khoo M. Hussain Wala, Near members in households visited. Distribution of soap, Aqua Tabs, jerry cans, buckets, water filters and IEC among them. by Taleri Nehar, UC Taleri; AWD Punjab Muzaffargarh Basti Babrey, Moza Chah 0 0 1 3 Nearest BHU Doaba was visited and MO was given briefing on the situation, control measures and importance of awareness among general masses about safe drinking water, food and personal hygiene, it was also suggested to advise LHWs, CDC 19‐Jul Godhar, UC Van Patafi; Dera Murad Wala, Chah Pir Wala, supervisor & School Health & Nutrition Supervisor to impart above said information among community while conducting UC Bhutta Pur their HE sessions in the catchment area. EM & EH assessment was also done at BHU. Village Ali junejo,Deh Alert for 4 cases of AWD. Reinforced case management, active surveillance done, Health education, ORS, Aqua tabs and Zinc 18‐Jul AWD Sindh TM Khan jaith,UC Dhando,Taluka 1 0 2 1 Tando ghulam haider tabs Provided, DMT & EDO‐H informed, 1 stool sample collected and found positive for V.c. Ogawa, 2 Water samples taken. Tando Allah Village Azizullah memon Alert for 24 cases suspected Pertussis. Reinforced case management, active surveillance done, Health education, Erythromy‐ 21‐Jul Pertussis Sindh 6 3 12 3 Yar farm cin provided for cases, 3 throat swab samples taken. This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, 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 Epidemiological Bulletin: DEWS, Pakistan, Week no. 29 (15 - 21 July, 2011) Current week's Outbreaks: Continued Date Disease Province District Area M F Action Taken Village Fazal rind, UC 10 AWD cases reported, reinforced case management. No new cases found during active surveillance. Two S. Benazira‐ 18‐Jul AWD Sindh Jamal shah, Taluka 3 4 0 3 water samples found contaminated. Health education sessions conducted. Aqua tabs, ORS, Zinc tabs were bad Daur provided. EDO‐H informed.

Hearji Kolhi village, 16 AWD cases reported, reinforced case management. No new cases found during active surveillance. Two Tando Allah 21‐Jul AWD Sindh UC Missan, Taluka 2 7 3 4 water samples found contaminated. Health education sessions conducted. Aqua tabs, ORS, Zinc tabs, jerry Yar Jhando mari cans and hygiene kits were provided. EDO‐H informed.

UC Kot Mithan, Six suspected measles cases were reported, During field investigation no more cases found. Vit‐A given to 19‐Jul Measles Punjab Rajanpur 0 1 2 3 Tehsil Rajanpur the cases. Health education session conducted. Mass measles campaign planned by EDO‐H.

Village Shashoo; Two AWD cases investigated in THQ Sadda. 1/2 sample found positive for V.c. Ogawa. CTC as already Kurram 19‐Jul AWD FATA Durrani camp, 0 2 0 0 established by MSF. Proper treatment provided to the patients. Health education imparted. Use of ORS agency Sadda, THQ Sadda was stressed. Situation is under control and in consultation with EDO‐H. Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response Post Flood 2010 2011 Current Week Total Disease A O A O A O A O Acute Watery Diarrhoea 209 85 436 154 54 16 699 255 Acute Jaundice Syndrome 5 2 29 12 ‐ ‐ 34 14 Bloody Diarrhoea 10 1 45 8 3 1 58 10 Measles 48 6 1128 80 39 1 1215 87 Pertussis 1 ‐ 164 16 6 1 171 17 NNT + Tetanus 5 ‐ 103 ‐ 4 ‐ 112 ‐ Malaria 12 7 41 29 5 3 58 39 Leishmaniasis 1 ‐ 62 17 5 ‐ 68 17 Others 156 43 318 34 11 1 485 78 Total 447 144 2326 350 127 23 2900 517 Province Khyber Pakhtunkhwa: Figure-3: Three years trend of Acute diarrhoea, province KPK • This week 21 districts reported to DEWS from 749

health facilities with a total of 183,356 patients con- 30 sultations. 25

• AD cases reported were showing a consistent upward 20

trend and accounted for 14% - 17% of the total con- 15 sultations in last 4 weeks. Percentage 10

• 36 alerts were reported in this week, 16 were for 5 Measles, 16 for AWD, 2 for Bloody diarrhoea, while 2009 2010 2011 0 1 each for Pertussis and Scabies. 1 4 7 101316192225283134374043464952 Epi‐Week

Province Sindh:

Figure-5: Three years trend of Acute diarrhoea, province Sindh • This week 21 districts reported to DEWS from 1,000 30 health centers with a total of 466,653 patient consultations during the reporting period of week 29, 2011. 25

20 • In Sindh, AD cases reported were 41,903 (9%), same proportional morbidity as compared with last week. 15 Percentage 10 • 29 alerts were reported from Sindh in this week: 12 were for AWD, 9 for Measles, two each were for 5 2009 2010 2011 Leishmaniasis, Neonatal tetanus and Pertussis, while 0 one each for Bloody diarrhoea and Malaria. 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Epi‐Week

for Mumps, while one each for Meningitis, Pertussis and 0

Scabies. 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Epi‐week

Province Balochistan: Figure-6: Three years trend of Acute diarrhoea, province Balochistan • In this week, 18 districts reported to DEWS from Balochistan province. 436 health centers reported a 30 total of 63,828 patient consultations. 25 AD reported in 9,020 (14%) of the total consulta- • 20 tions, 1% higher proportional morbidity as compared with last week. 15 Percentage 10 • 26 alerts were reported in this week from Balochis- tan, 7 were for Measles, 5 for AWD, 3 each for 5 2009 2010 2011 Leishmaniasis, Malaria and Chicken pox, 2 for Per- 0

tussis, while one each for Neonatal tetanus, Typhoid 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 and Mumps. Epi‐week

Gilgit Baltistan:

Figure-7: Trend of priority communicable diseases, Gilgit Baltistan (25 March to 21 July 2011) • In this week, 62 health centers from 7 districts in 50 Gilgit Baltistan sent weekly report with a total of AD BD ARI S. Malaria 25,247 patient consultations. 45 40 35 • ARI cases reported were 2,938 (12%), while Acute 30 25 Diarrhoea 3,908 (15%). 20 Percentage 15 • Three alerts two for Measles and one for Malaria 10 were received and responded this week. 5 0 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

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

State of Azad Jammu and Kashmir: FATA:

• In this week, weekly report received from 80 health centers from 10 • This week 50 health centers in 3 agencies reported from FATA, districts, with a total of 26,271 patient consultations. with a total of 9,955 patient consultations. • ARI cases reported were 3,747 (14%), while Acute diarrhoea reported • ARI cases reported were 1,706 (17%), while Acute diarrhoea 2,513 (10%) cases. reported 961 cases (10%)

• Two alerts one for AWD and one for Neonatal tetanus were • Three AWD alerts reported and responded in this week. received and responded this week.

50 50 AD BD AD BD ARI S. Malaria 40 40 30 30

Percentage 20 Percentage 20 10 10 0 0 6 7 8 9 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 10

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

Current week's Alerts: Province Balochistan Number of ale rts dete cte d by week, province Kh yb er Pakhtunkhwa, (Week26 to 29 , 20 11) 25 Date Disease District Area <5M >5M <5F >5F 22 AWD MS Pertussis Leish 20 18 19‐Jul AWD Awaran Nokjo Tehsil Mashkai 0 0 0 0 16 16 13 14 17‐Jul AWD Khuzdar Kehn, Barani Bhaint UC Ornach tehsil Nall 6 24 2 21 15 10

20‐Jul AWD Khuzdar Khormaistan UC Nall tehsil Nall 1 0 0 4 alerts 10 7

44 16‐Jul AWD Lasbela Village Kud SayanUC Kathore Tehsil Bela 7 9 4 15 # 5 3 1 1 2 1 Union Council Tasp Sarekalat, Mohallah 21‐Jul AWD Panjgur 5 4 1 2 0 Johan Dun Wk 26 Wk 27 Wk 28 Wk 29 Chicken Pox 15‐Jul Khuzdar Taj Abad UC Baleena Kattan tehsil Khuzdar 1 2 0 2 Epi‐week 19‐Jul Chicken Pox Sibi Village rahozai, Talli 1 0 2 0 20‐Jul Chicken Pox Ziarat Gogai, Ziarat Town 1 0 0 1 Number of ale rts dete cte d by week, province Sindh (Week 26 to 29 , 20 11) Leishmaniasis 21‐Jul Jaffarabad Town City of Gandakha, UC Gandakha 0 0 0 1 25 18‐Jul Leishmaniasis Khuzdar Ismail Abad UC Gazgi Tehsil Khuzdar 0 1 0 0 19 AWD MS Pertussis Leish 20 17 16 15‐Jul Leishmaniasis Lasbela National Eint Bhata Rana Bhit UC Sonmiani 0 1 0 0 15 12

21‐Jul Malaria Jaffarabad CD Meher Ali, Tehsil Sohbat Pur 8 12 4 19 ale rts 9 8 9 of

10 21‐Jul Malaria Lasbela Jam Ghulam Qadir Hospital, Hub 0 0 0 0 # 6 5 5 2 21‐Jul Malaria Nasirabad BHU Kot Mengal 4 11 5 9 1 2 17‐Jul Measles Chagai Girdi jungle, UC Chilghazi 0 0 0 1 0

20‐Jul Measles Jaffarabad Town City of Sohbat Pur, UC Sohbat Pur 1 0 0 0 Wk 26 Wk 27 Wk 28 Wk 29 Epi‐week 15‐Jul Measles Kalat Samori UC Jeeva tehsil Surab 0 1 0 0 15‐Jul Measles Khuzdar Bazgeer UC Kand tehsil Khuzdar 0 0 1 0 Number of ale rts dete cte d by week, province Pu njab (Week 26 to 29, 201 1) 19‐Jul Measles Lasbela Haji Mitha Khan Mari Goth 1 0 0 0 25 AWD MS Pertussis Leish 19‐Jul Measles Lasbela Raja Goth Hub 1 0 0 0 20 Ghot Mir Mohammad, UC Quba Sher Khan, 20‐Jul Measles Nasirabad 3 0 1 0 15 12 Rabi Area 9 ale rts 10 7 6 7 16‐Jul Mumps Khuzdar Bolan Colony UC Gazgi tehsil Khuzdar 0 0 1 0 of

# 4 4 21‐Jul NNT Chagai Killi Khuasti Khan saindak UC Taftan 0 0 1 0 5 2 2 1 20‐Jul Pertussis Jaffarabad Ghot Gul Hassan Baghdari, UC Thull 2 0 1 0 0 20‐Jul Pertussis Nasirabad Ghot Haji Lashkar khan, Tehsil D.M.J 0 2 1 0 Wk 26 Wk 27 Wk 28 Wk 29 Zahoor colony UC Sadder, Killi Dilmurad UC Epi‐week 19‐Jul Typhoid Chagai 0 2 2 1 Padag Current week's Alerts: AJK; FATA; GB and ICT Number of alerts dete cte d by week, province Balochistan (Week 26 to 29, 2011) Date Disease District Area <5M >5M <5F >5F 25 AWD MS Pertussis Leish 21‐Jul AWD Bagh FGSH Islamabad (Dhirkot Bagh) 0 0 0 1 20

village Kals chottagala UC Dothan Tehsil 15 20‐Jul AWD Poonch 4 9 3 26

Rawalakot alerts 10 7 of

6 6

# 5 21‐Jul AWD Sudhnoti village Khawas UC Hamroota Tehsil Blouch 18 29 30 42 443 33 5 1 1 22 Bajaur Mohallah Eidgah Masjid, Khar Bazaar, 21‐Jul AWD 0 1 0 0 0 Agency Tehsil Khar Wk 26 Wk 27 Wk 28 Wk 29 Bajaur Village Malasaid‐Salarzai & Village 20‐Jul NNT 2 0 0 0 Epi‐week Agency Kohemoor‐Barang

Village Thaus UC Thaus Tehsil Yasin District 20‐Jul Malaria Ghizer 0 0 0 3 Ghizer Number of ale rts dete cte d by week, AJK (Week 26 to 29, 201 1) 25 Village Gahkuch Paeen Mohallah Khari UC AWD MS Pertussis Leish 19‐Jul Measles Ghizer 1 0 0 0 Gahkuch Tehsil Punial 20 15 23‐Jul Measles Skardu Sikandar Abad Oro Kumra 1 0 0 0 alerts 10 of

# 5 333 Distribution of alerts by diseases, week 29 (15 ‐ 21 1 11 0 July), 2011 (n=127) Pertussis, 6 Wk 26 Wk 27 Wk 28 Wk 29 Measles, 39 AD, 5 Epi‐week Leish, 5 Malaria, 5

NNT + Tetanus, 4 Number of ale rts dete cte d by week, province Gilgit Baltistan (Week 26 to 29 , 20 11) 25 Measles 20

Mumps, 4 15 ale rts

of BD, 3 10 # 6 4 C. Pox, 3 5 2 2

Scabies, 2 0

Typhoid, 1 Wk 26 Wk 27 Wk 28 Wk 29 Epi‐week AWD, 49 Meningitis, 1

This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, 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]. 05 Epidemiological Bulletin: DEWS, Pakistan, Week no. 29 (15 - 21 July, 2011) Current week's Alerts: Province Sindh Current week's Alerts: Province Khyber Pakhtunkhwa Date Disease District Area <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F 15‐Jul AD Haripur Village Barkot, UC Barkot 6 8 2 13 Village Ganja Tunia UC Mad Abhoo talka 20‐Jul AWD Larkana 0 1 0 0 Bakrani 15‐Jul AWD Abbottabad Old Board Office, Kehal 0 1 0 3 21‐Jul AWD Buner Bambalay Baba 0 0 1 0 Naushahro Village Mullo Ujjan, UC Palhano, Tehsil 21‐Jul AWD Buner Sawarai Mela, Dag Gagra 1 0 0 0 19‐Jul AWD 0 1 0 0 Feroze Bhiria Adjacent High School Village Amirzai Shabqadar 18‐Jul AWD Charsadda 0 1 0 0 Dheri Qambar Village Khair pur juso UC Khair pur juso Village Baji Sar, Union Council Kundi, Tehsil 20‐Jul AWD 0 1 0 0 15‐Jul AWD Haripur 3 15 4 24 Shahdadkot taluka naser abad Ghazi 20‐Jul AWD Kohistan Sazeen, Dasu 0 0 1 1 Village Fazal rind,UC Jamal shah,Taluka 18‐Jul AWD S. Benazirabad 3 4 0 3 20‐Jul AWD Mardan Babeni, Swabi Road 0 0 0 1 Daur 20‐Jul AWD Mardan Saeed Abad, Rustam 3 0 1 2 22‐Jul AWD Peshawar Gulabad board area 0 4 0 0 18‐Jul AWD Shikarpur UC Ruk, Mahar Mohalla 0 0 1 0 22‐Jul AWD Peshawar Gulberg No. 4 0 0 0 1 22‐Jul AWD Peshawar Palosai Tarlarzai 0 1 0 0 19‐Jul AWD Swabi CD Utla Gadoon, Mohalla Beta Galli 0 0 0 1 20‐Jul AWD Shikarpur THQ Lakhi 0 0 1 0 22‐Jul AWD Upper Dir Khagram, Warrai 0 0 3 4 16‐Jul BD Haripur Khalabut Township Sector 1, UC Khalabut 1 2 2 3 20‐Jul AWD Sukkur BHU Thariri, Tehsil Saleh Pat 0 1 0 0 16‐Jul BD Haripur Village Muslimabad, UC Muslimabad 0 21 0 0 19‐Jul Measles Abbottabad Bagh 1 0 0 0 Tando Allah Hearji Kolhi Village, UC Missan, Taluka 16‐Jul Measles Battagram Chota Maira 1 0 0 0 21‐Jul AWD 2 7 3 4 Yar Jhando mari 19‐Jul Measles Buner Nagrai Bazar, CD Amazai 0 0 1 1 21‐Jul Measles Buner Sonogram, Gagra 1 0 0 0 Tando Allah Village Ali Muhammad Khoso, Taluka 21‐Jul AWD 0 4 0 0 20‐Jul Measles Haripur Village Bagra, UC Bagra 0 0 1 0 Yar Jhando mari 15‐Jul Measles Shangla Village Kadona,UC Puran 0 0 1 0 18‐Jul Measles Shangla Village Faizdara, UC Damorai 1 0 0 0 Tando Muham‐Village Ali junejo,Deh jaith,UC 18‐Jul AWD 1 0 2 1 mad khan Dhando,Taluka Tando ghulam haider 18‐Jul Measles Shangla Village Pishloor 0 0 1 0 18‐Jul Measles Shangla Village Sheshan, UC Lelonai 1 0 0 0 Tando Muham‐Village Mithal Sathio, Deh Sathiar, UC 19‐Jul AWD 0 1 2 1 20‐Jul Measles Swabi BMC Swabi, UC Kunda 1 0 0 0 mad khan Saeed matto 21‐Jul Measles Swabi CH Topi, UC Zaroobi 1 0 1 0 20‐Jul Measles Swat Village Baligram, UC Jambel, Tehsil Babuzai 1 0 0 0 Village Katho Pathai,UC Gadhro, Taluka 21‐Jul AWD Tharparkar 0 1 0 1 Chachro 20‐Jul Measles Swat Village Galoch, UC Kabal, Tehsil Kabal 0 0 0 1 20‐Jul Measles Swat Village Shaheen Abad, UC Saidu, Tehsil Babuzai 0 0 1 0 Police Line Gowlimar Colny,Taluka 21‐Jul Measles Tank Gara Pattar 0 0 1 0 20‐Jul BD S. Benazirabad 1 0 1 1 Nawabshah 21‐Jul Measles Upper Dir Achar Payeen 1 0 0 0 Village Dara, Mohallah Chep Khan, UC Tirath, Leishma‐ 21‐Jul Pertussis Swat 4 1 0 0 16‐Jul Kashmore Kashmore 0 1 0 0 Tehsil Madyan niasis 16‐Jul Scabies Haripur Village Muslimabad, UC Muslimabad 0 0 1 35 Current week's Alerts: Province Punjab Leishma‐ Qambar 16‐Jul Qambar Shahdadkot 0 1 0 0 niasis Shahdadkot Date Disease District Area <5M >5M <5F >5F Chimni Mohallah, UC Bhakkar Urban III, Teshil 20‐Jul AD Bhakkar 1 0 1 9 Bhakkar 19‐Jul Malaria Sukkur Public School hostel 0 0 0 1 16‐Jul AD Layyah BHU jhoak jaskani uc noshera Thal kalan 0 0 0 0 15‐Jul AD Rahim Yar Khan Kotla Pathan, Tehsil Khanpur 13 18 11 17 18‐Jul Measles Ghotki Anwar abad Mohalla, Ghotki City 0 0 1 0 15‐Jul AD Rahim Yar Khan UC Gehna Lar tehsil Khanpur 6 11 9 14 20‐Jul AD Rahim Yar Khan UC Rajanpur Kalan, Tehsil Rahim Yar Khan 11 8 12 12 21‐Jul AWD Bhakkar Basti Kapahi, UC Gauhar Wala, Tehsil Mankera 0 1 0 0 19‐Jul Measles Hyderabad Ghoomanabad Town, Paretabad area 2 0 1 0 Mohalla Dhirkhana,Sharqeedub,Bub balo‐ 20‐Jul AWD Mianwali 1 1 1 2 cha,Piplan 20‐Jul AWD Mianwali Mohallah Mubarak Abad,UC Daudkel 3 0 1 0 21‐Jul Measles Jacobabad UC Logi, Tehsil Thull 1 0 0 0 20‐Jul AWD Mianwali Mohallah Qasaban,UC Dub Baloochan,Piplan 3 1 0 0 Chah Mithoo Wala, Near by Sardar Koorey 15‐Jul AWD Muzaffargarh 0 0 0 1 Khan School 21‐Jul Measles Jacobabad UC Mirpur 1 0 0 0 15‐Jul AWD Muzaffargarh Khoo M. Hussain Wala, Near by Taleri Nehar 0 0 0 1 15‐Jul AWD Muzaffargarh Mohallah Panwar Shumali, UC Mehmood Kot 0 1 0 0 19‐Jul Measles Jamshoro UC Sonwallar‐1, Taluka Kotri 1 0 0 0 18‐Jul AWD Muzaffargarh Basti Yaroo Wala, UC Noohan Wali 0 0 0 1 Basti Babrey, Moza Chah Godhar, UC Van 19‐Jul AWD Muzaffargarh 0 0 0 1 Patafi 19‐Jul Measles Jamshoro UC Sonwallar‐2, Taluka Kotri 0 0 1 0 Dera Murad Wala, Chah Pir Wala, UC Bhutta 19‐Jul AWD Muzaffargarh 0 0 1 0 Pur Mea‐ Khwaja Fareed Colony, Moza Chak Mithan, UC Darghai Samito, UC Pir Hayat Shah, Tehsil 16‐Jul Muzaffargarh 0 0 1 0 19‐Jul Measles Khairpur 0 0 1 0 sles City‐3 Sobho Dero Mea‐ House # 25, New Coloney, Fazal Cloth Mill, UC 18‐Jul Muzaffargarh 0 0 2 0 sles Bhutta Pur Naushahro 15‐Jul Measles Village Tufail Arain, UC Dageja 0 0 1 0 Mea‐ Feroze 18‐Jul Muzaffargarh Khoo Pathan Wala, Basti Baseera, UC Mondaka 0 0 0 1 sles Mea‐ Basti Dari Bahawal, Moza Gohar Jahania, UC 21‐Jul Muzaffargarh 1 0 0 0 18‐Jul Measles Tharparkar Village Kankio, UC Hirar, Taluka Chachro 0 1 0 0 sles Van Patafi Mea‐ 19‐Jul Rajanpur Ward No. 4‐5, UC Kot Mithan, Tehsil Rajanpur 0 1 2 3 sles 21‐Jul NNT Ghotki Village Chack Shahbaz UC Ranwatti 1 0 0 0 Menin‐ 16‐Jul Layyah Chak no 150 uc jaman shah 0 1 0 0 gitis 20‐Jul Mumps D. G. Khan Peerwala uc Ghousabad 2 0 2 0 15‐Jul NNT Karachi NICH Karachi 0 0 1 0 Basti Allah ditta Misna, Mouza Trinda M.Yar, 21‐Jul Mumps Rahim Yar Khan 2 5 0 1 UC Baloqiwala, tehsil RYKhan Basti Khan Mohammad, UC Baloqiwala, Tehsil Village Gul Bahar Kandhro, UC Panhwar, 21‐Jul Mumps Rahim Yar Khan 4 2 0 0 21‐Jul Pertussis Sukkur 0 0 1 0 RYKhan Tehsil Rohri Pertus‐ Solani Dak khana Bagal Chor, Kharar Buzdar uc 18‐Jul D. G. Khan 1 0 0 0 sis Mubarkee Tando Allah 21‐Jul Pertussis Village Azizullah memon farm, 6 3 12 3 Chah Patwari Wala, UC Barranga, Tehsil Darya Yar 19‐Jul Scabies Bhakkar 0 3 0 3 Khan This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, 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 Epidemiological Bulletin: DEWS, Pakistan, Week no. 29 (15 - 21 July, 2011) Table‐1: Leading causes of seeking health care in flood affected districts, 29 July 2010 to 21 July 2011, Figure‐2: Weekly number of reporting health facilities (Wk 33/2010 to Wk 29/2011) compiled from weekly reports

4000 Diseases Total Mobile Fixed 6 6 6

3500 7 2 2 7 3 8 6 7 7 7 6 8

3000 13 6 Skin Diseases 3,975,573 (11%) 6 6 8 8 8 8 8

2500 11 11 8 11

Acute Respiratory Infection 8,692,193 (23%) 8

2000 8 12 411 400 375 331 11 215 361

1500 3375 192 3363 3354 Acute Diarrhoea 3,498,428 (9%) 26 3259 3256 3248 3250 3231 153 3215

3196 3120 26 3058 3021 3022 128 2982 2935 2909 2785 105 2745 46 81 2547 58 2466 2450

1000 2404 2349 2322 2262 2255 2251 2199 2022 2021

Bloody Diarrhoea 321,453 (1%) 1797 1680

500 1463 1289 1215 1167 1158 1143 999 1130 967 1111 1113 949 1073 1067 879 854 Suspected Malaria 2,186,406 (6%) 0 3 5 7 9

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

1 Wk Wk Wk Wk Unexplained Fever 1,436,567 (4%) Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Total Consultations 37,391,802 Wk

Focus on: Contaminated water sources causing diarrhea outbreaks in Province Khyber Pakhtunkhwa Most diarrhea outbreaks are associated with contaminated water sources. Following are the types of contamination identified by WHO Environmental Health Engineers responding to Suspected Cholera Outbreaks with the DEWS team. Mardan 24 July, 2011: Five types of flaws in the Water Supply and Sanitation System have been identified in Mardan. • Piped Network: Clean water pipe lines pass adjacent or even through the sewer lines, and these pipes are mostly found broken or leaking, especially at joints. • Over Head Water Tanks (OHWTs): Overhead water reservoirs are not cleaned periodically, and most of them are not cleaned even once after their construction. Moreover most of them are not covered. However, HRDS is now on a mission to clean all 42 OHWTs in District Mardan. • Bore Holes (Hand Pumps): Shallow boring (shallow wells) are pumping water from ‘Un‐confined Aquifers’ which are highly exposed to contamination. Deep boring, pumping water from ‘Confined Aquifers’ is safer, but as it costs more to go deeper therefore the poor community stops boring as soon as they find the water table. Moreover the area around hand pumps is usually not properly cemented. • Open Wells: Open wells which are not properly lined from inside also contribute in contamination of water and usually there are no proper arrangements made to cover them. • Distance between Latrines and Water Supply Installations: It is also observed that the distance between Latrines and Water Supply Installations (Hand pumps, Open wells, Bore holes etc) is very less, and they are built very near or even adjacent to each other. Nowshera, 12 July 2011: Similar problems were noted in Nowshera: Open unprotected well or spring sources; old rusted leaking pipes; Flood‐affected or high water table contaminating water in shallow wells; and latrines too close to the water source. DI Khan, 6 July 2011: Analysis of the water problems in DI Khan found more contributing factors. Due to low voltage electricity, the tube wells cannot operate continuously and they are in insufficient numbers. Therefore, people store water in under ground water tanks (UGWT) in the area which have no chlorination facility and are accessed unhygienically. Poor hygiene in the household is another reason for water contamination and broken pipes are also a problem. Haripur, 21 June 2011: Some of the same issues were found in Haripur: Pipes older than their designed life have rusted and leaking joints; some places have direct pumping without chlorinators; eg. Kalabat township and Afghan Refugee Camp; contamination of water supply lines with sewerage system lines; open unprotected wells and spring sources; high water table; latrines close to the water source; and lack of awareness about necessary hand washing practices after using toilet and before preparing food. During an outbreak, communities are urged to boil their water or disinfect it with chlorine. WHO and UNICEF collaborate with partners and local authorities to improve chlorination of water sources, clean tanks, repair pipes and assist households to increase distance between latrines and shallow wells or establish deep wells for use by several households.

Distribution of Wild Polio Virus cases Pakistan 2010 and 2011 Year 2010: The total number of polio cases reported in 2010 is 144 including 120 type‐1 cases and 24 type‐3 from 40 infected districts/towns/agencies.

Year 2011: The total number of polio cases confirmed by the laboratory is 60 (59=type ‐1, and 1=type3) till date from 25 districts.

Province Cases 2010 Cases 2011 P1 P3 P1 P3 Punjab 6 1 - -

Sindh 26 1 14 -

Khyber Pakhtunkhwa 19 5 6 - FATA 63 11 19 1 Balochistan 6 6 19 - AJK - - - - Gilgit‐Baltistan - - 1 - Islamabad - - - - Total 120 24 59 1 This weekly Epidemiological Bulletin is published jointly by the Federal Ministry of Health, Government of Pakistan, 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]. 07 Epidemiological Bulletin: DEWS, Pakistan, Week no. 29 (15 - 21 July, 2011) Alerts and outbreaks, week 29, 2011