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 45, Monday 14 November, 2011

Highlights Priority diseases

under surveillance Epidemiological week no. 45 (4 to 10 November, 2011) in DEWS

Acute Flaccid Paralysis (AFP) • 80 districts and 2 agencies provided surveillance data to the DEWS this week from 2,314 health facilities. Data from mobile teams is reported through sponsoring BHU or Acute Jaundice Syndrome (AJS)

RHC. Acute Respiratory Infections (Upper and Lower) (ARI) • A total of 397,222 consultations were reported through DEWS of which 97,966 Acute Watery Diarrhoea (AWD)/ (25%) were acute respiratory infections (ARI); 33,447 (8%) were Skin disease; 31,381 Suspected Cholera (8%) were acute diarrhoea; and 29,893 (8%) were suspected malaria. The timeliness Acute Bloody Diarrhoea (BD) decreased compared with last week due to EID holidays. Other Acute Diarrhoeas (AD)

• A total of 59 alerts with 6 outbreaks were reported in week‐45, 2011: Altogether Suspected Viral Hemorrhagic 15 alerts for AWD, 7 for Neonatal tetanus, 6 each for Leishmaniasis and Measles, 2 for Fever (VHF)

Malaria, 1 each for Bloody diarrhoea and Pertussis, while 21 for other non‐ Suspected Malaria (Mal) communicable diseases. Suspected Measles (MS)

• National Polio Eradication Initiative reported in this week no new polio case was Suspected Meningitis (MG)

reported from any district. Others

Figure‐1: Weekly trend of leading priority diseases in Pakistan, 29 July 2010 to 27 October 2011 (Epi week 31, 2010 to week 45, 2011)

AD BD ARI S. Malaria 45

30 Percentage

0 1 3 5 7 9

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

Disease Wk-38 Wk-39 Wk-40 Wk-41 Wk-42 Wk-43 Wk-44 Wk-45

Acute respiratory infection 193,771 (19%) 205,597 (21%) 209,436 (21%) 223,902 (22%) 213,432 (24%) 193,364 (24%) 217,168 (25%) 97,966 (25%)

Skin diseases 107,243 (11%) 105,912 (11%) 95,842 (9%) 94,167 (9%) 81,161 (9%) 69,317 (9%) 77,697 (9%) 33,447 (8%)

Acute diarrhoea 110,835 (11%) 105,295 (11%) 97,007 (10%) 93,085 (9%) 74,189 (8%) 62,498 (8%) 65,503 (7%) 31,381 (8%)

Bloody diarrhoea 8,676 (0.86%) 9,393 (0.94%) 8,075 (0.80%) 8,107 (0.78%) 6,089 (0.68%) 5,445 (.67%) 5,276 (0.60%) 2,647 (.67%)

Suspected malaria 78,109 (8%) 83,684 (8%) 82,802 (8%) 86,326 (8%) 68,441 (8%) 58,552 (7%) 69,281 (8%) 29,893 (8%)

Total consultation 1,005,251 995,450 1,014,266 1,033,276 897,598 807,463 877,957 397,222

Since July 29, 2010, approximately 51,215,386 patient consultations have been reported to the DEWS from all provinces, FATA and AJ&K. While we still receive reports on around 1,000,000 consultations per week, there is a drop in timely reporting due to EID holidays, challenges in accessibility caused by floods, security and infrastructure. The above graph shows the weekly trend of four major diseases as percentage of cases out of total consultations reported to DEWS. From last 8 weeks (38 to 45, 2011) acute diarrhoea cases have been decreased (From 11% to 8%), while at the same time cases of ARI have been increased (From 19% to 25%). Sus‐ pected malaria cases have also shown seasonal increase from week 35 especially from districts in Sindh and Balochistan.

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 Epidemiological Bulletin: DEWS, Pakistan, Week no. 45 (3 to 10 November, 2011) Current week's Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken Alert for malaria, reported from BHU Sarangani and investigated. All cases were reported Balochis‐ from village Sarangani. A total of 36 cases were attended and 32 samples were taken. 19 5‐Nov Malaria Jhal Magsi BHU Sarangani 9 11 7 9 tan samples were found positive (P.f. 8, P.v. 8 and mixed 3) (SPR =59.38%; FR = 57.90%) and treated. Malaria representative was informed for further preventive measures. Alert for malaria investigated, all cases were reported from town area of Jhalmagsi. A total of 301 suspected cases were reported and 184 samples were tested from which 143 (SPR = 78%) Balochis‐ 10‐Nov Malaria Jhal Magsi RHC Jhal Magsi 78 93 57 73 verified positive and treated (P.f. 47, P.v. 56 and mixed 40) (FR = 60.84%). DHO and Malaria tan representative was informed and briefed about the severity of the disease and requested for preventive measures. Probable diphtheria case, 6 years old, not vaccinated except polio, hospitalized on 6 Nov, Chunggi, Pind Paracha tracheotomy, ADS 80,000 IU, expired on 7 Nov 11 pm, respiratory distress, 2 siblings and 7 6‐Nov Diphtheria ICT Islamabad 0 1 0 0 (PIMS Hosp) cousins in household also un‐vaccinated, started on prophylactic erythromycin, EPI coverage survey ongoing and vaccination response planned. Probable diphtheria case, 20 months old female, not vaccinated except polio drops, hospital‐ ized on 6 Nov, ADS 80,000 IU, tracheotomy on 7 Nov, acute renal failure, myocarditis, expired 6‐Nov Diphtheria ICT Islamabad G‐Sokh, Bharakaho 1 0 0 0 8 Nov, 6 siblings un‐vaccinated, family moved from Bajaour 6 years ago, erythromycin pro‐ vided for all household members, field investigation ongoing, coordination of outreach vacci‐ nation planned. A Case of suspected AWD was reported, on active surveillance 5 more cases were found in same area with severe dehydration, all the patients were referred to DHQ Hospital for IV Village Gular, UC & 11‐Nov AWD KPK Lower Dir 0 2 2 2 therapy, Stool samples collected for lab confirmation, Water Samples taken for any fecal Tehsil Samar Bagh contamination, ORS, Hygiene kits & Aqua tabs distributed, Health & Hygiene promotion Ses‐ sion conducted with family members. EDO‐H was informed.

6 New cases of Leishmaniasis reported. No travel history. Clinical diagnosis was confirmed by IRC trained HCPs. Antileishmaniasis IM & IL injections provided. Community visited for active Leishmani‐ Tolla Mangalli, UC 4‐Nov Punjab Mianwali 0 2 0 4 case finding but no more cases found. Health Education was given to the family. Vector con‐ asis Chapri, Tehsil Issakhel trol of the area was advised. Line listing is ensured. BHU Chapri has an HCP trained on Leishmaniasis management.

Current week's Alerts: Province Sindh Current week's Alerts: Province Punjab <5M >5M <5F >5F Date Disease District Area <5M >5M <5F >5F Date Disease District Area 4‐Nov AD Bhakkar Chuni Shumali, UC Gadola 2 9 3 10 4‐Nov AWD Dadu Marakhpur City Dadu 0 0 1 1 4‐Nov ARI RY Khan UC Langiwaar, Tehsil Khanpur 31 12 39 23 10‐Nov AWD Hyderabad Laloo Lashari, Kali Mori Taluka Hyderabad 0 1 0 0 5‐Nov ARI RY Khan UC Arif Balouch, Tehsil Liaqatpur 19 15 26 21 10‐Nov AWD Hyderabad Near Pathan Colony Hyderabad 0 1 0 0 5‐Nov ARI RY Khan UC Arif Balouch. Tehsil Liaqatpur 21 28 17 30 5‐Nov DHF Bhakkar DHQ Hospital Bhakkar, Chimni Mohallah 0 1 0 0 10‐Nov AWD Jamshoro Mahboob colony, Garibabad, UC Sanwaller 0 1 1 1 7‐Nov DHF DG Khan Block 18, Fareed abad Colony 0 1 0 0 10‐Nov AWD Matiari City Nasarpur Taluka Matirai 1 0 0 0 10‐Nov DHF Khanewal Nishter Hospital Multan‐Khanewal 0 38 0 2 10‐Nov AWD Mirpur Khas Bunglani Muhalla, Village Ali Nawaz Shah 1 1 1 0 4‐Nov DHF Multan Nishter Hospital Multan‐Muzaffargarh 0 2 0 0 6‐Nov AWD T Allah Yar Qubo Stop Taluka Tando Allahyar 0 0 0 1 10‐Nov DHF Multan Nishter Hospital Multan‐Multan City 0 7 0 2 4‐Nov DHF Muzaffargarh Moza Thathi Hamza, Chah Sar wala 0 1 0 0 10‐Nov AWD T Allah Yar Capri Cinema, Tando Adam city 1 0 0 0 9‐Nov DHF Pakpattan Nishter Hospital Multan‐Pakpattan 0 3 0 1 10‐Nov AWD T Allah Yar Siddique Akbar Madarsah 0 1 0 0 10‐Nov DHF RY Khan Sheikh Zaid Hospital‐Mohalla Gharibabad 0 2 0 0 Leishmani‐ 10‐Nov AWD Tharparkar IDP Camp Naukot, UC Mohrano 0 1 0 0 10‐Nov DG Khan Chah Chajrewala, near Basti Jam 0 1 0 0 asis 5‐Nov AWD Thatta Village M. Siddique, UC Chuohar Jamali 1 1 0 1 Leishmani‐ 4‐Nov Mianwali Tolla Mangalli, UC Chapri, Tehsil Issakhel 0 2 0 4 10‐Nov AWD Thatta UC 2 Makli cement factory, Taluka Thatta 1 0 0 0 asis Leishmani‐ 4‐Nov Rajanpur Basti Sontra, Moza Qazi Wala 0 0 0 2 10‐Nov AWD Thatta Village Soof Khaskhali UC Chillya 0 0 0 1 asis 10‐Nov AWD Thatta Village Umar Khaskhali UC Kala Kot 1 0 0 0 10‐Nov Scabies Muzaffargarh Basti Ahmad Mohana & Basti Jarh 28 41 33 50 9‐Nov UXF Mianwali THQ Kalalbagh, Mohalla Zameerabad 4 42 6 74 5‐Nov BD T Allah Yar Village Ghulam Hussain Lashari 2 1 1 1 10‐Nov UXF Muzaffargarh BHU Usman Koria 2 4 8 5 10‐Nov DHF Sukkur SZH RY Khan 0 1 0 0 Current week's Alerts: Province Khyber Pakhtunkhwa 10‐Nov Measles Sanghar Village Bochan Keerio, UC Kanahar 4 0 2 0 Date Disease District Area <5M >5M <5F >5F 10‐Nov NNT Karachi 12.No, Baldia Town 1 0 0 0 11‐Nov AWD Lower Dir Village Gular, UC & Tehsil Samar Bagh 0 2 2 2 10‐Nov NNT Karachi Mohalla Firdaus Chali, Quaidabad 0 0 1 0 10‐Nov NNT Kashmore Village Saendad Bhangwar, taluka Tangwani 1 0 0 0 4‐Nov DHF Haripur Afghan Refugee camp 20 0 1 0 0 10‐Nov NNT Khairpur Village Allah dino Bhutto, UC Rasool abad 0 0 1 0 4‐Nov DHF Haripur Village Muradabad 0 1 0 0 10‐Nov NNT Benazirabad Village Nabi Buksh, UC Haber 1 0 0 0 9‐Nov NNT Shikarpur Village Channa Junejo near Madeji 1 0 0 0 7‐Nov DHF Swabi National Program Swabi, Marghuz 0 1 0 0

10‐Nov NNT Sukkur Village Mohbat Abro, UC Lal Jurio 1 0 0 0 10‐Nov Measles Haripur Afghan Refugee camp Bassu Mera 1 0 0 0 9‐Nov Pertussis Badin Village Dikko, UC Saeedpur, Taluka Talhar 1 0 2 0 Village Devlai Darbar Dherai, UC Devlai, 5‐Nov Measles Swat 0 0 1 0 Current week's Alerts: Province Balochistan Tehsil Kabal Date Disease District Area <5M >5M <5F >5F 5‐Nov Measles Swat Village Natmira, UC and Tehsil Barikot 0 0 1 0 10‐Nov Leishmaniasis Panjgur UC Gwargo Mohallah Gwargo 1 0 0 0 6‐Nov Measles Swat Village and UC Kala Kale near Bus stop 2 0 0 0 4‐Nov Leishmaniasis Sibi Village Dehpal kolan 0 1 0 1 Current week's Alerts: AJK; FATA; GB and ICT 5‐Nov Leishmaniasis Sibi Shaheed Aziz colony, Allabad, UC 3 0 1 0 0 Date Disease District Area <5M >5M <5F >5F

5‐Nov Malaria Jhal Magsi BHU Sarangani 9 11 7 9 6‐Nov Diphtheria ICT Chunggi, Pind Paracha (PIMS Hosp) 0 1 0 0

10‐Nov Malaria Jhal Magsi RHC Jhal Magsi 78 93 57 73 6‐Nov Diphtheria ICT G‐Sokh, Bharakaho 1 0 0 0 10‐Nov Measles Lasbela Hospital Colony, UC Beroot, Bela 3 0 0 0

3500 7 2 2 7 3 Acute respiratory infection 11,532,515 (22%) 8 6 7 7 7 6 8

3000 13 6 6 6 8 8 Skin diseases 5,525,103 (11%) 8 8 8 2500 11 11 8 11 8 11

2000 8

Acute diarrhoea 12 4,901,041 (9%) 411

400 375 331 11 215 361 3375 192 3363

1500 3354 3329 26 3259 3259 3251 3250 3234 153 3215 3196 3156 3142 3120 3109 26 3058 3021 3022 128 2982 2935 2909 2785 105 2752 2745 2716 2696 46 2671 2648 2597 81 2564 2547 2540 2532 2522 2466 58 2450

Bloody diarrhoea 2404

433,977 (1%) 1000 2349 2322 2314 2262 2255 2251 2199 2022 2021 1797 1680 1488 500 1463 1289 1215 1167 1158 1143 1130 999 1113 1111 967 949 1073 1067 879 Suspected malaria 3,196,153 (6%) 854 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 31 33 35 37 39 41 43 45 ‐

Unexplained fever 1,980,004 (4%) 1 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 Total consultations 51,625,840 Epi‐week Table‐2: Total number of alerts and outbreaks reported and investigated with appropriate response Post Flood 2010 2011 (up till wk 44) Current Week (45) Total Disease A O A O A O A O Acute watery diarrhoea 209 85 1247 532 15 1 1471 618 Acute jaundice syndrome 5 2 42 14 ‐ ‐ 47 16 Bloody diarrhoea 10 1 90 19 1 ‐ 101 20 Dengue fever 81 32 761 111 ‐ ‐ 842 143 Measles 48 6 1484 88 6 ‐ 1538 94 Pertussis 1 ‐ 243 61 1 ‐ 245 61 NNT + tetanus 5 ‐ 292 ‐ 7 ‐ 304 0 Malaria 12 7 101 67 2 2 115 76 Leishmaniasis 1 ‐ 204 27 6 1 211 28 Others 75 11 509 58 21 2 605 71 Total 447 144 4973 977 59 6 5479 1127 Province Khyber Pakhtunkhwa: Figure-3: Trend of priority communicable diseases, province KPK This week 545 health facilities from 17 districts reported to • 50 DEWS with a total of 60,548 patients consultations. AD BD ARI S. Malaria

40 • The proportional morbidity of AD showing 1% higher as

compared with last week. 30

• 8 alerts were reported in this week, 4 were for Measles; 3 for Percentage 20 DHF; while 1 for AWD.

10 • 1 outbreak for AWD from Lower Dir was received and responded this week. 0

1 3 5 7 9

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

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

Province Sindh: Figure-4: Trend of priority communicable diseases, province Sindh • This week 805 health centers from 22 districts reported to 50 DEWS with a total of 177,200 patient consultations. AD BD ARI S. Malaria

40 • In Sindh, AD cases reported were 15,706 (9%), 1% higher proportional morbidity as compared with last week . 30

Percentage • 25 alerts were reported from Sindh in this week: 14 were for 20 AWD; 7 for Neonatal tetanus; while 1 for Bloody diarrhoea, DHF, Measles and Pertussis. 10

• No outbreak for any disease was received this week. 0 1 3 5 7 9

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

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

18 alerts were reported in this week from Punjab; 8 were for 20

• Percentage DHF; 3 each for Leishmaniasis and ARI; 2 for unexplained fever; while 1 each for Acute diarrhoea and Scabies. 10

• 1 outbreak of Leishmaniasis was received and responded this 0 1 3 5 7 9

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

week. 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

Province Balochistan: Figure-6: Trend of priority communicable diseases, province Balochistan • In this week, 16 districts reported to DEWS from Ba-

lochistan province. 310 health centers reported a total 50 of 23,380 patient consultations. AD BD ARI S. Malaria

40 • AD reported in 2,560 (11%) of the total consultations, 1% higher proportional morbidity as compared with the 30 last week.

Percentage 20 • 6 alerts were reported in this week from Balochistan, 3 for Leishmaniasis; 2 for Malaria; while 1 for Measles. 10

• 2 outbreaks for malaria was received and responded 0 1 3 5 7 9

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

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

Province Gilgit Baltistan:

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

• In this week, 55 health centers from 7 districts in Gilgit 50 Baltistan sent weekly report with a total of 9,69 patient AD BD ARI S. Malaria consultations. 40

• ARI cases reported were 1,940(20%), while Acute diar- 30 rhoea were 706 (7%). 20 Percentage

• No alert o outbreak was received week from any area 10 of Gilgit Baltistan. 0 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

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:

• In this week, reports were received from 100 health facilities from 10 • This week 30 health facilities in 2 agencies reported from FATA, districts with a total of 9,299 patient consultations. with a total of 2,311 patient consultations. • ARI cases reported were 1,577 (17%), while Acute diarrhoea reported • ARI cases reported were 587 (25%), while Acute diarrhoea was re- 474 (5%) cases. ported 211 cases (9%) • No alerts or outbreak was received this week from any area of AJ&K. • No alerts or outbreak was received this week.

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

30 30 20 20 Percentage 10

10 Percentage 0 0 6 7 8 9

39 40 41 42 43 10 44 11 45 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

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 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 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

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: As of 10 November, 2011, the total number of polio cases confirmed by the laboratory is 145 (143=type‐1, and 2=type3) from 44 districts.

Cases 2010 Cases 2011 Province P1 P3 P1 P3 Punjab 6 1 2 - Sindh 26 1 29 - Khyber Pakhtunkhwa 19 5 12 - FATA 63 11 40 2 Balochistan 6 6 59 - AJK - - - - Gilgit‐Baltistan - - 1 - Islamabad - - - - Total 120 24 143 2 Pakistan Dengue Situation, 5th November 2011 Since the beginning of the year and as of Week 45th 2011; 543,352 cases of suspected dengue fever cases and 22,778 Lab confirmed cases were reported across the country with 353 deaths (CFR = 1.55%). Over 90% of cases were reported in Punjab province.

2011 Provinces Suspected Confirmed Deaths

Punjab 540419 20976 329

Sindh 1333 940 16

Islamabad 980 620 2

Khyber Pakhtunkhwa 502 210 6

AJK 99 21 0

FATA 7 6 0

Balochistan 6 3 0

Gilgit Baltistan 6 2 0

Total 543352 22778 353

Focus on: Emergency situation in provinces Sindh, Khyber Pakhtunkhwa and FATA Sindh: • Still some health facilities are under water in Badin 04 (RHC Pangrio, GD Saman Sarkar, and GD Hamid Shah and BHU Mataro Man‐ dhro). There are 2 GDs under water in Tharparker. In Umarkot there are 3 health facilities under water namely THQ Samaro, BHU Darelo, GD Sajan Chandio. In Mirpurkhas there are 6 health facilities under water including BHU Karam Ali Laghari, BHU Abdul Qaya‐ oom Khair, BHU Kot Mir Jan Muhammad, GD Ahori, GD, GD Roshanabad and GD Dengan Bhurgri Rasti. There are 3 BHUs under water in District Sanghar, namely BHU Gujri, BHU Chak 08 and BHU Bassi. • There are some places in Badin, Tharparker, Umarkot, Mirpurkhas and Sanghar where the people are still surrounded by water like Phat Farm area for Badin and Tharparker, UC Ahori and Roshanabad in Mirpurkhas, Taluka Kunri and Samaro of District Umarkot. In Sanghar UC Mian, UC Kanar, UC Berani, UC Kandiari. Khyber Pakhtunkhwa and FATA: • Fresh influx of IDPs from Khyber Agency into Jalozai IDP Camp. The health facilities are providing adequate health services to the IDPs in the camp. 4 BHUs and 2 MCH centers are providing PHC and MCH services in the Jalozai IDP camp (Population = 40,000 individuals approx.) DEWS data is shared regularly with WHO. • Heavy snowfall in Malakand division (Upper Dir, Lower Dir, Upper Swat, Shangla and Kohistan) resulted in sudden drop in temperature and chilling cold may result in increase in ARI cases in vulnerable groups in the said districts.