September 23, 2013 DISEASE EARLY WARNING SYSTEM WER-38 (7th Yr) DEWS WEEKLY EPIDEMIOLOGICAL REPORT

SUMMARY:

 This report includes surveillance data from 14 September to 20 September 2013.  Out of 360 functional Sentinel sites (SS), 357 (99.1%) have submitted reports for Week-38 of 2013.  Out of a total of 325,197consultations (137,642 male, 187,555 female) recorded in Week-38 of 2013, 34 % or 110,441 (53,300 male, 57,141 female) consultations were reported due to DEWS target diseases.  Main causes of consultations this week were Acute Respiratory Infections (ARI) (18.1%) and Acute Diarrheal Diseases (ADD) (14.4%) from total clients in a continuing trend from the week before.  37 (18 male, 19 female) deaths resulted from Pneumonia, Diarrheal Diseases and Meningitis/Severely Ill Children, which includes 18 deaths (9 male, 9 female) caused by Pneumonia, 12 deaths (6 male, 6 female) caused by Diarrheal Diseases and 7 deaths (3 male, 4 female) caused by Meningitis/Severely Ill Children.  In this reporting week, a Cholera Outbreak reported from and a Suspected Cholera Outbreak reported from .

REPORTS RECEIVED FROM REPORTING SITES:

As of September 20, 2013, 360 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of . In this reporting week, 357 sentinel sites have sent their reports on new cases of DEWS target diseases recorded during the reporting week. 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-38, 2013

Central Central East Central West North North East West South East South East Total No. of Expected Reports from 56 32 57 47 38 49 45 36 360 Sentinel Sites No. of Reports Received in this 55 32 56 47 38 49 45 35 357 week

DEWS Sentinel Sites: Figure-1(Map) shows the Table-2: DEWS Epidemiological Regions and distribution of DEWS sentinel Sentinel Sites by type in Week-38, 2013

sites already established in the

relevant regions/provinces by Type of SS

September 20, 2013. Table-2

East Central West North North East West South East South East Total shows the SS distribution by type Central of health facility. Data on 15 CHC/BHC 28 19 42 36 24 39 35 28 251 DEWS target diseases are being DH 12 9 10 7 9 5 7 4 63 collected from these sentinel sites (SS). The symbols on the map PH/RH/SH 14 4 5 4 4 5 3 4 43 show the number of sentinel sites Poly Clinic 2 0 0 0 1 0 0 0 3 in each region/province, and do Total 56 32 57 47 38 49 45 36 360 not indicate the GPS of the SS CHC=Comprehensive Health Center, DH=District Hospital, PH=Provincial Hospital, locations. RH= Regional Hospital, SH= Specialized Hospital

DEWS Data in Epidemiological Week-38 of 2013: Fig-2: Percentages of DEWS Target Diseases by Out of a total of 325,197 clients recorded in week-38 of Gender in W38-13 20 2013, 15.8% (51,468) of consultations were reported

18 due to Cough and Cold and 2.3% (7,589) of consultations was reported due to Pneumonia. In the 16 same reporting period, 14.4% or 46,935 events were 14

reported due to diarrheal illnesses (10.7% due to Acute 12 Percentage Watery Diarrhea, 2.5% due to Bloody Diarrhea and 10 1.2% due to Acute Watery Diarrhea with Dehydration). 8 In comparison with the previous week (W37 of 2013) 6 the percentage of ARI disease has increased by 0.9% to 4 18.1%, and the percentage of Acute Diarrheal Disease 2 0 has decreased by 0.7% to 14.4%. These variations ARI Men/SI Malari TyphFe ARI Pn AwD BD AwDw AVHep Measle could be due to changes in temperature /weather during C&C C a v the reporting week. Figure-2 (right) shows the Male 17.5 2.8 12.5 2.8 1.5 0.1 0.1 0 0.7 0.6 percentages of DEWS target diseases by gender in Female 14.6 2 9.4 2.3 1 0 0.1 0 0.5 0.6 week-38 of 2013. Total 15.8 2.3 10.7 2.5 1.2 0 0.1 0 0.6 0.6 Percentage of ARI by Weeks and by Age Groups: In the epidemiological week-38 a total of 59,057 events of ARI were reported. 22.4 % of total clients less than 5 years of age were Cough & Cold patients and 12.8% were among the age group 5 years and over. The percentage of C&C (<5 years) consultations in week-28, in comparison with the percentage of C&C in week-38 of 2013, increased by 5.9%, whereas in case of 5 years and above increased by 3.1% to 12.8% in this reporting week. The trend of ARI diseases in last 11 weeks can be read in Table-3. The percentages of consultations on Pneumonia cases of age group less than 5 years increased by 0.8% in last 11 weeks, whereas the percentage of age group 5 years and over increased by 0.1% to 1.1% .

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- 28-13 29-13 30-13 31-13 32-13 33-13 34-13 35-13 36-13 37-13 38-13 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 Yr. 16.5 16.6 16.8 16.9 16.6 16.5 18.7 20 21.2 21.1 22.4 5+ 9.7 9.8 9.8 10.1 9.6 9.3 10.9 11.5 12.1 12 12.8 ARI- <5 Yr. 4.2 4.2 4.3 4.1 3.9 3.9 4.2 4.8 4.9 4.9 5 Pneumonia >=5Yr. 1 0.9 0.9 0.8 0.9 0.9 1 1 1.1 1.1 1.1

In the reporting week-38 of 2013, the highest percentages of Cough & Cold were recorded in Khost, Kapisa and Nuristan provinces with 28.9%, 27.2% and 23.8%, whereas the lowest percentages of C&C were reported from Farah, Ghor and Badghis provinces with 6.1%, 8% and 9% respectively. The highest percentages of Pneumonia cases were reported from Saripul, Samangan and Takhar provinces with 6.2%, 3.9% and 3.8 respectively, whereas the lowest percentages of Pneumonia cases were recorded in Zabul, Urozgan and Paktika provinces with 0.2 and 0.5% respectively. (Fig-3)

35 Fig-3: Percentages of ARI from Total Clients in week-38 of 2013 30

25 20 15

Percentage 10 5 0 TAK NI UR WA BA BD FAR GH NA NU SA JO KU GH KH HIL KAN ZAB KAB KAP LOGPANPAR DAY HER LAG KNR BAL FYB SAR BDS HA BGL PIA PKA M O R M G AH O N R M W N A O R Pneumonia 1.1 2.2 1 0.2 0.5 3.4 2.1 3.6 2.1 2.5 2 3.6 1.1 0.7 0.6 0.6 1 1.9 3 3.2 2.5 3.9 3.2 3.7 2.2 6.2 2.6 3.8 3.8 2.8 0.7 0.7 0.5 1 Cough&Cold 16 15 12 9.9 12 14 27 20 14 15 16 15 22 9 14 6.1 8 22 11 19 24 19 16 12 17 15 15 17 16 17 9.8 18 15 29

Percentages of Diarrheal Diseases by Weeks and by Age Groups: 20 Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-38 of 2013

15

10 Percentage 5

0

HIL

PIA

FYB

BAL

BGL

SAR

ZAB

BDS

LAG

HER

PKA KAP

PAR

KAB

LOG

DAY

KNR

PAN

NIM

KAN

BDG

KHO

KUN

GHA NUR

URO

JOW

NAN

GHO

SAM

BAM

WAR

FARAH TAKHAR Provinces AWD BD AWDwD

Figure-4 above shows the percentages of diarrheal diseases (Acute Watery Diarrhea, Bloody Diarrhea and Acute Watery Diarrhea with Dehydration) from week-28 to week-38 of 2013 from total clients, Acute Watery Diarrhea among children less than five years of age has decreased from 23.1% in week-28 to 20.6% in the reporting week, whereas Acute Watery Diarrhea among age group 5 years and above has been decreased by 1.4% to 6.1 % (Table-4). Bloody Diarrhea in age group less than 5 years decreased by 0.2% in last 11 weeks, while in case of age group 5 years and above also has been decreased by 0.2%. Acute Watery Diarrhea with Dehydration in age group less than 5 years show an decrease by 1% in last 11 weeks, while in case of five years and above AWDwD decreased by 0.2% to 0.7 in last 11 weeks.

Table-4: Percentages of Diarrheal Diseases from Total Clients during 11 recent weeks by age groups.

Week Week Week Week Week Week Week Week Week Week- Week- -28- -29- -30- -31- -33- -34- -35- -37- -38- Disease Age 32-13 36-13 13 13 13 13 13 13 13 13 13 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 23.1 24.6 25.6 25.9 26.2 26.5 24.7 23.5 22.2 21.5 20.6 >= 5 Diarrhea 7.5 7.6 7.4 7.8 8.5 8.5 7.4 6.6 6.9 6.3 6.1 Years <5 Years Bloody 3.8 4.1 3.9 3.9 3.9 4 3.9 3.9 3.8 3.6 3.6 >=5 2.1 2.1 2.1 2.2 2.2 2.3 2.1 2.1 2.1 1.9 1.9 Diarrhea Years Acute Watery <5 Years 3.3 3.3 3.5 3.1 3.3 4 2.7 2.7 2.5 2.5 2.3 Diarrhea with ≥5 Years 0.9 0.9 0.9 0.9 0.9 1 0.8 0.8 0.8 0.8 0.7 Dehydration

Percentages of suspected Meningitis/SIC, Malaria and Typhoid Fever by Region:

In the epidemiologic week-38 of 2013, a Fig-6: Percentages of Meningitis,Malaria & typhoid Fever from total of 130 suspected cases of Total Clients in W38-13 Meningitis/Severely Ill Child were reported from all regions and the highest percentage was recorded in Central East and South regions. In the same reporting week, from all regions, 2047 Malaria consultations were reported by Sentinel Sites and the highest percentages of Malaria cases were reported from East, South East and South regions with 2.2%, 1% and 0.5% respectively. Out of the total clients, 1981 cases or 0.6% at the national level were reported to be suspected SR CER CWR WR ER NR NER SER Typhoid Fever and the highest percentages Men/SIC 0.1 0.1 0 0 0 0 0 0 of Typhoid Fever cases were reported Malaria 0.5 0.1 0.1 0.1 2.2 0.3 0.2 1 from South East and South and East regions with 1.1% and1% and 0.5% Typhoid Fev 1 0.3 0.5 0.3 1 0.3 0.5 1.1 respectively.

Vaccine Preventable Diseases: Among DEWS target diseases (priority diseases) seven vaccine preventable diseases are included, and their occurrences are changing by seasonal variations. Among these diseases Meningitis/Severely Ill Child is being reported mostly from the North region. In this week out of total 130 cases in country level, 41 cases have been reported from Central East region, 25 cases from the South region and 22 cases from the North region.

In general the highest number of cases of Acute Viral Hepatitis has been reported from the East and South East regions, so in the reporting week out of total 267 cases, 114 cases reported from Central East region, 32 cases were reported from South and South East and 31 cases were reported from North East regions. From a total of 16 Measles cases reported in the reporting week, 8 cases were recorded in South and 5 cases were reported from the Central East regions. Table-5 (below) shows the distribution of vaccine preventable diseases across all reporting regions. Table-5: Suspected Cases of Vaccine Preventable Diseases in W-38 of 2013 by Region Meningitis/ Acute Viral Acute Flaccid Regions Severely Ill Measles Pertussis Diphtheria Tetanus Hepatitis Paralysis Children 25 32 8 0 0 2 0 SR 41 114 5 0 0 0 1 CER 4 0 3 0 0 0 0 CWR 17 21 0 0 0 0 0 WR 2 30 0 0 0 2 1 ER 22 7 0 0 0 0 2 NR 15 31 0 0 0 0 0 NER 4 32 0 0 0 0 0 SER 130 267 16 0 0 4 4 Total

Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks (trend from W25 of 2012 to W38 of 2013): Among the DEWS target diseases, Acute Respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) are the 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-25 of 2012 to week-38 of 2013. In week-25 of 2012, the ARI and ADD curves crossed each other, as ARI started decreasing and ADD changed its course to increase. By the end of the summer season in 2012, these curves crossed one another again in week-36 and from that time to week-06 of 2013; the percentages of ARI were increasing, while the percentages of ADD were decreasing. Both of these groups of diseases reached their extreme points (maximum and minimum values) respectively. In this regard we can say that week-6 of current year was a turning point for both of these groups of diseases, as ARI percentages decreased while ADD percentages increased until the end of summer season. In week-24 and in week-35 the ARI and ADD curves crossed each other. In comparison with previous week the percentage of ARI increased by 0.9% to 18.1%, while the percentage of ADD decreased by 0.7% to 14.4% (Fig-7).

35.0 Fig.-7: Trend of ARI/ADD as Propotion of Total Clients From Week-25 of 2012 to Week- 38 of 2013 ARI 30.0 32.632.3 32.4 32.4 31.2 31.6 ADD 30.5 29.3 29.4 29.1 28.3 28.7 28.4 25.0 27.4 26.1 26.1 24.9 25.1

24.3 23.4 18.9 23.0 18.718.9 20.0 22.022.5 22.2 18.1 17.717.3 17.6 21.8 21.5 17.7 16.816.8 16.5 16.8 20.920.5 16.6 16.816.8 17.0 15.715.7 15.7 19.920.0 19.8 16.015.7 14.4 14.7 19.0 19.1 15.2 15.1 14.4 17.9 18.214.2 14.5 17.2 17.113.3 17.7 16.817.0 14.8 17.317.2 18.1 15.0 16.4 12.6 16.5 16.3 12.012.0 12.0 15.6 14.5 15.2 15.3 10.9 15.4 14.6 14.3 14.5 10.210.3 10.3 10.210.6 14.2 Percentages 14.013.6 13.7 14.0 13.9 13.6 9.8 13.913.9 14.0 13.813.4 12.6 8.8 9.0 10.0 8.17.8 8.3 7.3 6.9 6.87.2 6.4 6.1 6.2 5.4 5.55.8 5.24.9 4.7 4.6 4.7 4.7 4.7 4.8 5.2 5.0

0.0

Weeks of the Year

Mortality: Among DEWS target diseases Pneumonia, Diarrheal Diseases and Meningitis/Severely Ill Children (SIC) are main causes of mortality which generally amount to more than 95% of total deaths of surveillance target diseases. Usually deaths due to diarrheal diseases increase during the summer season, while the number of deaths due to Pneumonia increases during the cold period/Winter Season. In this week out of 37 (18 male, 19 female) deaths reported from all regions, 18 deaths (9 male, 9 female) were caused by Pneumonia, 12 deaths (6 male, 6 female) were caused by diarrheal diseases and 7 deaths (3 male, 4 female) were caused by Meningitis/Severely Ill Children. (Table-6)

Table-6: Deaths by Main Causes of Mortality and by Region in W38 of 2013

Grand Main

Total Total

East East East East West West

Causes of West

North North

South South

Region Region Region Region Region Region Region Region Central

Deaths Central

F F F F F F F F F

M M M M M M M M M Pneumonia 1 1 0 0 2 2 0 0 0 0 4 2 1 1 1 3 9 9 18

Diarrheal 0 1 4 3 1 0 0 0 0 0 1 2 0 0 0 0 6 6 12 Diseases Meningitis/ 0 0 0 2 0 0 0 1 0 0 2 0 0 0 1 1 3 4 7 SIC 1 2 4 5 3 2 0 1 0 0 7 4 1 1 2 4 18 19 37 Total M: Male F: Female

Number of Outbreaks investigated in 2013 with details of W37/W38: Reported outbreaks since first week of 2013 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 10 10 Avian/Swine Flu ARI 3 1 2 SARI 2 2 Measles 29 2 27 Diarrhea 3 1 2 Cholera 16 1 15 Meningitis Hepatitis 3 1 2 Malaria Typhoid 1 1 CCHF 30 30 Bloody Diarrhea 2 2 Chickenpox 7 7 Other 41 2 39 Total 147 7 140

Epidemiological week- 37  Suspected Cholera Outbreak: Reported from Gizak village of Suorai district on Sept 07, 2013. An investigation was conducted on the following day. The health team investigated the affected area and they found 21 cases of suspected cholera cases. There were one case of under five years old and 20 cases of over five years old .Based on sex, there were 10 female and 11 male cases with no deaths associated. It was a clinically confirmed outbreak .The team collected the specimens and sent them to CPHL. The patients were treated and health education and hygiene sessions were conducted for caregivers in addition to also the wells chlorination campaign. Active surveillance system is in place for investigation of further cases.  Suspected CCHF Outbreak: Reported from district nine of Kandahar city of on Sept 08, 2013.The team investigated the case on the same day .The patient has been admitted at the Regional hospital. During the investigation, there was one suspected CCHF case and she was a 16 year old girl .It was a clinically confirmed outbreak and had following signs and symptoms Fever, headache, body pain, Vaginal bleeding and gum bleeding and the team collected lab samples and send them to CPHL .The case was treated and health education session was conducted for his family members The team is investigating for further cases.  Rumor suspected measles Outbreak: reported from Baharak village of Raghistan district of province on Sept 04/2013, the team investigated the area on Sept 06/2013. During the investigation there was no case of measles, and it was a rumor not an outbreak.  Suspected CCHF Outbreak: Reported from Fagdan village of Ghorayan district of on Sept 10, 2013.The team investigated the case on the following day .The patient has been admitted at the regional hospital. During the investigation, there was one suspected CCHF case and field investigation has been perform .It was a clinically confirmed outbreak and the patient was 45year woman .She had contact with animal. The team collected lab samples and send them to CPHL .The case was treated and health education session was conducted for his family members and other .The team is investigating for further cases.  Suspected CCHF Outbreak: Reported from Taryak village of of Herat province on Sept 10, 2013.The team investigated the case on the same day .The patient has been admitted at the regional hospital. During the investigation, there was one suspected CCHF case and field investigation has been perform .It was a clinically confirmed outbreak and the patient was 55 year old man and had contact with animal. The team collected lab samples and send them to CPHL .The case was treated and health education session was conducted for his family members and other .The team is investigating for further cases.

Epidemiological week- 38  Cholera Outbreak: Reported from Metani village of Nangarhar province on Sept 17, 2013. An investigation was conducted on the Sept 18, 2013. The health team investigated the affected area and they found one case of cholera cases with no deaths associated. There was one case of over five years old .The patient was male. It was a clinically confirmed outbreak .The team collected the specimens and sent them to CPHL and the result was positive. The patients were treated and health education and hygiene sessions were conducted for caregivers and villagers in addition to also the wells chlorination campaign. Active surveillance system is in place for investigation of further cases.  Suspected Cholera Outbreak: Reported from Sayed village of Khulm district on Sept 15, 2013. An investigation was conducted on the same day. The health team investigated the affected area and they found 174 cases of suspected cholera cases. There were 90 cases of under five years old and 84 cases of over five years old .Based on sex, there were 85 female and 89 male cases with one deaths associated . It was a clinically confirmed outbreak .The team collected the specimens and sent them to CPHL. The patients were treated and health education and hygiene sessions were conducted for caregivers and surrounding villages in addition to also the wells chlorination campaign. Active surveillance system is in place for investigation of further cases.

ANNEX: Mapping of Density Cases of Selected Diseases in Week-38 of 2013 by Province ª Density Cases of Acute Viral Hepatitis in Week-38 of 2013

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Legend Ghazni Khowst Province_34 Oruzgan (Uruzgan) AVH Farah Paktika 0.000000 Zabol (Zabul) 0.000001 - 2.000000 2.000001 - 3.000000 3.000001 - 7.000000 Helmand Kandahar Nimruz 7.000001 - 9.000000 9.000001 - 10.000000 10.000001 - 12.000000 12.000001 - 16.000000 16.000001 - 23.000000 In this week 357 sentinel sites sent their report 23.000001 - 107.000000

ª Density Cases of Malaria in Week-38 of 2013

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Legend Ghazni Khowst Province_34 Oruzgan (Uruzgan) Mal Farah Paktika 0.000000 - 2.000000 Zabol (Zabul) 2.000001 - 5.000000 5.000001 - 8.000000 8.000001 - 25.000000 Helmand Kandahar Nimruz 25.000001 - 39.000000 39.000001 - 49.000000 49.000001 - 69.000000 69.000001 - 112.000000 112.000001 - 396.000000 In this week 357 sentinel sites sent their report 396.000001 - 738.000000

ª Density Cases of Typhoid Fever in Week-38 of 2013

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Legend Ghazni Khowst Province_34 Oruzgan (Uruzgan) TF Farah Paktika 1.000000 - 4.000000 Zabol (Zabul) 4.000001 - 15.000000 15.000001 - 21.000000 21.000001 - 32.000000 Helmand Kandahar Nimruz 32.000001 - 42.000000 42.000001 - 48.000000 48.000001 - 69.000000 69.000001 - 87.000000 87.000001 - 144.000000 In this week 357 sentinel sites sent their report 144.000001 - 191.000000

ª Density Cases of Pneumonia in Week-38 of 2013

Jowzjan Kondoz (Kunduz) Badakhshan Balkh Takhar

Faryab Samangan Baghlan Sar-e Pol PanjshirNurestan Badghis Konar (Kunar) Bamian Parvan (Parwan) Laghman Kabol (Kabul) Vardak (Wardag) Nangarhar Herat Ghowr Lowgar Daykondi Paktia Legend Ghazni Khowst Province_34 Oruzgan (Uruzgan) Pn Farah Paktika 9.000000 - 24.000000 Zabol (Zabul) 24.000001 - 41.000000 41.000001 - 55.000000 55.000001 - 78.000000 Helmand Kandahar Nimruz 78.000001 - 120.000000 120.000001 - 177.000000 177.000001 - 275.000000 275.000001 - 376.000000 376.000001 - 609.000000 In this week 357 sentinel sites sent their report 609.000001 - 1720.000000