May 5, 2014 DISEASE EARLY WARNING SYSTEM WER-17 (8th Yr) WEEKLY EPIDEMIOLOGICAL REPORT

Summary:

 The surveillance data collected for this weekly report is from 26 April – 2 May 2014.  Out of 378 functional Sentinel sites (SS), 375 (99.2%) have submitted reports for Week-17 of 2014.  Out of a total of 334,602 consultations (142,232 male, 192,370 female) recorded in Week-17 of 2014, 32.9% or 110,155 (52,966 male, 57,189 female) consultations were reported due to DEWS targeted diseases.  Main causes of consultations this week were Acute Respiratory Infections (ARI) (21.6%) and Acute Diarrheal Diseases (ADD) (10.5%) from total clients in a continuing trend from the week before.  A total of 45 deaths reported due to DEWS targeted Diseases, which includes 31 deaths (14 male, 17 female) caused by Pneumonia, 4 death (2 male, 2 female) caused by Diarrheal Diseases, 9 deaths (5 male, 4 female) caused by Meningitis/Severely Ill Children and 1 death (0 male, 1 female) caused by Measles.  In this reporting week, a Suspected Measles Outbreak reported from Urozgan and Kunar provinces.

Reports Received From Reporting Sites:

As of May 2, 2014, 378 sentinel sites were functioning in eight epidemiological regions, in 34 provinces of . In this reporting week, 375 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-17, 2014

h h

Region

Central Central East Central West North Nort East West South East South East Total No. of Expected Reports from 55 33 58 50 39 51 49 43 378 Sentinel Sites No. of Reports Received in this 55 33 58 49 39 49 49 43 375 week

Figure-1 DEWS Sentinel Sites: Table-2: DEWS Epidemiological Regions and Figure-1(Map) shows the Sentinel Sites by type in Week- 17, 2014 distribution of DEWS sentinel

sites established in the

regions/provinces by May 2, h

Type of SS

2014. Table-2 shows the SS

East Central West North North East West Sout East South East Total distribution by type of health Central facility. Data on 15 DEWS target CHC/BHC 28 20 43 39 25 41 39 35 270 diseases are being collected from DH 12 9 10 7 9 5 7 4 63 these sentinel sites (SS). The symbols on the map show the PH/RH/SH 13 4 5 4 4 5 3 4 42 number of sentinel sites in each Poly Clinic 2 0 0 0 1 0 0 0 3 region/province, and do not Total 55 33 58 50 39 51 49 43 378 indicate the GPS of the SS CHC=Comprehensive Health Center, DH=District Hospital, PH=Provincial locations. Hospital, RH= Regional Hospital, SH= Specialized Hospital

DEWS Data in Epidemiological Week-17 of 2014: Out of a total of 334,602 clients recorded in week- 17 of 2014, 18.4% (61,536) of consultations were Fig-2: Percentages of DEWS Target Diseases by

reported due to Cough and Cold and 3.2% (10,550) 25.00 Gender in W17-14 of consultations was reported due to Pneumonia. In 20.00 the same reporting period, 10.5% or 35,213 events 15.00 were reported due to diarrheal illnesses (7.7% due to 10.00

Acute Watery Diarrhea, 2.2% due to Bloody Percentage Diarrhea and 0.6% due to Acute Watery Diarrhea 5.00 with Dehydration). In comparison with the previous 0.00 ARI Men/SI week (W16 of 2014) the percentage of ARI disease ARI Pn AwD BD AwDw AVHep Measle Malaria has decreased by 1.2% to 21.6%, and the percentage C&C C of Acute Diarrheal Disease has increased by 1.5% to Male 20.15 3.77 9.13 2.52 0.76 0.06 0.05 0.05 0.28 10.5%. These variations could be due to changes in Female 17.09 2.69 6.66 1.93 0.55 0.03 0.03 0.04 0.24 temperature /weather during the reporting week. Total 18.39 3.15 7.71 2.18 0.64 0.04 0.04 0.04 0.26 Figure-2 (right) shows the percentages of DEWS target diseases by gender in week-17 of 2014. Percentage of ARI by Weeks and by Age Groups: In the epidemiological week-17 a total of 72,086 events of ARI were reported. 26.2 % of total clients less than 5 years of age were Cough & Cold patients and 14.8% were among the age group 5 years and over. The percentage of C&C (<5 years) consultations in week-8, in comparison with the percentage of C&C in week-17 of 2014, decreased by 7.4%, whereas in case of 5 years and above decreased by 4.9% to 14.8% in this reporting week. The trend of ARI diseases in last 10 weeks can be read in Table-3. The percentages of consultations on Pneumonia cases of age group less than 5 years decreased by 6% in last 10 weeks, whereas the percentage of age group 5 years and over decreased by 1% to 1.5% .

Table-3: Percentages of ARI Diseases during 10 recent weeks by age groups and by weeks Disease Age Week- Week- Week- Week- Week- Week- Week- Week- Week- Week- 8-14 9-14 10-14 11-14 12-14 13-14 14-14 15-14 16-14 17-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) ARI- C&C <5 33.6 33.4 33.8 32.7 30.1 31 30.2 28.2 28.3 26.2 Years ≥5 19.7 19.1 18.8 16.9 17.9 17.6 16.2 15.8 15.6 14.8 Years ARI- <5 12.6 11.4 11 9.5 9.1 9.6 8.6 7.5 6.8 6.6 Pneumonia Years ≥5 2.5 2.4 2.6 2.1 2.3 2 1.8 1.7 1.6 1.5 Years

In the reporting week-17 of 2014, the highest percentages of Cough & Cold were recorded in Khost, Kapisa and Parwan provinces with 37.1%, 26.7% and 25.9%, whereas the lowest percentages of C&C were reported from Farah, Nimroz and Laqghman provinces with 6.7%, 7% and 9.9% respectively. The highest percentages of Pneumonia cases were reported from , Bamyan and Saripul provinces with 6.3%, 6.2% and 6% respectively, whereas the lowest percentages of Pneumonia cases were recorded in Zabul, Nimroz and Paktika provinces with 0.4%, 0.5% and 0.6% respectively. (Fig-3)

50 Fig-3: Percentages of ARI from Total Clients in Week-17 of 2014 40

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SAM BAM Province WAR Pneumonia Cough&Cold

Percentages of Diarrheal Diseases by Weeks and by Age Groups: Figure-4 below shows the percentages of diarrheal diseases (Acute Watery Diarrhea, Bloody Diarrhea and Acute Watery Diarrhea with Dehydration)

30 Fig-4: Percentages of Diarrheal Diseases from Total Clients in week-17 of 2014

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BAM WAR Provinces AWD BD AWDwD

From week-8 to week-17 of 2014 from total clients, Acute Watery Diarrhea among children less than five years of age has increased from 6.7% in week-8 to 14.7% in the reporting week, whereas Acute Watery Diarrhea among age group 5 years and above has been increased by 2.3% to 4.5% (Table-4). Bloody Diarrhea in age group less than 5 years increased by 1.4% in last 10 weeks, while in case of age group 5 years and above has been increased by 0.5%. Acute Watery Diarrhea with Dehydration in age group less than 5 years show an increase by 0.7% in last 10 weeks, while in case of five years and above AWDwD increased by 0.2% in last 10 weeks.

Table-4: Percentages of Diarrheal Diseases from Total Clients during 10 recent weeks by age groups

Week- Week- Week- Week- Week- Week- Week- Week- Week- Week- Disease Age 8-14 9-14 10-14 11-14 12-14 13-14 14-14 15-14 16-14 17-14 (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Acute Watery <5 Years 6.7 6.9 7.5 7.7 8.3 9.2 10.4 11.1 12.4 14.7 Diarrhea ≥5 Years 2.2 2.3 2.6 2.3 2.8 2.9 3.1 3.5 3.8 4.5 <5 Years 2 2 2.1 2.3 2.4 2.4 2.6 2.8 3.1 3.4 Bloody Diarrhea ≥5 Years 1.1 1.2 1.3 1.1 1.4 1.3 1.4 1.5 1.6 1.6 Acute Watery <5 Years 0.5 0.6 0.6 0.6 0.7 0.6 0.8 1 0.8 1.2 Diarrhea with ≥5 Years 0.2 0.3 0.2 0.2 0.2 0.2 0.2 0.3 0.3 0.4 Dehydration

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

In the epidemiologic week-17 of Fig-5: Percentages of Meningitis, Malaria & Typhoid Fever from Total 2014, a total of 143 suspected Clients in W17-14 cases of Meningitis/Severely Ill 1 Child were reported from all regions and the highest 0.8 percentage was recorded in North and Central East regions. In the same reporting week, 0.6

from all regions, 861 Malaria Percentage consultations were reported by 0.4 Sentinel Sites and the highest percentages of Malaria cases 0.2 were reported from East, South and South East regions with 1% 0 and 0.32% respectively. Out of SR CER CWR WR ER NR NER SER the total clients, 1546 cases or Men/SIC 0.05 0.05 0.01 0.05 0.00 0.08 0.04 0.03 0.5% at the national level were Malaria 0.32 0.02 0.03 0.02 1.00 0.15 0.06 0.32 reported to be suspected Typhoid Fever and the highest Typhoid Fev 0.80 0.19 0.38 0.25 0.81 0.37 0.36 0.72 percentages of Typhoid Fever cases were reported from East, South and South East regions with 0.81%, 0.80% and 0.72% 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 143 cases in country level, 44 cases have been reported from North region, 37 cases from the Central East region and 19 cases from the South 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 134 cases, 40 cases reported from Central East region, 24 cases were reported from South East and 16 were reported from South regions. From a total of 146 Measles cases reported in the reporting week, 54 cases were recorded in South, 36 cases were reported from North and 19 cases were reported from 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- 17 of 2014 by Region Meningitis/ Acute Viral Acute Flaccid Total Regions Severely Ill Measles Pertussis Diphtheria Tetanus Hepatitis Paralysis Children 19 16 54 0 0 3 0 92 SR 37 40 9 0 0 0 3 89 CER 3 4 0 0 0 0 2 9 CWR 16 17 5 0 0 0 2 40 WR 1 14 19 0 0 0 1 35 ER 44 6 52 1 0 2 1 106 NR 14 13 7 9 0 0 1 44 NER 9 24 0 0 0 0 0 33 SER 143 134 146 10 0 5 10 448 Total

Percentages of ARI & Diarrheal Diseases by Epidemiological Weeks (trend from W24 of 2013 to W17 of 2014): 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-24 of 2013 to week-17 of 2014. In week-24 of 2013, 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 2013, these curves crossed one another again in week-35 and from that time to week-7 of 2014; the percentages of ARI were increasing, while the percentages of ADD were decreasing and both of these groups of diseases reached their Extreme points (maximum and minimum values) respectively, In this regard we can say that week-7 of current year was a turning point for both of these groups of diseases, namely ARI percentages will decrease, while ADD percentages will increase till end of summer season. Comparing this week data with previous week-16 of 2014, ARI decreased by 1.2% to 21.6%, while ADD increased by 1.5% to 10.5% (Fig-6).

Fig-6: Trend of ARI/ADD as Propotion of Total Clients From Week-24 of 2013 to Week-17 of 2014 40.0

35.0 ARI ADD

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0.0 W24 W26 W28 W30 W32 W34 W36 W38 W40 W42 W44 W46 W48 W50 W52 W1 W3 W5 W7 W9 W11 W13 W15 W17

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 a total of 45 deaths reported due to DEWS targeted Diseases, which includes 31 deaths (14 male, 17 female) caused by Pneumonia, 4 death (2 male, 2 female) caused by Diarrheal Diseases, 9 deaths (5 male, 4 female) caused by Meningitis/Severely Ill Children and 1 death (0 male, 1 female) caused by Measles.(Fig-7)

Fig-7: Deaths due to DEWS targeted diseases in week-17 of 2014

15.50% 2.00% 4.50% 0.50%

Pn 72.04% Diarrheal Disease

Men/SIC

Measles

Other

Report of Outbreaks: Last week, a Suspected Measles Outbreak reported from Wardak, Urozgan, Zabul, Nuristan and Badghis provinces and a Suspected Tinea Outbreak reported from Nimroz province and in this reporting week a Suspected Measles Outbreak reported from Urozgan and Kunar provinces.Table-7 (below) shows the number of outbreaks investigated in 2014 with details of week-16 and week-17 of 2014.

Table-7: Reported outbreaks since first week of 2014 to date Type of outbreak Investigated Rumor Clinic-ally/lab Pertussis 1 1 Avian/Swine Flu 1 1 ARI 4 2 2 Measles 42 42 Diarrhea Meningitis Hepatitis Malaria Typhoid CCHF 4 4 Bl. Diarrhea Chickenpox 6 6 Other 9 1 8 Total 67 3 64

Epidemiological week- 16

 Suspected Measles Outbreak: Reported from Akakhail village of Sayed Abad district, Wardak province on April 19/2014, the team investigated the area on the following day, Vaccination coverage is 40%. During the investigation there were 11 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old and 6 case was over five years old .Based on sex, there was 4 female and 7 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Tinea Outbreak: Reported from nursery school of , Nimroz province on April 01/2014, the team investigated the area on the following day. During the investigation there were 9 Tinea cases ,it was clinical confirm outbreak , There were no cases of under five years old and 9 cases were over five years old .Based on sex, there were no female case and 9 male cases. The cases treated and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Garmab village of district, Urozgan province on April 22/2014, the team investigated the area on the following day, Vaccination coverage is 45%. During the investigation there were 8 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old and 3 case was over five years old .Based on sex, there was 3 female and 5 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Arghandabi village of , on April 22/2014, the team investigated the area on the following day, Vaccination coverage is 33%. During the investigation there were 9 suspected measles cases ,it was clinical confirm outbreak , There were 3 cases of under five years old and 6 case was over five years old .Based on sex, there was 5 female and 4 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Katar Gabir village of Want district, on April 17/2014, the team investigated the area on the April 19/2014, Vaccination coverage is 45%. During the investigation there were 7 suspected measles cases ,it was clinical confirm outbreak , There were 6 cases of under five years old and one case was over five years old .Based on sex, there was 3 female and 4 male cases with one deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Akazia village of Murqab district, on April 17/2014, the team investigated the area on the same day, Vaccination coverage is 100%. During the investigation there were 5 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old but no case of over five years old .Based on sex, there was one female and 4 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases. Epidemiological week- 17

 Suspected Measles Outbreak: Reported from Ashizai Village Urozgan Province on April 26/2014, the team investigated the area on the following day, Vaccination coverage is 30%. During the investigation there were 8 suspected measles cases ,it was clinical confirm outbreak , There were 4 cases of under five years old and 4 cases of over five years old .Based on sex, there was 3 female and 5 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.  Suspected Measles Outbreak: Reported from Shangar and Shal Khaur Village Asmar district on April 26/2014, the team investigated the area on the following day, Vaccination coverage is 70%. During the investigation there were 15 suspected measles cases ,it was clinical confirm outbreak , There were 5 cases of under five years old and 10 cases of over five years old .Based on sex, there was 7 female and 8 male cases with no deaths associated. The team collected lab samples and send them to CPHL, the cases treated. Vaccination campaign was conducted, Vita A supplements was distributed and health education session conducted in surrounding villages, the active surveillance has been established for investigation of further cases.

Recommendations:

 High number of deaths due to Pneumonia and Meningitis/SIC can be analyzed/discussed at provincial level among stakeholders to find out the gaps results the high morbidity and mortality, especially in East and North East regions.  High incidence of Pneumonia overall up to 3.2% and 6.6% in the age group of less than five years should be analyzed and stakeholders should ensure the adequate amount of medicine for the treatment of the cases.  The high number of Meningitis in North, high number of Meningitis and Acute Viral Hepatitis cases in Central East, high number of Measles cases in South and North regions should be analyzed at peripheral level.  The increase in the outbreaks of Measles in South and East regions is to be given serious consideration at the provincial level coordinating agencies.  DEWS focal points should coordinate AFP cases with the provincial AFP surveillance focal point.

ANNEX: Mapping of Density Cases of Selected Diseases in Week-17 of 2014 by Province 8 Density Cases of Pneumonia in Week-17 of 2014

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 Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Legend Zabol (Zabul) Province_34 Pn Helmand Kandahar 15.000000 - 77.000000 Nimruz 77.000001 - 233.000000 233.000001 - 491.000000 491.000001 - 913.000000 913.000001 - 2726.000000

8 Density Cases of Typhoid Fever in Week-17 of 2014

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 Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Legend Zabol (Zabul) Province_34 TF 2.000000 - 12.000000 Helmand Kandahar Nimruz 12.000001 - 26.000000 26.000001 - 61.000000 61.000001 - 104.000000 104.000001 - 164.000000

8 Density Cases of Acute Viral Hepatitis in Week-17 of 2014

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 Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Legend Zabol (Zabul) Province_34 AVH 0.000000 - 1.000000 Helmand Kandahar Nimruz 1.000001 - 4.000000 4.000001 - 7.000000 7.000001 - 13.000000 13.000001 - 39.000000

8 Density Cases of Malaria in Week-17 of 2014

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 Ghazni Khowst

Oruzgan (Uruzgan) Farah Paktika Legend Zabol (Zabul) Province_34 Mal 0.000000 - 5.000000 Helmand Kandahar Nimruz 5.000001 - 15.000000 15.000001 - 38.000000 38.000001 - 70.000000 70.000001 - 315.000000