Epidemiological Week N00 21 (20 – 26 May 2006) 31 May 06/ Vol. 26/ DEWS 2006-21

Reporting Units...... 2 Total number of consultations ...... 2 DEWS Data, Epidemiological Week N0 21 2006...... 3 DEWS Data, Monthly Summary ...... 5 Acute Diarrhoea...... 7 Bloody Diarrhoea...... 7 Acute Jaundice Syndrome...... 8 Malaria ...... 8 Measles ...... 9 Acute Respiratory Infection ...... 10 Maternal and Neonatal Health (UNFPA) ...... 11 Scabies remains a problem in the earthquake-affected areas. The distribution Outbreak Alert and Response ...... 12 of soaps and benzyl benzoate lotion to treat Measles ...... 12 the skin condition caused by bad hygiene Acute Jaundice Syndrome...... 12 due to lack of water is ongoing. Malaria...... 12 For more information on scabies: Number of reported cases and deaths AJK ...... 13 http://www.who.int/water_sanitation_health/di seases/scabies/en/ Number of reported cases and deaths NWFP ...... 14

ƒ In the past month (Epidemiological ƒ Two (2) cases of suspected weeks 18-21 inclusive), 341,521 meningitis with no related death health events under surveillance were reported; 1 case from were reported including 47 deaths. and 1 case from ƒ This week, 213 of the 215 reporting Rawalakot/Poonch district. units (99%) reported a total of ƒ Five hundred and seventy-two (572) 89,374 consultations, including 9 cases of Bloody diarrhoea were deaths. reported; of them, 38% were from ƒ A total of 16,471 ARI cases with 5 district. related death (CFR, 0.030). ƒ Thirty-one (31) cases of suspected ƒ No case of Acute Flaccid Paralysis measles were reported; 58% (18/31) reported from any district. were from .

The Weekly Morbidity and Mortality Report (WMMR) is published by the Ministry of Health of (MOH) and the World Health Organization (WHO). The WMMR is built on surveillance data that health service providers and NGOs transmit on a weekly basis from health facilities and hospitals in those areas affected by the earthquake that struck Pakistan on 8 October 2005.

The WMMR objectives are to monitor the trend of health conditions over a period of time and provide vital information to all health partners. The WMMR is only a snapshot of the health conditions in those facilities where events are registered and data collected and does not necessarily reflect the situation from other health facilities.

The WMMR is a publication that has been developed for emergencies and previously used in other areas such as the Darfur Crisis.

The WMMR is published by the World Health Organization (WHO), Health Emergency Operation Centre, House #6, Street #20, F-7/2, , Pakistan For More Information, please contact: Dr. Hammam El Sakka, Senior Medical Epidemiologist, WHO/EHA/Pakistan; [email protected] or Dr. Birjees Mazher Kazi, Chief, Public Health Laboratories Division, NIH MOH; [email protected] or WHO Webpage: http://www.whopak.org/disaster WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Reporting Units

The total number of reporting sites trained for the Disease Early Warning System (DEWS) in the earthquake affected areas remains 215; 213 (99%) sent their surveillance data on time during the epidemiological week 21 (20-26 May 2006). The reporting timeliness of the DEWS system has increased by 4% compared with the previous week (Epidemiological week 20); mainly due to increase of units reporting from Mansehra, Muzaffarabad and Poonch districts but decreasing in Battagram/Shangla. As the WHO offices in and Mansehra were merged, the surveillance data from Balakot was included together with Mansehra district data (Table 1). Table 1. Number of reporting heath facilities by district, Earthquake Affected Areas, Pakistan, 21 April-26 May 2006. Reporting Health Facilities Area Population 29Apr-5May 6-12 May 13-19 May 20-26 May Week 18 Week 19 Week 20 Week 21 Muzaffarabad 894,364 31 28 27 33 Bagh 452,532 25 31 34 34 Poonch 633,712 50 51 48 52 Mansehra / Balakot 1,154,804 66 62 62 64 Battagram / Shangla 592,256 24 19 32 29 Islamabad 10,500 1 1 1 1 Total 3,738,168 197 (92%) 192 (89%) 204 (95%) 213 (99%)

Total number of consultations

The total number of units reporting on time increased by 9 this week, over the previous week (from 204 units last week to 213 units this week), reporting units are increased in Mansehra, Muzaffarabad and Poonch districts but decrease in . The total number of consultations reported throughout DEWS increased by 9% compared with the previous week (81,821 to 89374). The weekly trend of reporting units participating in the DEWS and the number of consultations is shown in Figure 1.

No. Unit Reporting Units and Consultations No. Consult. 200000 200 Reporting Unit Consultation

150000 150

100000 100

50 50000

0 0 W42W43W44W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21 Week

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 -26 May 2006.

2 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

DEWS Data, Epidemiological Week N0 21 2006

Between 20 and 26 May 2006, 89,374 consultations for health events under surveillance were reported through DEWS. Overall, 19% (16,471) were due to Acute Respiratory Infections (ARI), 11% (9,690) due to Acute Diarrhoea (AWD), 6% (5,813) due to Fever of Unknown Origin (FUO), and 5% (4,418) due to Injuries (INJ). ARI represented 26% and 17% in the less than 5 years old and 5 or more years old respectively. AWD was found to be higher in those less than 5 years old and represented 18% of the total consultations compared to 9% in those 5 years old or more (Figure 2).

AWD ARI AWD ARI 11% 19% 18% 26% AWD ARI 9% 17% FUO 6% FUO FUO 6% INJ 8% 5% INJ INJ OTH 5% OTH 44% 4% 59%

OTH 63%

< 5yrs (n=20,655) ≥ 5yrs (n=68,719) All Ages (n=89,374)

Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 20-26 May 2006. During this reporting week, 33% (29,933/89,374) of all reportable conditions were reported from Mansehra district, 22% (19,870) reported from Muzaffarabad, followed by 19% (17,366) from Bagh district. Less than 1% of the consultations were reported from H-11 camp in Islamabad, due to the decrease in number of IDPs to less than 1,000 populations. The distribution of the total number of consultations by age and district is shown in Figure 3.

No. Cases Consultations by Age and District (n=89,374) 25000 < 5yrs >= 5yrs 20000

15000

10000

5000

0 MUZ-AJK BAG-AJK POO-AJK MAN-NWFP BAT-NWFP ISLA

District / Province

Figure 3. The total number of consultations by age and district, Earthquake Affected Areas, Pakistan, 20-26 May 2006.

3 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

DEWS Data, Epidemiological Week N0 21, 2006, 5 years of age and older In the current week, ARI was the most common health event reported among 5 years of age and older, with 7 related deaths (CFR 0.010). Seventeen (17) clinically diagnosed measles (MES) were reported; of them, 76% (13/17) from Mansehra, 12% (2/17) from Bagh, 1 case from Muzaffarabad and 1 from Poonch district. No measles (MES) cases were reported from Battagram district and H-11 camp Islamabad. One meningitis (MEN) case was reported from Poonch district. No cases of Acute Flaccid Paralysis (AFP) were reported (Figure 4).

12,000

8,000

4,000

0 ARI AWD FUO INJ BD MAL JAU MES MEN AFP TET AHF Cases 11,360 5,875 4,098 3,559 413 289 56 17 1 0 0 0 CFR % 0.044 0 0 0 0 0 0 0 0 0 0 0

Figure 4. Primary causes for the reported cases and weekly CFRs, 5 years of age and older, Earthquake Affected Areas, Pakistan, 20-26 May 2006.

DEWS Data, Epidemiological Week N0 21, 2006, less than 5 years

In the less than 5 year age group, 20,655 consultations were reported; 25% (5,111) of these reported were attributed to ARI with no related death, while 18% (3,815) were due to acute watery diarrhoea (AWD) with no related death. Fourteen (14) clinically diagnosed Measles (MES) cases were reported; of them 36% (5/14) from Mansehra, 3 cases (21%) from Muzaffarabad, 3 cases from Bagh district, 2 cases from Battagram and 1 case from Poonch district . No measles cases were reported from H-11 camp Islamabad. No AFP case reported from any district. One (1) suspected meningitis (MEN) cases were reported from (Figure 5). Please see attached tables (6-11) for district wise reporting.

8,000

4,000

0 ARI AWD FUO INJ BD MAL MES JAU AHF MEN AFP TET Cases 5,111 3815 1,715 859 159 118 14 9 1 1 0 0 CFR % 000000000000

Figure 5. Primary causes for the reported cases and their weekly CFRs, LESS than 5 years old, Earthquake Affected Areas, Pakistan, 20 -26 May 2006.

4 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

DEWS Data, Monthly Summary (Epidemiological Weeks N0 18-21)

In summary for the past month between 21 April and 26 May (Epidemiological weeks 18-21 inclusive), a total of 341,521 health events under surveillance were reported, of which 19% (64,952) were due to acute respiratory infection (ARI), 9% (31,871) acute diarrhoea (AWD), 6% (19,578) Unexplained fever (FUO) and 5% (17,238) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 21 April-19 May 2006. Week WEEK 18 WEEK 19 WEEK 20 WEEK 21 TOTAL CFR% Event C D C D C D C D C D AWD 6475 1 7122 0 8236 0 9690 0 31871 1 0.003 BD 233 1 365 0 404 0 572 0 1597 1 0.000 AFP 2 0 1 0 1 0 0 0 4 0 0.000 MAL 240 0 230 0 263 0 407 0 1176 0 0.000 ARI 17048 1 16026 3 14884 3 16471 5 64952 12 0.018 MES 24 0 24 0 21 0 31 0 101 0 0.000 MEN 2 0 12 2 2 0 2 0 18 2 11.000 JAU 63 0 62 0 82 0 65 0 275 0 0.000 TET 0 0 0 0 0 0 0 0 0 0 0.000 AHF 0 0 0 0 8 0 1 0 9 0 0.000 FUO 4341 0 4703 0 4698 0 5813 0 19578 0 0.000 INJ 3922 1 3993 0 4790 1 4418 0 17238 2 0.012 OTH 52402 10 50440 8 48432 7 51904 4 204702 29 0.014 TOTAL 84752 14 82978 13 81821 11 89374 9 341521 47 RU 197 192 204 213

C – Cases, D – Deaths, AWD - Acute Diarrhoea, BD - Bloody Diarrhoea, AFP - Acute Flaccid Paralysis, MAL – Malaria, ARI - Acute Respiratory Infection, MES – Measles, Men - Meningitis, JAU - Acute Jaundice Syndrome, TET - Neonatal Tetanus, AHF Acute Hemorrhagic Fever, FUO –Unexplained fever, INJ – Injuries, OTH – Others, RU – Reporting Units. Please note data from late reporting in previous weeks has been updated. During the same reporting period, 81,512 consultations were reported in the less than 5 years old group, (24% of the total consultations), of which 26% (21,202) were due to ARI, 16% (12,999) due to AWD, 7% (5,992) due to FUO and 4% (3,523) were reported as injuries (INJ).

Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 21 April-26 May 2006. Week WEEK 18 WEEK 19 WEEK 20 WEEK 21 TOTAL CFR% Event C D C D C D C D C D AWD 2792 1 3028 0 3289 0 3815 0 12999 1 0.008 BD 83 1 125 0 133 0 159 0 508 1 0.197 AFP 1 0 0 0 1 0 0 0 2 0 0.000 MAL 52 0 44 0 52 0 118 0 271 0 0.000 ARI 5808 1 5292 3 4856 1 5111 0 21202 5 0.024 MES 12 0 11 0 16 0 14 0 54 0 0.000 MEN 2 0 6 2 2 0 1 0 11 2 18.000 JAU 21 0 11 0 12 0 9 0 55 0 0.000 TET 0 0 0 0 0 0 0 0 0 0 0.000 AHF 0 0 0 0 4 0 1 0 5 0 0.000 FUO 1331 0 1404 0 1539 0 1715 0 5992 0 0.000 INJ 898 0 750 0 1004 0 859 0 3523 0 0.000 OTH 10033 4 8591 2 9267 0 8853 2 36890 8 0.022 TOTAL 21033 7 19262 7 20175 1 20655 2 81512 17 RU 197 192 204 213

5 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

In the current week, ARI continues to contribute significantly to the overall consultations in all reporting, and showed increase in the total number of cases as compared with the previous week (14,884 last week to 16,471 this week). In the same period, 9,690 AWD cases with no related death were reported and showed an increase in the number of reported cases (from 8,236 last week to 9,690 this week) but not in the overall proportion (10% for the last 2 weeks). The weekly proportion of ARI and AWD is shown in figure 6.

% Consultation ARI and AWD percents of the total consultations 40 35 ARI AWD 30 25 20 15 10 5 0 W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21 Week

Figure 6. Weekly trend of percent consultations of reported ARI and AWD cases, Earthquake Affected Areas, Pakistan, 5 November-26 May 2006.

Since the start of the DEWS system as of 15 October 2005, a total of 380 deaths were reported from the earthquake affected areas; of them, 67% (246/380) were due to disease not under surveillance. Twelve percent (29/246) of the non-communicable disease related deaths were due to injuries. Seventy-six percent (93/123) of the communicable disease-related death were ARI- related deaths. To improve the quality of mortality data, an active collection of the mortality data from DHQ hospitals was established since week 8 of 2006. In the current week, there were 11 reported deaths of them; 3 were ARI-related, and 8 were due to other (OTH) causes. The weekly trend of reported deaths is shown in figure 7.

No. Deaths Total Reported Deaths (n=380) 30 Communicable Diseases* Non Commmunicable 25 20

15 10

5 0 W42W43W44W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21

*Communicable diseases include; ARI, measles, BD, AWD, Tetanus and Meningitis Week

Figure 7. Weekly trend of reported deaths, Earthquake Affected Areas, Pakistan, 5 November 2005-26 May 2006.

6 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Acute Diarrhoea

During the epidemiological week 21, a total of 9,690 AWD cases were reported with No related death; of them, 38% (3,676/9,690) were reported from Mansehra district. In all districts, the number of AWD cases over 5 years old is greater than the number under 5 years of age (5,875 and 3,815 respectively). The distribution of reported AWD cases by age and district is shown in figure 8.

AWD Cases by Age and District

29 ISLA 17 Cases < 5yrs Cases >= 5yrs 721 POO 424 800 BAT 444 876

District BAG 461 1473 MUZ 769 1976 MAN 1700

Figure 8. Distribution of AWD cases by age and district, Earthquake Affected Areas, 20-26 May 2006.

Bloody Diarrhoea

Between 15 October 2005 and 26 May 2006, a total of 12,693 cases of clinically diagnosed Bloody diarrhoea (BD) were reported from the earthquake affected areas. In the current week, 572 cases with no related death were reported; of them, 38% (220/572) were reported from Mansehra followed by 31% (178/572) from Muzaffarabad, and 14% (81/572) from Bagh district. The weekly trend of bloody diarrhoea cases is shown in figure 9.

Bloody Diarrhoea Cases (n=12,693) No. Cases 1400 1200 1000 800 600 400 200 0 W42W43W44W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21

Week

Figure 9. Weekly trend of reported bloody diarrhoea cases, Earthquake Affected Areas, Pakistan, 15 October 2005 -26 May 2006.

7 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Acute Jaundice Syndrome

Between 15 October 2005 and 26 May 2006, a total of 1,538 cases of Acute Jaundice syndrome (AJS) with 5 related deaths were reported from the earthquake affected areas. In the current week, 65 cases with no related death were reported; of them, 37% (24/65) were reported from Mansehra followed by Bagh 29% (19/65) and 20% (13/65) from Muzaffarabad district. Up to date, NIH, Islamabad, reported 20 positive Hepatitis E IgM positive results (out of 157 samples) using Enzyme Immuno Assay (EIA), 11 cases from Bagh, 7 cases form Mansehra and 2 case from Poonch district. The weekly trend of reported cases is shown in figure 10.

Acute Jaundice Syndrome Cases (n=1,538) No. Cases 200

150

100

50

0 W42W43W44W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21

Week

Figure 10. Weekly trend of Acute Jaundice Syndrome, Earthquake Affected Areas, Pakistan, 15 October 2005-26 May 2006.

Malaria

So far, 3,319 cases of clinically diagnosed malaria were reported from the earthquake-affected areas. In the current week, 407 cases with no related death were reported; of them, 36% (146/407) were reported from Poonch followed by Mansehra 35% (145/407) and 12% (51/407) from Muzaffarabad district. One Malaria (MAL) Case reported from H-11 camp Islamabad. The weekly distribution of the reported malaria cases is shown in figure 11.

Malaria Cases (n=3,319) No. Cases 500

400 300 200

100

0 W42W43W44W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21

Week

Figure 11. Weekly trend of reported bloody diarrhoea cases, Earthquake Affected Areas, Pakistan, 15 October 2005 -26 May 2006.

8 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Measles

Between 5 November 2005, and 26 May 2006, a total of 531 clinically diagnosed measles including 2 related deaths (CFR 0.372) were reported from the earthquake-affected areas. In the current week, 31 cases of suspected measles were reported and showed increase compared with the previous week. In the current week, 31 cases with no related death were reported; of them 45% (14/31) were under 5 year old. Overall, 58% (18/31) were reported from Mansehra district, followed by 16% (5/31) from Bagh district, 4 cases from Muzaffarabad district, 2 cases from Battagram and 2 cases were reported from Poonch district. No case were reported from and H- 11 camp, Islamabad The weekly trend of measles cases is shown in figure 12.

Measles Cases (n = 531) No. Cases 50 47 40 36 31 30 26 24 20 22 19 24 22 24 20 23 21 21 17 17 17 15 13 11 15 14 12 10 10 9 10 4 5 8 0 W45W46W47W48W49W50W51W52W1W2W3W4W5W6W7W8W9W10W11W12W13W14W15W16W17W18W19W20W21

Week

Figure 12. Weekly trend of reported measles cases, Earthquake Affected Areas, Pakistan, 5 November 2005-26 May 2006.

Between 1st of November and 26th of May, a total of 81 samples of clinically diagnosed measles cases were collected from the earthquake affected areas and sent to NIH, Islamabad for laboratory confirmation; of them 75% (61/81) were positive either for measles IgM or IgG using Enzyme Immuno Assay (EIA). Seventy-seven percent (47/61) were positive for IgM, 10% were positive for both IgM and IgG and 13% (8/61) were positive for measles IgG. From the overall positive samples (either IgM alone or both IgM and IgG; n=53); 47% (25/53) were reported from Muzaffarabad, 42% (22/53) from Bagh, 12% (6/53) from H-11 Camp, Islamabad, followed by 9% (5/53) and 6% (3/53) were reported from Battagram and Mansehra respectively. No laboratory confirmed measles cases were reported from Poonch district. The distribution of measles serology results is shown in table 4. Table 4. Distribution of Measles Serology results by district, Earthquake Affected Areas, Pakistan, 1 November 2005-23 May 2006. District / Province Area AJK NWFP ICT TOTAL MUZ BAG POO BAT MAN H-11 ISL Measles IgM 25 10 0 5 1 6 47 IgM and IgG 0 5 0 0 1 0 6 Measles IgG 0 7 0 0 1 0 8 TOTAL 25 22 0 5 3 6 61 MUZ –Muzaffarabad, BAG-Bagh, POO-Poonch, BAT-Battagram, MAN-Mansehra, and ISL-Islamabad

9 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Acute Respiratory Infection

In the last four epidemiological weeks, there was a decrease of number of reported ARI cases but increase in Muzaffarabad and Poonch district. Overall, the number of reported ARI cases increase by 10% compared to the last week (from 14,884 last week to 16,471 this week). The weekly distribution of reported ARI cases by district is shown in figure 13.

No. Cases Weekly ARI Cases by District 8000 W18 W19 W20 W21 6000

4000

2000

0 MAN-NWFP BAT-NWFP MUZ-AJK BAG-AJK POO-AJK ISLA

District

Figure 13. The weekly distribution of reported ARI cases by district, Earthquake Affected Areas, Pakistan, 20-26 May 2006.

In the current week, although the number of ARI cases 5 years old and older is greater than the number under 5 years old (11,360 and 5,111 respectively), the overall portion of the disease is higher in the under 5 years old of age (13% and 6% respectively). Overall, 35% (5,710/16,471) were reported from Mansehra district, followed by Muzaffarabad and Bagh districts (25% and 19% respectively). The distribution of ARI cases by age and district is shown in figure 14.

ARI Cases (n = 16,471) No. Cases 8000 Cases < 5yrs Cases >= 5yrs 6000

4000

2000

0 MUZ-AJK BAG-AJK POO-AJK MAN-NWFP BAT-NWFP ISLA

District

Figure 14. Distribution of ARI cases by age and district, Earthquake Affected Areas Pakistan, 20-26 May 2006.

10 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Maternal and Neonatal Health (UNFPA)

Services provided by 9 MSUs in 3 districts and prefab MCH units (October 2005-28 May 2006)

Total no. of deliveries 2,215 Total no. of referrals for c-sections 272 Total no. of patient seen 214,408

The seventh prefabricated Rural Health Centre has been installed in Chowki, Mansehra district. Besides the hospital part, a residential area of health staff is provided.

UNFPA and the Ministry of Health in Mansehra provided 600 clean delivery kits to the NGO Mercy Corps as well as 6 sets of Maternal and Child Health Care educational charts (covering different pregnancy-related complications) for their six health facilities in Sirin and Konsh Valleys. Mercy Corps assisted UNFPA in the distribution of 200 hygiene kits during their Health and Hygiene sessions.

On the occasion Mother’s Day, UNFPA arranged for several celebrations in Muzaffarabad district.

A one-day conference on postpartum haemorrhage and its management for doctors and other health personal was conducted by UNFPA at AIMS hospital in Muzaffarabad.

Table 5. Weekly Maternal and Neonatal Health caseload, Earthquake Affected Areas 1-28 May 2006. 1-7 May 2006 8-14 May 2006 15-21 May 2006 22-28 May 2006 NWFP AJK NWFP AJK NWFP AJK NWFP AJK Antenatal care 398 1088 356 1164 356 1164 349 1345 Post natal care 110 208 100 213 100 213 106 212 Deliveries 36 127 25 74 25 74 25 108 Spontaneous 14 42 13 53 13 53 12 41 abortion MVA/ D&C 0 21 0 16 0 16 0 22 Retained placenta 5 2 2 6 2 6 3 2 referral for C- 0 12 0 67 0 67 0 18 section IUD 0 5 0 21 0 21 0 11 STI 32 49 37 30 37 30 26 25 FP 152 218 150 199 150 199 171 211 DUB 0 49 0 40 0 40 0 56 overall number of 2141 5561 1846 5071 1846 5071 1746 5927 patient contacts MVA - Manual Vacuum Aspiration, D&C - Dilatation & Curettage, IUD - Intrauterine Deaths, STI – Sexually Transmitted Infection, FP – Family Planning, DB - Dysfunctional Uterine Bleeding

11 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27/ DEWS 2006 -21

Outbreak Alert and Response1

Measles

Mansehra Case investigation into 9 suspected cases of measles reported by the Pakistani Army Field Hospital in Bassian, , revealed an incorrect diagnosis. WHO in collaboration with the Expanded Programme of Immunization (EPI) team will be conducting alert investigation in respective patients’ villages and/or settlements soon. Cluster of cases with Acute Jaundice Syndrome was reported by PIMA field clinic in Hassa, Balakot.

Rawlakot/Poonch One suspected case of measles was reported in Parahatti Rawalakot. The 8-year-old girl was apparently vaccinated. Blood sample was collected a for laboratory confirmation.

Acute Jaundice Syndrome

Mansehra Cluster of cases with Acute Jaundice Syndrome was reported by the PIMA field clinic in Hassa, Balakot.

Rawalakot/Poonch Two outbreak investigations were carried out into clusters of suspected cases of Acute Jaundice Syndrome in Paniola and Rehara. In Paniola, the 24-year-old man studies in , where several of his fellow students were reported to have similar symptoms. Blood sample was collected and sent for laboratory confirmation. In Rehara, blood sample was taken from a 10-year-old girl. Hygiene promotion sessions was conducted in the village.

Malaria

Mansehra A total of 53 suspected cases of malaria were reported by the Pakistan Army Field Hospital in Bassian, Balakot. Most of the cases were diagnosed on clinical basis. Hospital authorities were emphasized to carry out laboratory analysis for confirmation and identification of species.

1 Outbreak Investigation and response of Acute Jaundice Syndrome, Malaria, and Bloody Diarrhoea would only take place when a cluster of cases is identified or there is an increase in the incidence of the disease.

12 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27 / DEWS 2006-21

Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, Bagh District, Earthquake Affected Areas, Pakistan, 20-26 May 2006. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 18 1248 0 38 0 0 0 18 0 3390 0 1 0 0 0 14 0 0 0 0 0 550 0 798 0 9748 0 19 1219 0 67 0 0 0 8 0 3474 2 2 0 5 0 18 0 0 0 0 0 635 0 842 0 12324 0 20 1428 0 100 0 1 0 13 0 3256 0 4 0 0 0 24 0 0 0 0 0 565 0 1564 0 11027 0 21 1337 0 81 0 0 0 18 0 3096 5 5 0 0 0 19 0 0 0 0 0 497 0 889 0 11424 0 Total 5232 0 286 0 1 0 57 0 13216 7 12 0 5 0 75 0 0 0 0 0 2247 0 4093 0 44523 0

Table 7. Number of reported cases and deaths, Poonch District, Earthquake Affected Areas, Pakistan, 20-26 May 2006 AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 18 795 0 34 0 0 0 96 0 1831 0 1 0 1 0 5 0 0 0 0 0 975 0 622 0 6941 4 19 736 0 22 0 0 0 89 0 2034 0 0 0 2 1 6 0 0 0 0 0 1427 0 788 0 9693 2 20 836 0 15 0 0 0 86 0 1946 2 0 0 1 0 3 0 0 0 0 0 1238 0 835 1 8055 2 21 1145 0 46 0 0 0 146 0 2546 0 2 0 1 0 6 0 0 0 0 0 1186 0 776 0 9323 0 Total 3512 0 117 0 0 0 417 0 8357 2 3 0 5 1 20 0 0 0 0 0 4826 0 3021 1 34012 8

Table 8. Number of reported cases and deaths, Muzaffarabad District, Earthquake Affected Areas, Pakistan, 20-26 May 2006 AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 18 1172 1 71 1 0 0 81 0 3266 0 15 0 0 0 14 0 0 0 0 0 767 0 1295 0 11594 1 19 1831 0 100 0 0 0 81 0 3867 0 10 0 3 0 13 0 0 0 0 0 1005 0 1537 0 10446 0 20 1827 0 67 0 0 0 47 0 3144 0 6 0 0 0 9 0 0 0 8 0 736 0 1053 0 11012 0 21 2242 0 178 0 0 0 51 0 4074 0 4 0 1 0 13 0 0 0 1 0 1126 0 1455 0 10725 0 Total 7072 1 416 1 0 0 260 0 14351 0 35 0 4 0 49 0 0 0 9 0 3634 0 5340 0 43777 1

13 WMMR Weekly Morbidity and Mortality Report Pakistan 30 May 2006 / Vol. 27 / DEWS 2006-21

Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 20-26 May 2006 AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 18 985 0 21 0 0 0 4 0 1447 0 2 0 0 0 3 0 0 0 0 0 538 0 196 0 4975 0 19 830 0 32 0 0 0 22 0 1121 0 4 0 0 0 3 0 0 0 0 0 228 0 196 0 2612 0 20 1330 0 87 0 0 0 74 0 1176 0 11 0 0 0 23 0 0 0 0 0 357 0 174 0 3414 0 21 1244 0 47 0 0 0 46 0 1024 0 2 0 0 0 3 0 0 0 0 0 428 0 193 0 3860 0 Total 4389 0 187 0 0 0 146 0 4768 0 19 0 0 0 32 0 0 0 0 0 1551 0 759 0 14861 0

Table 10. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 20-26 May 2006 AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 18 2218 0 64 0 2 0 41 0 7064 1 0 0 1 0 27 0 0 0 0 0 1480 0 998 1 18921 4 19 2451 0 144 0 1 0 30 0 5514 1 3 0 2 1 21 0 0 0 0 0 1408 0 622 0 15246 6 20 3129 0 159 0 0 0 79 0 5862 1 1 0 1 0 26 0 0 0 0 0 1770 0 1273 0 16395 5 21 3676 0 220 0 0 0 145 0 5710 0 18 0 0 0 24 0 0 0 0 0 2538 0 1092 0 16510 4 Total 11474 0 587 0 3 0 295 0 24150 3 22 0 4 1 98 0 0 0 0 0 7196 0 3985 1 67072 19 Data from Balakot Tehsil were merged with the data from Mansehra district (Balakot data was presented in the previous weeks as separated table).

Table 11. Number of reported cases and deaths, Islamabad, H-11 Camp, Pakistan, 20-26 May 2006 AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH Week C D C D C D C D C D C D C D C D C D C D C D C D C D 18 57 0 5 0 0 0 0 0 50 0 5 0 0 0 0 0 0 0 0 0 31 0 13 0 223 0 19 55 0 0 0 0 0 0 0 16 0 5 0 0 0 1 0 0 0 0 0 0 0 8 0 119 0 20 34 0 2 0 0 0 0 0 23 0 0 0 0 0 0 0 0 0 0 0 55 0 6 0 53 0 21 46 0 0 0 0 0 1 0 21 0 0 0 0 0 0 0 0 0 0 0 38 0 13 0 62 0 Total 192 0 7 0 0 0 1 0 110 0 10 0 0 0 1 0 0 0 0 0 124 0 40 0 457 0

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