Weekly Bulletin Epidemiological Disease early warning system and response in Pakistan Volume 2, Issue 23, Monday 14 June, 2011 Highlights Priority diseases under surveillance Epidemiological week no. 23 (3 - 9 June, 2011) in DEWS Acute Flaccid Paralysis (AFP) • 89 districts in 5 provinces, FATA, AJK, and ICT provided surveillance data to the DEWS. This sys- tem is gradually expanding to provide information about communicable disease threats in all parts of Acute Jaundice Syndrome (AJS) Pakistan. Currently 76 DEWS surveillance officers are responding to alerts in 104 districts and agen- Acute Respiratory Infections cies. (Upper and Lower) (ARI) • 3,194 fixed health facilities and 3 mobile medical outreach centres provided surveillance data for this Acute Watery Diarrhoea (AWD)/ week. Suspected Cholera • A total of 995,760 consultations were reported through DEWS of which 19% were acute respiratory Acute Bloody Diarrhoea (BD) infections (ARI), 10% acute diarrhoea, 10% skin disease, and 6% were suspected Malaria. Other Acute Diarrhoeas (AD) • A total of 135 alerts were reported in week-23, 2011: Altogether 70 alerts were for Measles; 33 were Suspected Viral Hemorrhagic for AWD, 10 were for Pertussis, 5 were for Acute diarrhoea, 4 were for Leishmaniasis, 3 each were for Fever (VHF) Dengue Hemorrhagic Fever and Scabies, 2 each were for Malaria and Meningitis, while 1 each for Suspected Malaria (Mal) bloody diarrhoea, Monkeypox and Neonatal Tetanus. Suspected Measles (MS) • National Polio Eradication Initiative reported no confirmed polio case this week. Total 49 cases have been reported in 2011 from 23 districts. Suspected Meningitis (MG) Others Figure‐1: Three years trend of Acute diarrhoea in Pakistan, (2009, 2010 and 2011) 20 2009 2010 2011 16 12 Percentage 8 4 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Epi‐week Disease Wk-16 Wk-17 Wk-18 Wk-19 Wk-20 Wk-21 Wk-22 Wk-23 Other Acute Diarrhoea (Not Watery) 92,739 (10%) 90,508 (10%) 85,473 (10%) 94,472 (10%) 102,955 (11%) 106,720 (10%) 102,005 (10%) 98,438 (10%) Total consultation 966,371 893,017 864,932 904,711 976,358 1,020,071 995,731 995,760 Figure‐1 above represents trend of "proportional morbidity." This is the number of new consultations for acute diarrhea di‐ vided by the total number of consultations. The very dramatic peak starting about week 31, 2010, demonstrates the increase in acute diarrhoea cases from the flood‐affected areas starting in KP the first week of August 2010. The “proportional morbidity” of diarrhoea in 2011 so far follows the seasonal trend of 2009 and early 2010. While the overall diarrhea trend so far this year is following the usual proportional morbidity, the cholera cases and outbreaks are above the usual and starting earlier than usual. Last week 17 districts had outbreaks of AWD. 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. 23 (3 - 9 June, 2011) Table‐2: Leading causes of seeking health care in flood affected districts, 29 July 2010 to 9 June 2011, Figure‐2: Weekly number of reporting health facilities (Wk 33/2010 to Wk 23/2011) compiled from weekly reports 3500 Diseases Total 7 3 7 Mobile Fixed 8 6 7 7 7 6 8 3000 13 6 Skin Diseases 3,283,228 (11%) 6 6 8 8 8 2500 8 8 11 11 8 11 8 Acute Respiratory Infection 7,574,928 (24%) 11 2000 8 12 411 400 375 11 1500 331 215 361 192 3250 26 3215 3196 3194 3120 153 3058 26 3021 3022 Acute Diarrhoea 2,871,227 (9%) 2982 2935 2909 128 2785 2745 105 46 2547 81 2466 2450 2404 58 2349 1000 2322 2262 2255 2251 2199 2022 2021 1797 Bloody Diarrhoea 267,152 (1%) 1680 500 1463 1289 1215 1167 1158 1143 1130 999 1111 1113 967 949 1073 1067 879 854 Suspected Malaria 1,825,523 (6%) 0 9 7 5 3 11 11 13 15 17 19 21 23 33 35 37 39 41 43 45 47 49 51 ‐ Unexplained Fever 1,220,478 (4%) 1 Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Total Consultations 31,198,946 Wk Focus on: Crimean Congo Haemorrhagic Fever (CCHF) Following the report of two cases of Hemorrhagic Fever from KP with test pending, we would like to send reminder to all clinicians that incidence of Cri‐ mean Congo Haemorrhagic Fever (CCHF) typically has two peaks in Pakistan – June and September ‐ believed to correspond with the movement of live‐ stock to the mountains to graze in the spring and back to the valleys in the winter. CCHF is a viral haemorrhagic fever transmitted to humans by the bite of the Hyalomma tick or by di‐ rect contact with blood of an infected animal or hu‐ man. CCHF is a severe disease with a high case fatal‐ ity rate ranging from 2% to 50%. Survival is improved with appropriate treatment with fluids, blood products and Ribavirin (anti‐viral). Universal precautions should be taken to protect against infection from any hemorrhagic case appearing in the ER, for example, with ENT bleeding or acute abdomen. Prevention strategies focus on prevention of tick bites or handling ticks and careful management of slaughtering to avoid contact with fresh blood. Further information is available on NIH and WHO Pakistan websites. 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 new type-1 polio cases confirmed by the laboratory is 49 till date from 23 districts. Cases 2010 Cases 2011 Province P1 P3 P1 P3 Punjab 6 1 - - Sindh 26 1 12 - Khyber Pakhtunkhwa 19 5 5 - FATA 63 11 18 - Balochistan 6 6 13 - AJK - - - - Gilgit‐Baltistan - - 1 - Islamabad - - - - Total 120 24 49 - 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. 23 (3 - 9 June, 2011) Previous week's Outbreaks: Date Disease Province District Area <M >M <F >F Action Taken Field investigation conducted. Sample was collected and found positive for V.c. Ogawa. Source of drinking Lower Village Charingo 27 May. AWD KPK 0 1 0 0 water protected Tube well. Poor household and personal hygiene and water handling practice. Provided Dir Lajbook 200 aqua tabs, 20 soap units and IEC material to the affected families and Health education was given. 7 confirmed cases of enteric Fever/Typhoid fever were reported from BHU Bassu Mera. On investigation and active surveillance 3 more positive cases were found. Blood samples were taken from 2 cases for Afghan Refugee typhoid and they also reported positive. Environmental assessment was carried out, 2 out of 4 water 28 May. Typhoid KPK Haripur Camp Bassu Mera‐UC 0 3 0 7 samples were contaminated including source. 2000 Aqua tabs distributed. EDOH and Save the Children Gudwalian were informed and conducted Health and Hygiene sessions for the affected population. Health promotion campaign for all the Afghan refugee camps has been planned. 1 specimen was collected and found positive for V.c. Ogawa. The water sources were examined thor‐ oughly and 6/12 samples were found bacteriological contaminated. A medical relief camp was established (1 Doctor, 2 LHVs and one paramedical staff deployed) 6 were in Basti M. Buksh, Mouza Sikandarabad Rahim Sheikh Wahan Mian‐ 31‐May AD Punjab 0 8 1 10 where 53 AD patients treated on the first day. Staff of RHC Mianwali Qureshian trained in management of Yar Khan wali Qureshian Acute diarrheal diseases and stocks of essential medicine were moved to RHC. Aqua tabs, Jerry Cans, Life straws and Soaps were distributed among residents of all the 03 villages. Health Education sessions were conducted on Safe Drinking Water, use of ORS, use of life straws, and general health and hygiene. Stool sample was collected and found positive for V.c.Ogawa. 1 out of 2 Drinking water samples from water sources was contaminated. Nearest RHC was visited and briefed on the situation, control measures and importance of awareness among general masses about safe drinking water, food and personal hy‐ Mian‐ 2‐Jun AD Punjab DHQ Hospital ‐Moch 1 5 0 5 giene. EDO(H) Mianwali and MS of DHQ Hospital Mianwali were informed about the situation and provi‐ wali sion of rehydration medicine and support during the patient’s stay in hospital was ensured. In the locality/ area no more cases of AWD were found. Soap, water containers, aqua tabs and IEC materials distributed in community. Two samples were found positive for V.c. Ogawa. 4/9 water samples tested positive for bacteriological Chongi No. 6, Gul‐ contamination from different sources. Health education session were conducted. MD WASA was met 30‐May AWD Punjab Multan 0 2 0 0 gasht; Rasheedabad and requested for arrangement of filtration plant in the locality. During filed investigation 10 houses were investigated and no more cases found.