Ministry of Naonal Health Services, Regulaons & Coordinaon Government of Pakistan Naonal Instute of Health, Islamabad, Pakistan Field Epidemiology & Disease Surveillance Division (FE&DSD) Tel: 051-9255237, 9255575 Naonal Focal Point for Internaonal Health Regulaons (IHR) 48th Issue June - September 2020 SEASONAL AWARENESS AND ALERT LETTER (SAAL) For Epidemic-prone infectious diseases in Pakistan Summer / Monsoon Season OBJECTIVES OF SAAL Outbreak - Prone Diseases Alerts Ÿ To alert concerned health authories and professionals at all levels about the Chikungunya epidemic-prone infecous diseases in the summer/Monsoon season. Cholera (Acute watery Diarrhea) Ÿ To facilitate the preparaons for mely and efficient response to the Coronavirus disease 2019 (COVID-19) encountered alerts/outbreaks/ epidemics and thus reduce the associated Crimean Congo Hemorrhagic Fever (CCHF) morbidity and mortality. Dengue Fever DATA SOURCES Diphtheria The available naonal data collected during 2015 to May 2020 by FE&DSD, NIH, Leishmaniasis Provincial Health Departments, Provincial Disease Surveillance & Response Units Malaria (PDSRUs), Expanded Program on Immunizaon (EPI), Directorate of Malaria Control and laboratory based data from NIH has been analyzed to assess the Measles exhibited paerns of high priority communicable diseases. Meningococcal Meningis The descripon of all priority diseases has been arranged in an alphabecal order. Pertussis Addionally, under the secon of Naonal Potenal Public Health Events, Poliomyelis technical detail on the Heat stroke and Primary Amebic Meningoencephalis Typhoid Fever (XDR) infecon is included. Ebola Virus disease and Middle East Respiratory Syndrome High Alert- peak occurrence in the Summer/Monsoon season Corona Virus (MERS CoV) have been shared as Internaonal Public Health Events. Medium Alert- cases will be encountered and may show up as an outbreak Cholera (Acute Watery Diarrhea) Reported Lab Confirmed AWD Cases month wise in Pakistan from Introducon: Cholera is an acute, diarrheal illness caused by January 2014 to May 2020 (n=4,551) infecon of the intesne due to bacterium Vibrio cholerae. It 1200 remains a global threat to public health and is global indicator 1000 of inequity and lack of social development. It is esmated that 800 every year, there are 1.3 to 4.0 million cases of cholera, and 600 21,000 to 143,000 deaths worldwide due to the infecon (1). No. of Cases 400 Clinical Picture: Cholera infecon is oen mild or without 200 symptoms, but can somemes be severe and life threatening. 0 Approximately 5-10% infected persons in the early stages will Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec have severe disease characterized by profuse watery diarrhea, Months voming, and leg cramps. In these people, rapid loss of body Average Trend 2014 2015 2016 fluids leads to dehydraon and shock (1). 2017 2018 2019 2020 Reservoir of Infecon: Humans and aquac environment are Geographical Distribuon in Pakistan: reservoirs for V. cholerae O1 and O139. Humans are considered the primary reservoir and can be asymptomac Province/Area wise Distribuon of Lab Confirmed AWD Cases in carriers (2). Pakistan from January 2014 to May 2020 (n=4,551) Infecous Agent: Vibrio cholerae (1) 80.00% 72% Mode of transmission: Infecon results from ingeson of 70.00% organisms present in contaminated food and water or directly 60.00% from person to person by the fecal–oral route (3) e (%) ag t 50.00% Incubaon period: Few hours to 5 days (4) cen er Infecvity period: The contagious period for cholera begins as P 40.00% soon as the organism is excreted in the feces. This can occur as 30.00% early as about 6 to 12 hours aer exposure to the bacteria and 20.00% 13% 12% can last for about 7 to 14 days (5). 10.00% Seasonality: Throughout the year; higher incidence from 0.11% 1% 1.54% 0.00% 0.00% 0.00% August to November in hot, humid and rainy season (6). IslamabadPunjab Sindh KPK Balochistan AJK GB KPTDs Province/Area Alert Threshold: One suspected case of AWD is an alert (7). vaccinaon against cholera is not a substute for standard Outbreak Threshold: One lab confirmed case, or cluster of 6 or prevenon and control measures (4). more cases of AWD in one locaon, is an outbreak (7). References: References are available in online version at Case Definions: www.nih.org.pk Suspected case: Three or more abnormally loose or fluids Coronavirus Disease 2019 (COVID-19) stools in the past 24 hours and/with dehydraon Probable Case: Introducon: A Novel Coronavirus Disease (COVID-19), is a Ÿ Person aged over 5 years with severe dehydraon or death member of the coronavirus family that has never been from acute watery diarrhea with or without voming OR idenfied or encountered before. Coronaviruses are large Ÿ Person aged above / less 2 years with acute watery diarrhea family of viruses causing illness in humans as well as among in an area where there is a Cholera outbreak. animals i.e. camels, cats and bats. MERS-COV and SARS-CoV-1 Confirmed Case: Any suspected case confirmed through also belongs to the same family. isolaon of Vibrio cholerae 01 or 0139 from the stool (7) Outbreak of this viral disease started in Wuhan city, capital of Specimen Collecon and Transportaon: central China's Hubei province during late December 2019, Ÿ Place specimen in clean container and transport to when a cluster of paents were admied to hospitals in Wuhan laboratory within two hours of collecon at room with an inial diagnosis of pneumonia of unknown aeology temperature (1). The cluster was epidemiologically linked to a local seafood Ÿ If there is a 72 hours delay, place stools soaked swab in a and wet animal wholesale market, suggesve of zoonoc spill Cary-blair transport medium (7). over. Amid the rising spread of the 2019 Novel Coronavirus Case Management: ORS should be given orally every hour. Even cases globally, the World Health Organizaon has declared this with severe dehydraon, intravenous electrolyte soluons outbreak as a Public Health Emergency of Internaonal should be used only for inial rehydraon, including those who Concern (PHEIC) on January 30, 2020 (2). are in shock. Severely dehydrated paents require th st administraon of intravenous fluids. Ringer's Lactate Soluon COVID-19 cases from 26 February to 31 May, 2020 in Pakistan: (Hartman's Soluon) is the preferred fluid for intravenous Number of COVID-19 Number of COVID-19 Number of deaths rehydraon. suspected cases ll Lab. confirmed cases due to COVID-19 ll Anbiocs (Doxycycline, Ciprofloxacin, Cefixime, Co- date ll date date trimaxozole, Erythromycin) reduce the duraon of disease and 5,27,173 72,460 1,543 period of excreon of V. cholerae in the stool of an infected Infecous Agent: Severe acute respiratory syndrome paent (7). Prevenve measures & vaccinaon: Ensure adequate safe coronavirus-2 (SARS-CoV-2) belongs to the beta CoV category drinking water supply and proper sanitaon. (7). of coronavirus family. It's a single-stranded RNA genome (3). People (visitors or residents) in areas where cholera is occurring Clinical Picture: The clinical course of the COVID-19 is divided o r h a s o c c u r re d s h o u l d o b s e r v e t h e fo l l o w i n g into three categories; recommendaons: Mild Symptoms: It usually presents with symptoms of upper Ÿ Drink only boled, or chemically treated water and boled respiratory tract viral infecon, including fever, cough (dry), or canned carbonated beverages. When using boled sore throat, and nasal congeson. Some paents may present drinks, make sure that the seal has not been broken. To with gastrointesnal symptoms like nausea, voming, make water safe for drinking, it is advisable to boil or diarrhea, loss of sense of smell and taste. chlorinate it. Moderate Symptoms: Respiratory symptoms include cough Ÿ Use boled, boiled or chemically treated water to wash and shortness of breath (or tachypnea in children) with or Fruits, Vegetables & dishes and for preparing food. without fever may present, coupled with headache, muscle Ÿ To disinfect water: boil for 1 minute or filter the water and pain, or malaise and later loss of smell and taste in some cases. add 2 drops of household bleach or ½ an iodine tablet per Severe Symptoms: High grade fever is associated with severe liter of water dyspnea, respiratory distress, tachypnea (> 30 breaths/min), Ÿ Avoid drinking tap water and hypoxia (SpO2 < 90% on room air). However, the fever Ÿ Wash hands oen with soap and clean water symptom must be interpreted carefully as even in severe forms Ÿ If no water and soap are available, use an alcohol-based of the disease, it can be moderate or even absent. Cyanosis can hand cleaner (with at least 70% ethyl alcohol) occur in children. In this definion, the diagnosis is clinical, and Ÿ Clean hands especially before eang or preparing food and radiologic imaging is used for excluding complicaons. Chest aer using the bathroom imaging ulized includes chest radiograph, CT scan, or lung Ÿ Eat food that is packaged or is freshly cooked. ultrasound demonstrang bilateral opacies (lung infiltrates > Ÿ Do not eat raw and undercooked meat or unpeeled fruits 50%) (4). and vegetables Asymptomac/Atypical presentaon: Nasopharyngeal/ Ÿ Dispose off feces in a sanitary manner to prevent Oropharyngeal RT- PCR posive for SARS-CoV-2 but having no contaminaon of water and food sources (4) symptoms. Vaccinaon: A single-dose live oral cholera vaccine (lyophilized Reservoir: Its origin is not enrely understood, the genomic CVD 103-HgR) for adults 18 – 64 years old is recommended who analyses suggest that SARS-CoV-2 probably evolved from a are traveling to an area of acve cholera transmission. Two strain found in bats and snakes.