Weekly Epidemiological Flood Response in Pakistan · 27-Nov-10 NNT Sind Ghotki MCH Centre Ghotki 6...

Weekly Epidemiological Bulletin

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].

Epidemiological week no 48 (26 November - 2 December 2010) • Between 26 November - 2 December 2010 (epidemiological week no. 48), 57 districts in 4 provinces

provided surveillance data to the DEWS system.

• 1,342 fixed health and 11 mobile medical outreach centres provided surveillance data for this week. As people move back to their homes, the mobile teams are winding. DEWS Surveillance Officers are establishing new reporting flows from fixed centers.

• A total of 404,355 consultations were reported through DEWS of which 29% were acute respiratory infections (ARI), 9% skin disease, 8% acute diarrhoea, and 7% were suspected Malaria.

• Total 8 alerts were received and responded in this week: 4 alerts were for Measles, 2 were for Viral Hemorrhagic Fever (VHF), 1 was for Neonatal Tetanus and 1 was for ARI.

• Three cases of poliomyelitis confirmed this week.

Note: All presented data are based on the number of patient consultations and include information on priority diseases under surveillance as well as major health events reported through DEWS.

Highlights

Flood Response in Pakistan

01

Volume 1, Issue 16 Monday 6 December 2010

Table-1: Priority diseases reported during the week 38 - 48, 2010 (8 October - 2 December 2010)

Priority diseases under surveillance

in the flood affected areas

Acute Flaccid Paralysis

Acute Jaundice Syndrome

Acute Respiratory Infections

Acute Watery Diarrhoea/Suspected Cholera

Bloody Diarrhoea

Other Diarrhoea

Suspected Hemorrhagic Fever

Suspected Malaria

Suspected Measles

Suspected Meningitis

Unexplained Fever

Others

Diseases Wk‐41 Wk‐42 Wk‐43 Wk‐44 Wk‐45 Wk‐46

Skin Disease 37, 541 (10%) 33,129 (10%) 29, 452 (9%) 25, 920 (9%) 27,009 (8%) 23,693 (8%)

ARI (URI and LRI) 80,073 (22%) 79,860 (23%) 78,580 (23%) 72,582 (24%) 93,704 (27%) 78,863 (28%)

Acute Diarrhoea 37,298 (10%) 33,317 (10%) 27,686 (8%) 22,923 (8%) 24,915 (7%) 19,985 (7%)

Bloody Diarrhoea 5,764 (2%) 4,659 (1%) 4,306 (1%) 2,843 (1%) 2,889 (1%) 2,540 (1%)

Suspected Malaria 27,473 (8%) 32,153 (9%) 30,345 (9%) 24,589 (8%) 26,843 (8%) 21,671 (8%)

Total consultation 361,817 344,085 341,661 300,924 340,761 279,146

Wk‐47

29,044 (8%)

98,601 (27%)

26,985 (7%)

3,422 (1%)

27,155 (7%)

364,163

Wk‐48

37,167 (9%)

117,990 (29%)

32,444 (8%)

2,754 (1%)

29,813 (7%)

404,355

Figure-1: Weekly trend of leading priority diseases in flood affected districts of Pakistan, 29 July to 2 December 2010 (Epi week 31 - 48, 2010)

Epidemiological Bulletin: Flood Response in Pakistan Figure-2: Weekly average number of fixed and mobile reporting units by province (Week 33- 48, 2010)

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

Table-3: Leading causes of seeking health care in the flood affected districts as of 2 December 2010

Figure-4: Leading causes of seeking health care in the flood affected districts by province, 29 July to 2 December 2010

Diseases Total

Skin Diseases 1,394,154 (14%)

Acute Respiratory Infection 1,901,065 (19%)

Acute Diarrhoea 1,154,734 (12%)

Bloody Diarrhoea 110,665 (1%)

Suspected Malaria 561,719 (6%)

Unexplained Fever 484,843 (5%)

Total Consultations 9,809,449

Province Targeted Districts Functioning Handed over

KPK 16 1 27

Punjab 9 0 12

Balochistan 7 3 10

Sindh (Sukkur) 7 1 9

Sindh (Hyderabad) 5 1 4

Gilgit / Baltistan 2 0 2

Total 46 6 64

Table-2: DTCs functioning with WHO and health partners support

11,491 14,103

311,863

70,211

808,894

440,539

108,876

35,845

739,724

550,776 530,158

80,407

506,151

378,380

209,037

61,166

358,214

101,035114,85858,506

76,492

95524,761 14,738

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

Punjab Sindh Khyber Pakhtunkhwa Balochistan

Number of cases

Skin Ds.

ARIAD

UFS. Mal

BD

Table-4: Follow-up alerts reported in week 47, 2010. Epidemiological Bulletin: Flood Response in Pakistan


Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes

20-Nov-10 VHF Sind Ghotki CH Sukkur (Budho Kalari Village - Ghotki) 13 F

1 death from Dengue Hemorrhagic Fever reported from Budho Kalari Village district Ghotki. Fumigation is already done in the village.

20-Nov-10 VHF Sind Ghotki Jinnah Clinic (Private) 4.5, 5, 1.5

M, F, F Samples were negative for Dengue Hemorrhagic Fever

20-Nov-10 Measles Sind Ghotki Bhatti Hospital - Sukkur 7 F Suspected Measles case was found admitted in serious condition. Patient died due to measles encephalitis

21-Nov-10 AWD Sind Hyderabad DTC TH Hala (Qasim Bhughio Village) 8 F

1 AWD death reported in severely malnourished girl under treat‐ment for TB.

22-Nov-10 VHF Sind Ghotki TH Ghotki (Dur Muhammad Shar Village) 4 M

Death was reported from Dur Muhammad Shar Village due to suspected Dengue. Health education was provided in the com‐munity.

22-Nov-10 VHF KPK Abbottabad Ayub Teaching Hospital (Banda Nabi - Abbottabad) 13 F Sample collected and sent to NIH. See number 1 above.

22-Nov-10 VHF KPK Abbottabad Ayub Teaching Hospital (Chappar Bala - Mansehra) 18 M Sample collected and sent to NIH. See number 1 above.

22-Nov-10 VHF KPK Abbottabad Ayub Teaching Hospital (P.O Machipul - Mansehra) 24 M Sample collected and sent to NIH. See number 1 above.

22-Nov-10 Malaria Balu Jaffarabad BHU Digri - Goth Azam Khan Khosa ** **

13 cases with 4 deaths were reported. RDTs were distributed and health facilities staff was sensitized.

25-Nov-10 Measles KPK Mardan DHQ Mardan (Jan Khel Village - Takhtbhai) 1 M Sample was Positive for Measles. Active surveillance was done.

23-Nov-10 VHF Punjab Rahim Yar Khan Sheikh Zaid Hospital - Muja-hid Colony 17 , 19 M, M Suspected cases were found, See number 1 above.

23-Nov-10 AWD KPK Swat THQ Matta (Terat Village - Madyan) 55, 12 M, M Samples were found negative for cholera, See number 2 above.

23-Nov-10 VHF KPK Swat SGTH (Mansab Khel Mohalla) 19 M Sample was Positive for DF, see number 1 above.

23-Nov-10 Diph KPK Peshawar KTH (ASC Colony-Nowshera) 3 M Probable diphtheria case, lab results negative. Contacts treated

23-Nov-10 VHF KPK Peshawar KTH (Juma Khan Kalay) 60 F Sample collected and sent to NIH. See number 1 above.

24-Nov-10 Measles Sind Kashmore Wahid Bux Jaffery 4, 3, 5 M, F, F

Samples collected and sent to NIH. Active surveillance is under way.

25-Nov-10 Diph KPK Peshawar KTH (Latif Abad Ring Road) 16 M Probable diphtheria case, lab results negative, contacts treated

25-Nov-10 Diph KPK Peshawar HMC (Khandii Khel Mohalla - Karak) 17 M

Probable diphtheria case, lab results negative, contacts treated. Campaign in affected UCs completed

• All the alerts received were responded within 24 hour as follow

1. In case of VHF alert, awareness raising in the household and community regarding mosquito control and prevention of bites and early referral of hemorrhagic cases. At hospital level, the team shared information regarding case manage‐ment of DHF.

2. In case of AWD alert, the team visited the community and assessed the source of drinking water for the affected popu‐lation and provided Aqua‐tabs and /or Life Straw filters for household purification. The team provided materials to the LHWs for IEC regarding hygiene and personally conveyed the messages door‐to‐door while distributing soap. ORS was provided for early treatment of mild cases in the community. Referrals were arranged to the DTC or local hospital for severe cases. The Environmental Health unit arranged chlorination of water source or other appropriate intervention.

Table-5: Alerts and Outbreaks (Week 48, 2010)

Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes

26-Nov-10 Mea-sles Sind Kashmore BHU Sardarabad

(Taluka Kandhkot) 54m M Sample collected and sent to NIH. Active surveillance is under way.

27-Nov-10 VHF Sind Ghotki MCH Centre Ghotki 15m, 2, 54m, 5 M, F, M, F

Samples collected and sent to NIH. See number 1 above.

27-Nov-10 NNT Sind Ghotki MCH Centre Ghotki 6 days M Patient Left against medical advice

27-Nov-10 Mea-sles Sind Ghotki UC Qadarpur 8, 3, 3, 8,

3 M, F, M, F,

M

23 post measles cases with 2 deaths were found upon active surveillance in two villages of the UC. Samples from 5 suspected cases were collected and sent to NIH. Active surveillance is under process.

30-Nov-10 Mea-sles KPK Mardan DHQ Mardan (Maseeti

Phatak) 42m M Sample collected and sent to NIH. Active surveillance is under way.

1-Dec-10 ARI Sind Dadu CH Dadu ** **

5 neonatal deaths were reported due to suspected Pneumonia. In response improved staffing, availabil‐ity of essential medicines, improved infection control measures and raised awareness of provincial govt. and NGO's.

1-Dec-10 Mea-sles KPK Malakand DHQ Batkhela 4, 2, 6 F, M, M

Sample collected and sent to NIH. Active surveillance is under way.

2-Dec-10 VHF Sind Ghotki DHQ Mirpur Mathelo (Taluka Ghotki) 5 M

Samples collected and sent to NIH. See number 1 above.

Table-6: List of confirmed Polio Cases from flood affected districts, week 48-2010

S. NO. Province Districts SEX AGE (m) Date onset of Paralysis WPV Type

1 KPK Peshawar F 11 15‐11‐2010 NSL1

2 KPK Mohmand F 7 17‐10‐2010 NSL1

3 Sindh Jacobabad M 30 23‐10‐2010 NSL1

Epidemiological Bulletin: Flood Response in Pakistan


• All the alerts received in this week were responded within 24 hour as follow

1. In case of VHF alert, awareness raising in the household and community regarding mosquito control and prevention of bites and early referral of hemorrhagic cases. At hospital level, the team shared information regarding case manage‐ment of DHF.

2. In case of AWD alert, the team visited the community and assessed the source of drinking water for the affected popu‐lation and provided Aqua‐tabs and /or Life Straw filters for household purification. The team provided materials to the LHWs for IEC regarding hygiene and personally conveyed the messages door‐to‐door while distributing soap. ORS was provided for early treatment of mild cases in the community. Referrals were arranged to the DTC or local hospital for severe cases. The Environmental Health unit arranged chlorination of water source or other appropriate intervention.



Province KPK • This week 14 districts reported to DEWS from KPK

province, 398 health centers reported 100,827 patients consultations to DEWS.

• ARI is the leading disease in KPK province

• Two alerts were received and investigated this week; both alerts were for Measles. 1 was reported from DHQ hospital district Mardan and 1 was reported from DHQ hospital Batkhela district Malakand.

• The above mentioned reports are reporting from health facilities to DEWS system on weekly basis, we are hereby using the same data providing transition to our weekly reporting system.

Province Punjab • 11 districts reported data to DEWS from Punjab prov-

ince

• 331 fixed health centers and 3 mobile medical outreach centers reported to DEWS

• A total of 124,881 patient consultations were reported during this reporting period

• In Punjab, a higher proportion of suspected malaria was reported again this week (7%). Although a peak of ma-laria in October reflects seasonal trend of diseases, DEWS officers are collaborating with Malaria Control Program to investigate areas of increased malaria, pro-viding rapid diagnostic test kits and appropriate medi-cines.

Figure-5: Trend of priority communicable diseases, province KPK (31-July - 2 December 2010)

Figure-7: Trend of priority communicable diseases, province Punjab (3 August - 2 December 2010)

Diseases Wk-45 Wk-48

Skin Diseases 4,411 (%) 4,793 (5%)

ARI (URI and LRI) 34,750 (%) 37459 (37%)

Acute Diarrhea 7,441 (%) 8,034 (8%)

Bloody Diarrhea 1,124 (%) 780 (1%)

Total consultations 91,799 100,827

Suspected Malaria 2,379 (%) 2,041 (2%)

Wk-46

3,453 (5%)

25,907 (36%)

5,555 (8%)

785 (1%)

2,310 (3%)

71,716

Wk-47

4,818 (5%)

31,954 (36%)

7,604 (9%)

945 (1%)

2,520 (3%)

89,077


Skin Diseases 10,231 (10%) 16,349 (13%)

ARI (URI and LRI) 21,299 (20%) 29,304 (23%)

Acute Diarrhea 7,409 (7%) 11,305 (9%)

Bloody Diarrhea 20 27


Suspected Malaria 8,794 (8%) 9,119 (7%)

Wk-46

7,526 (10%)

15,490 (21%)

4,382 (6%)

3

6,488 (9%)

72,618

Wk-47

8,395 (8%)

19,607 (19%)

6,401 (6%)

5

7,085 (7%)

100,579


06


Province Sindh • This week 21 districts reported to DEWS from

Sindh province

• 354 fixed health centers reported to DEWS

• A total of 138,362 patient consultations were reported during the reporting period of week 48.

• In Sindh, proportional morbidity of major health events remained the same when com-pared to last week.

• Six alerts were received and responded this week; 2 for Viral Hemorrhagic Fever (VHF) and 2 were for measles and 1 was for AWD and 1 was for Neonatal Tetanus.

• Four (4) training sessions on Dengue case man-agement and Nursing care were conducted in Sindh by a team of experts from Thailand

Province Balochistan

• In this week, 11 districts reported to DEWS from Balochistan province.

• 259 fixed health centers and 8 mobile medical outreach centers reported to DEWS

• A total of 40,285 patient consultations were reported during the reporting period of week 48, 2010

• In Jaffarabad higher than usual levels of sus-pected malaria cases are being reported during the last few weeks. Malaria outbreaks in dis-tricts Jaffarabad, Naseerabad, Sibi, Zhob and Jhal Magsi are being addressed in collaboration with the Malaria Control Program.


Skin Diseases 8,459 (9%) 13,777 (10%)

ARI (URI and LRI) 28,267 (29%) 40,538 (29%)

Acute Diarrhea 6,299 (6%) 8, 545 (6%)

Bloody Diarrhea 611 (1%) 863 (1%)


Suspected Malaria 8,933 (9%) 13, 273 (10%)

Wk-46

10,641 (10%)

30,471 (29%)

7,297 (7%)

885 (1%)

9,413 (9%)

106,102

Wk-47

13,519 (10%)

37,487 (27%)

8,805 (6%)

1,175 (1%)

13,150 (10%)

137,552

Figure-9: Trend of priority communicable diseases, province Sindh (6 August - 2 December 2010)

Figure-11: Trend of priority communicable diseases, province Balochistan (6 August - 2 December 2010)


Skin Diseases 3,908 (9%) 2,248 (6%)

ARI (URI and LRI) 9,388 (21%) 10,689 (27%)

Acute Diarrhea 3,766 (8%) 4,557 (11%)

Bloody Diarrhea 1,134 (3%) 1,084 (3%)


Suspected Malaria 6,737 (15%) 5,380 (13%)

Wk-46

2,073 (7%)

6,995 (24%)

2,751 (10%)

867 (3%)

3,460 (12%)

28,710

Wk-47

2,312 (6%)

9,553 (26%)

4,175 (11%)

1,297 (4%)

4,400 (12%)

36,955


07


The objective of this weekly epidemiological bulletin is to provide a snap shot on selected health events reported from the communities affected by the current flood in Pakistan. While every attempt is made to present the weekly trend of the epidemic prone diseases, the information presented in the bulletin needs to be interpreted in the context that precise information on the reference populations is not always available, The bulletin also includes information collected by DEWS teams established during earlier emergencies, including 2005 earthquake, 2007 floods and 2008 ID crises. The primary focus of DEWS is the early detection of epidemic prone diseases, to facilitate a rapid public health response. We would like to thank all the numerous national and international partners who have contributed to the Disease Early Warning System.

Since July 29, 2010, approximately 9,809,449 pa‐tient consultations have been reported to DEWS from the flood affected districts in 4 provinces in Pakistan. The major causes for seeking healthcare by the af‐fected communities continue to be diarrheal dis‐eases, acute respiratory infections, skin diseases and suspected malaria. In KPK, proportional morbidity of AD reported to 8% this week (Please see Fig.13)

While Disease Early Warning System (DEWS) is an active surveillance system for early identification and response to epidemic‐prone diseases, a side benefit of notification of “clusters of unusual health events” is the identification of emerging diseases, environmental disasters, and gaps in health care delivery. In the last few weeks, two districts sent alerts for possible increase in numbers of neonatal deaths. In Naseerabad, it was found that 17 deaths had occurred over a three month period from neonatal tetanus. In Dadu, five neonatal deaths oc‐curred in past week and 198 deaths were recorded in past four months with one case diagnosed as neonatal tetanus. Pakistan overall neonatal mortality rate as assessed by the DHS 2006‐7 is 53 per 1000 live births while infant mortality rate is 81 per 1000 live births and under‐five mortality rate is 101 per 1000 live births. 1 According to assessed causes, birth asphyxia (22%), sepsis (14%), prematurity (9%) and con‐genital abnormalities (4%) are the chief contributing causes of infant death that occur in neonates, while NNT is mentioned as causing 0.6% of deaths under age five.2

Tetanus immunization coverage among women has been meas‐ured as 50‐60% in Pakistan overall but in Naseerabad district is reported by EPI to be less than 5%.3 One would thus expect no improvement from the scenario in 1994 when data showed that 18% of neonatal mortality in Baluchistan was due to neo‐natal tetanus.4 Reduction of neonatal tetanus also requires an improvement in clean delivery and cord care. A 2004 case‐control study showed that application of substance to the cord, home delivery and illiterate mother were risk factors for neona‐tal tetanus in Karachi5 and DHS 2006‐7 also showed Baluchistan to have only 23%of deliveries by skilled birth attendant. WHO and health partners are actively responding to both the low TT coverage and other problems in care of newborns in these districts. DEWS reports have helped to focus these efforts, and we encourage all districts to support the transparent reporting of health events so that Pakistan health system can improve and benefit all the population’s health. 1.Demographic and Health Survey, Pakistan, 2006-7. 2.UNICEF, Representatives Meeting, November 3-5, 2008, Islamabad, Pakistan. 3. EPI report of Naseerabad, 2010 4. Fikree FF, Azam SI, Berendes HW. (2002) Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan. Bull World Health Org 80(4):271-6. 5. Raza SA, Akhtar S, Avan BI, Hamza H, Rahbar MH. A matched case-control study of risk factors for neonatal tetanus in Karachi, Pakistan .J Postgrad Med 2004;50:247-251

Figure-13: AD trends, KPK, 2009 and 2010

Focus on: Neonatal Deaths (6 Dec 2010)

Summary of Health Event in Flood affected districts

Congenital Abnormality, 4

Tetanus, 0.6

Prematurity, 9.2

Birth asphyxia, 22.1

Sepsis, 14.2Pneumonia, 13.3

Meningitis, 4

Diarrhoea, 10.8

Accident/Injuries, 2.4

Measles, 1.7

Severe Acute Malnutrition, 0.8

Others, 16.9

Causes of Under‐five deaths

44.4

37.9 37.7

23

0

10

20

30

40

50

Sindh KPK Punjab Balochistan

% of birth

s assisted by skilled birth attend

ant

Percent of births assisted by skilled birth attendant, DHS 2006‐7

0

4

8

12

16

20

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

Percentage

Epi‐week

Weekly pattern of acute diarrhea, IDP crises and flood affected districts, Khyber Pakhtunkhwa (2009‐2010)

2009

2010

Confirmed Alerts (31 July to 2 December 2010)


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