Weekly Epidemiological Flood Response in Pakistan...Weekly Epidemiological Bulletin This weekly...

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 52 (24 - 30 December 2010) • Between 24 - 30 December 2010 (epidemiological week no. 52), 53 districts in 4 provinces provided

surveillance data to the DEWS system.

• 1,939 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 down. DEWS Surveillance Offi-cers are establishing new reporting flows from fixed centers.

• A total of 487,063 consultations were reported through DEWS of which 31% were acute respiratory infections (ARI), 8% skin disease, 6% acute diarrhoea, and 5% were suspected Malaria.

• Total 18 alerts were received and responded in this week: 6 were for Measles, 4 for suspected Influ-enza, and 2 for probable Diphtheria, while 1 each for Acute Watery Diarrhoea, Bloody Diarrhoea, suspected meningitis, Pneumonia, Pertussis and Neonatal Tetanus.

• One case of confirmed poliomyelitis reported this week from Tank, KP Province, a flood–affected district.

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 20 Monday 3 January 2011

Table-1: Priority diseases reported during the week 45 - 52, 2010

Priority diseases under surveillance

in the flood affected areas

Acute Flaccid Paralysis (AFP)

Acute Jaundice Syndrome (AJS)

Acute Respiratory Infections (ARI)

Acute Watery Diarrhoea/ (AWD) Suspected Cholera

Bloody Diarrhoea (BD)

Acute Diarrhoea (AD)

Suspected Hemorrhagic Fever (VHF)

Suspected Malaria (Mal)

Suspected Measles (Ms)

Suspected Meningitis (Mg)

Others

Diseases Wk‐45 Wk‐46 Wk‐47 Wk‐48 Wk‐49 Wk‐50

Skin Disease 27,009 (8%) 23,784 (8%) 29,056 (8%) 38,022 (9%) 40,533 (8%) 35,475 (8%)

ARI (URI and LRI) 93,704 (27%) 79,391 (28%) 98,719 (27%) 126,265 (29%) 156,168 (30%) 129,690 (30%)

Acute Diarrhoea 24,915 (7%) 20,138 (7%) 27,007 (7%) 34,377 (8%) 33,188 (6%) 27,573 (6%)

Bloody Diarrhoea 2,889 (1%) 2,578 (1%) 3,422 (1%) 2,972 (1%) 3,943 (1%) 3,032 (1%)

Suspected Malaria 26,843 (8%) 21,726 (8%) 27,198 (7%) 30,633 (7%) 31,780 (6%) 26,865 (6%)

Total consultation 340,761 280,676 364,543 428,159 522,284 437,946

Wk‐51

42,725 (8%)

164,886 (31%)

36,803 (7%)

3,887 (1%)

35,072 (7%)

538,992

Wk‐52

40,647 (8%)

150,475 (31%)

31,140 (6%)

3,108 (1%)

25,376 (5%)

487,063

Figure-1: Weekly trend of leading priority diseases in flood affected districts of Pakistan, 29 July to 30 December 2010 (Epi week 31 - 52, 2010)

Epidemiological Bulletin: Flood Response in Pakistan

Fig-2: Weekly number of reporting health units (Week 33– 52, 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-2: Leading causes of seeking health care in the flood affected districts, 29 July to 30 December 2010

Figure-3: Leading causes of seeking health care in the flood affected districts by province, 29 July to 30 December 2010

Diseases Total

Skin Diseases 1,554,492 (13%)

Acute Respiratory Infection 2,511,203 (21%)

Acute Diarrhoea 1,285,546 (11%) Bloody Diarrhoea 124,891 (1%) Suspected Malaria 681,730 (6%) Unexplained Fever 550,197 (5%)

Total Consultations 11,821,446

Since July 29, 2010, a total of 1,285,546 acute diarrhea patient consultations have been reported to DEWS from the flood affected districts of 4 provinces in Pakistan.

Proportional Morbidity in Provinces (Week 52‐2010): Khyber Pakhtunkhwa: Reported 5,996 (6%) remains the same percentage as compared with last week. Punjab: Reported 12,345 (6%), 2% decreased as compared with last week. Sindh: Reported 8,457 (6%) remains the same percentage as compared with last week. Balochistan: Reported 4,342 (8%) remains the same percentage as compared with last week.

Figure-4: Acute Diarrhea trends, Disaster affected districts, Pakistan 2009 and 2010

Since July 29, 2010, approximately 2,511,203 Acute Respiratory Infection patient consultations have been reported to DEWS from the flood affected districts of 4 provinces in Pakistan.

Proportional Morbidity in Provinces (Week 52‐2010): Khyber Pakhtunkhwa: Reported 44,757 (45%), 3% increased as compared with last week. Punjab: Reported 39,921 (21%), 3% decreased as compared with last week. Sindh: Reported 46,161 (33%), 4% increased as compared with last week. Balochistan: Reported 19,636 (36%), 4% increased as compared with last week.

Figure-5: Acute Respiratory Infection trends, Disaster affected districts, Pakistan 2009 and 2010

868,969

509,775

128,576

47,172

889,204

751,761 727,305

142,933

546,485

419,689

240,923

78,449

376,583

28,947

123,891

20,776

140,620

374,684

68,103 98,323

1,034

75,115 28,590 20,152

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Punjab Sindh Khyber Pakhtunkhwa Balochistan

Number of cases

Skin Ds.ARIADUFS. MalBD

0

2

4

6

8

10

12

14

16

18

20

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

Per

cent

age

Epi-week

2009 2010

0

5

10

15

20

25

30

35

40

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

Per

cent

age

Epi week

2009 2010

Table-3: Follow-up alerts reported in week 51, 2010. Epidemiological Bulletin: Flood Response in Pakistan


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

29‐Dec‐10 Meningitis Sindh Ghotki Asha Centre (Sachal Ghoto Village)

7 M Upon field investigation 1 suspected case was found. Active surveillance is under process.

30‐Dec‐10 Measles KP Lower Dir BHU Toormang (Siar Village)

4 F Upon field investigation 1 suspected case was found. Sample was col‐lected and sent to NIH. Active surveillance is under process.

30‐Dec‐10 Measles KP Mardan Spogmay Hospital (Hatam Kallay Kot‐lamey)

** M Upon field investigation 1 suspected case was found. Sample was col‐lected and sent to NIH. Active surveillance is under process.

30‐Dec‐10 Pneumonia Balochistan Sibi DHQ Sibi ** M,M,M,M, F, F

Suspected cases were reported from the health facility but upon active surveillance patients could not be traced out due to lack of information

30‐Dec‐10 BD Balochistan Sibi RHC Lehri ** ** 27 suspected cases were reported from the health facility but upon active surveillance patients could not be traced out due to lack of information.

30‐Dec‐10 Measles Sindh Dadu UC TR Khan (Taluka Johi)

4 F Upon field investigation 1 suspected case was found. Sample was col‐lected and sent to NIH. Active surveillance is under process.

31‐Dec‐10 Pertussis Sindh Ghotki UC Bago Daho (Vasti Inayat Shah)

4, 6, 11 F, F, F Upon field investigation 3 suspected case were found. Sample was col‐lected from 1 patient and sent to NIH. Active surveillance is under process.

31‐Dec‐10 Measles KP Swat THQ Matta 2, 5 M, M 2 suspected cases were reported from the health facility. Samples were collected from both patients and sent to NIH. Active surveillance is under process.

31‐Dec‐10 NNT Sindh Ghotki UC Hussain Beli (Murad Ghoto Village)

7d M 1 suspected case was reported from the health facility in serious condi‐tion. TIG was provided by WHO but patient expired due to complications. Further analysis of public health issues is under process.

24‐Dec‐10 H1N1 (2009) KP Swabi BKMC (Kalal Village and Kotal Village )

24, 41 M,F Suspected cases were found with typical flu like symptoms. Samples tested at NIH showed positive H1N1 (2009).

24‐Dec‐10 H1N1 (2009) Punjab Rawalpindi CMH ** ** Suspected cases were found with typical flu like symptoms. Sample tested at NIH showed positive H1N1 (2009). Active surveillance is ongoing

24‐Dec‐10 Measles KP Swabi BKMC (Panjpir Village) 3 M Upon field investigation 1 suspected case was found. Sample was negative for Measles. Active surveillance was done.

24‐Dec‐10 Diphtheria KP Lakki Marwat Lady Reading Hospital (UC Baraam Khel)

8 F Probable diphtheria case was found. Contacts treated prophylactically with antibiotics. Field investigation is under way.

24‐Dec‐10 AWD Sindh Mirpurkhas RHC Phuladyoon* ** ** Upon field investigation acute diarrhoea patients were found which were misdiagnosed as Cholera.

26 to 30 Dec, 2010

H1N1 (2009) KP Swabi

Kala Village; Gajal Village, UC Panjpir; UC Gabasni; Minirin Payan; Chota Lahore

50, 19, 6, 35, 4, 19,

18

F, F,F,F,F,M,M

Suspected cases were found with typical flu like symptoms. Samples tested at NIH showed positive H1N1 (2009) for 5 cases; one waas negative and one is pending .

27‐Dec‐10 Diphtheria KP D.I. Khan Lady Reading Hospital (Kotjai ‐ Paharpur)

12 M

Probable diphtheria case was found. Field investigation located 3 contacts 8y, 4y, and 2.5y. Samples were collected and sent to NIH. Contacts treated prophylactically with antibiotics. Further investigation about vaccination coverage in the area is ongoing.

28‐Dec‐10 Measles KP Lower Dir DHQ Timergara (UC Toor Mang)

9 M Upon field investigation 1 suspected case was found. Sample was col‐lected and sent to NIH. Active surveillance is under process.

28‐Dec‐10 H1N1 (2009) Sindh Sukkur Anwar Paracha Teach‐ing Hospital

20 F Suspected cases were found with typical flu like symptoms. Sample tested at NIH showed positive H1N1 (2009). Active surveillance is ongoing

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

20‐Dec‐10 AFP Sindh Ghotki MCH Center (UC Qadirpur)

3 F Suspected AFP case was found. Polio team is investigating the case.

21‐Dec‐10 Measles Sindh Dadu TH Johi (UC Tando Rahim Khan)

5,4,*,*,3,5,3,5,3,7,

4

F,F,F,F,M,

F,F,M, F,F,M

Upon field investigation 11 cases including 5 deaths were found. From active cases 2 samples were collected and sent to NIH. Active surveillance is ongoing.

21‐Dec‐10 BD Punjab Jhang THQ Shorkot

5,45,10,14,3d,

40,5m,4m,10m,2m

M,F,M,F,M,F,

F,M,M,F

Upon field investigation 10 suspected cases were found in different villages with problems of hygiene, waste management and open defecation. Hygiene messages, soap and aqua tabs were distributed. From active cases 4 samples were collected and sent to IPH Lahore. Results on 1st January showed 4m male from Garhmor and 2m female from Dub Kalah were positive for Shigella flexnari. Follow‐up investigation planned.

21‐Dec‐10 VHF KP Lower Dir DHQ Timergara (Petto Dara Village)

24 M Sample was declared negative for DF by NIH. Intervention as above.

22‐Dec‐10 NNT Sindh Ghotki Jinnah Clinic (Sardar Khan Chachar Village)

14d F Suspected NNT case was found. Infant was delivered by untrained Dai and mother was unvaccinated. TIG was provided and infant survived. Case reported to EPI and MNCH for follow‐up.

22‐Dec‐10 Measles KP Malakand CH Thana ‐ Batkhela 2 M Upon field investigation 1 suspected case was found. Sample was positive for measles. Active surveillance found no further cases.

22‐Dec‐10 Measles KP Mardan MMC (Umerabad ‐ Takht bai)

23 M Upon field investigation 1 suspected case was found. Sample was positive for measles. Active surveillance found no further cases.

23‐Dec‐10 Measles Sindh Kashmore UC Gublo (Mahboob Khan Sundrani Village)

8,6,5,7,8,6,3

F,M,F,M,F,F,M

Upon field investigation 7 cases plus 9 unconfirmed deaths were found. From active cases 3 samples were collected and sent to NIH.

18‐Dec‐10 Tetanus Sindh Kamber Abdul Jaleel Cholyani Village (CMC Hospital)

8 F During field investigation a probable case of tetanus was identified. Patient expired due to complication including septicemia, aspiration Pneumonia.

Table-4: Alerts and Outbreaks (Week 52, 2010)

Table-5: List of confirmed Polio Cases from flood affected districts, week 52-2010

There was 1 case of confirmed poliomyelitis reported this week from flood affected district Tank, Khyber Pakhtunkhwa. Altogether, polio program has reported a total of 140 confirmed wild polio cases and one death including 1 more case from Mohmand Agency, FATA this week.



Province Khyber Pakhtunkhwa

• This week 14 districts reported to DEWS from KP province, 478 health centers reported 99,494 patients consultations to DEWS.

• ARI is the leading disease in KP province with proportional morbidity of 45%.

• Nine alerts were received and investigated this week; 5 alerts were for Suspected Measles, 2 were for Influenza, and 2 were for probable Diphtheria.

Province Punjab

• 11 districts reported data to DEWS from Punjab province

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

• A total of 192,119 patients consultations were reported during this reporting period

• In Punjab, ARI remains the higher proportion reported (21%) . This is consistent with expected seasonal trends.

• One alert of Influenza was reported and re-sponded this week.

Figure-6: Trend of priority communicable diseases, province KP (31-July - 30 December 2010)

Figure-7: Trend of priority communicable diseases, province Punjab (3 August - 30 December 2010)

Diseases Wk-49 Wk-52

Skin Diseases 5,488 (4%) 4,168 (4%)

ARI (URI and LRI) 47,993 (38%) 44,757 (45%)

Acute Diarrhea 8,769 (7%) 5,996 (6%)

Bloody Diarrhea 1,199 (1%) 626 (1%)

Total consultations 125,766 99,494

Suspected Malaria 2,928 (2%) 1,672 (2%)

Wk-50

4,636 (4%)

42,793 (39%)

7,488 (7%)

875 (1%)

2,155 (2%)

109,888

Wk-51

4,450 (3%)

52,739(42%)

7,525 (6%)

873 (1%)

1,924 (2%)

127,186

Diseases Wk-49 Wk-50 Wk-51 Wk-52

Skin Diseases 12,754 (9%) 13,491 (10%) 16,341 (10%) 17,489 (9%)

ARI (URI and LRI) 39,249 (27%) 30,854 (23%) 39,456 (24%) 39,921 (21%)

Acute Diarrhea 7,422 (5%) 7,272 (5%) 13,295 (8%) 12,345 (6%)

Suspected Malaria 4,587 (3%) 5,437 (4%) 8,473 (5%) 7,265 (4%)

Total consultations 144,799 135,438 166,799 192,119


05


Province Sindh

• This week 17 districts reported to DEWS from Sindh province

• 395 health centers were reported to DEWS this week

• A total of 141,563 patient consultations were reported during the reporting period of week 52.

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

• Six alerts were received and responded this week; 1 each was reported for Acute Watery Diarrhoea, Influenza, Meningitis, Suspected Measles, Pertussis and Neonatal Tetanus.

Province Balochistan

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

• 306 fixed and 8 mobile medical outreach cen-ters reported to DEWS

• A total of 53,887 patient consultations were reported during the reporting period of week 52, 2010

• Two alerts were received and responded this week; 1 each was for Bloody Diarrhoea and Pneumonia.

• High number of Malaria cases were reported from different areas of Jaffarabad district. A total of 819 malaria samples were tested of which 247 were posi-tive (slide positivity rate 30.1%). Falciparum Rate was 60.7%.


Skin Diseases 20,093 (10%) 15,393 (11%)

ARI (URI and LRI) 56,702 (27%) 46,161 (33%)

Acute Diarrhea 12,607 (6%) 8,457 (6%)

Bloody Diarrhea 1,383 (1%) 1,070 (1%)



Wk-50

14,629 (10%)

42,351 (29%)

8,641 (6%)

1,034 (1%)

14,271 (10%)

145,293

Wk-51

19,121 (10%)

55,771 (29%)

11,604 (6%)

1,417 (1%)

18,348 (10%)

191,328

Figure-8: Trend of priority communicable diseases, province Sindh (6 August - 30 December 2010)

Figure-9: Trend of priority communicable diseases, province Balochistan (6 August - 30 December 2010)


Skin Diseases 2,198 (5%) 3,597 (7%)

ARI (URI and LRI) 12,224 (28%) 19,636 (36%)

Acute Diarrhea 4,390 (10%) 4,342 (8%)

Bloody Diarrhea 1,323 (3%) 1,394 (3%)



Wk-50

2,719 (6%)

13,746 (29%)

4,172 (9%)

1,100 (2%)

5,002 (11%)

47,327

Wk-51

2,813 (5%)

16,920 (32%)

4,379 (8%)

1,597 (3%)

6,327 (12%)

53,679


06


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.

Appearing in April 2009, the novel strain of Influenza A H1N1(2009) virus caused serious disease in younger age groups, but overall the disease caused by this pandemic strain last year was milder than expected with low mortality rate globally (0.45%), comparable to seasonal influenza. In Pakistan, 294 cases of Influenza A H1N1(2009) were lab-confirmed at NIH including 29 deaths. In August 2010, WHO announced the end of the pandemic period, but recommended clinicians to remain vigilant and treat all suspected cases of H1N1 appropriately. The virus causes acute respiratory illness with high-grade fever, dry cough, headache, muscle and joint pains, sore throat, runny nose and sometimes vomiting and diarrhoea. The disease is spread through contact with droplets generated by coughing or sneezing of infected person in air or on contaminated surfaces. It is contagious from one day prior to the appearance of symp-toms and has an incubation period of 1-7 days. Management:

• The goal of treatment is to alleviate the symptoms. Warm fluids and bed rest are advisable until the fever has subsided. • A mild analgesic such as paracetamol 0.5 - 1g every 4-6 hours usually relieves the headache and generalized pains and meds such as pholcodine 5 -10mg 3-4 times daily may be used to suppress unproductive cough. • While antibiotics are not effective against viruses, specific treatment of complications such as bronchitis and pneumo nia may be necessary. • High risk patients, including pregnant women and children under age 5 years, should be treated with anti-virals osel tamivir or zanamivir as early as possible, preferably not later than 48 hours after onset of the symptoms to assure a posi tive clinical outcome.

Prevention & Control Measures:

• Annual winter immunization with seasonal anti-influenza vaccine containing H1N1(2009) antigen is recommended for health workers, pregnant women, young children, and patients suffering from pulmonary, cardiac or renal disease. • Improve ventilation in living places; avoid close contact with ill people and crowded settings. • Wash your hands thoroughly with soap and water. • Avoid touching mouth and nose. • Encourage sufferer to cover their faces with a mask or handkerchief when coughing and sneezing.

IHR: Under the International Health Regulations, WHO should be immediately notified if any of the following changes are de-tected:

• sustained transmission of antiviral-resistant H1N1 2009 influenza • human cases of infection with any influenza virus not currently circulating in human populations • any notable changes in the severity or other epidemiological or clinical characteristics of the H1N1 2009 virus, including changes in the age distribution, the clinical appearance, proportion of cases requiring intensive management, or unexpected increases in numbers of cases.

Phase 2 Mass immunization campaign is planned in some districts of Sindh and Balochistan from 5th to 16th January and in Punjab and Khyber Pakhtunkhwa from 10th to 22nd January.

Planned districts are as follows:

8 Districts of Sindh: Dadu, MirpurKhas, Jacobabad, Sanghar, Tando M. Khan, Tando Allah Yar, Tharparkar, Umer Kot; 4 Districts of Balochistan: Barkhan, Kohlu, Jhal Magsi, Bolan 11 Districts of Punjab: Attock, Chakwal, Gujrat, Hafizabad, Jhang, Lahore, Multan, Nankanasahib, Rawalpindi, Sargodha, Sialkot; and 7 Districts of Khyber Pakhtunkhwa: Bannu, Battagram, Karak, Lakki Marwat, Haripur, Abbotabad, Mansehra.

Focus on: Influenza A H1N1(2009)

Measles: Mass immunization campaign Phase-2

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