Weekly Epidemiological - WHOVolume 3, Issue 20, Wednesday 23 May 2012 • The graph (Figure‐1)...

Weekly Epidemiological Bulletin

This weekly Epidemiological Bulletin is published jointly by the 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. 20 (13 to 19 May 2012)

• 86 districts have reported in week 20, 2012, Please see map.

• 2,137 health centres have reported to the Disease Early Warning System (DEWS) in week 20, 2012

• 790,282 patients’ consultations were re‐ported over the week 20 compared to 756,457 consultations reported on week 19, 2012.

• Measles: 145 alerts investigated, respond‐ing to 10 outbreaks involving 272 measles cases. The most explosive outbreak is in Karachi.

• CCHF: 3 new cases including one death posi‐tive for CCHF from Quetta, bringing total to 11 cases and four deaths.

• Acute diarrhoea: Trend of acute diarrhoea in on the rise in all provinces. Districts in Sindh and Punjab are investigating alerts for acute watery diarrhoea/suspected cholera.

• No new polio case was reported in week 20, 2012.

Highlights

Disease early warning system and response in Pakistan

01

Volume 3, Issue 20, Wednesday 23 May 2012

• The graph (Figure‐1) shows the weekly trend of ARI; Acute diarrhoea; Bloody diarrhoea and Suspected malaria as propor‐tional morbidity (percentage of cases out of total consultations) reported to DEWS on weekly basis.

• Proportional morbidity of ARI is highest in Khyber Pakhtunkhwa, Sindh and Balochistan, while acute diarrhoea is highest in Khyber Pakhtunkhwa, FATA, Punjab, Sindh and Balochistan (please see the graphs for every province in page 3 and 4).

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AD BD ARI S. Malaria

Disease # of Cases Percentage

Acute diarrhoea 888,195 7%

Bloody diarrhoea 60,120 0.48%

ARI 2,708,139 21%

S. Malaria 539,775 4%

Skin Diseases 559,250 4%

Unexplained fever 434,014 3%

Total (All consultations) 12,651,539

Disease # of Cases Percentage

Acute diarrhoea 76,431 10%

Bloody diarrhoea 3,856 0.49%

ARI 125,835 16%

S. Malaria 39,185 5%

Skin Diseases 33,223 4%

Unexplained fever 27,856 4%

Total (All consultations) 790,282

Figure‐2: Weekly trend of Acute diarrhoea, Bloody diarrhoea, ARI and Suspected malaria in Pakistan Week‐1, 2011 to week‐20, 2012.

Figure‐1: 86 districts reported to DEWS in week 20, 2012.

Priority diseases under surveillance

in DEWS

Pneumonia Acute Watery Diarrhoea

Bloody diarrhoea Other Acute Diarrhoea

Suspected Enteric/Typhoid Fever Suspected Malaria

Suspected Meningitis Suspected Dengue fever

Suspected Viral Hemorrhagic Fever Suspected Measles

Suspected Diphtheria Suspected Pertussis

Suspected Acute Viral Hepatitis Neonatal Tetanus

Acute Flaccid Paralysis Scabies

Cutaneous Leishmaniasis Others Major health events reported during the

Epi‐week—20 (13—19 May 2012)

Cumulative number of selected health reported in Epi‐week 1—20, 2012

Weekly Bulletin: DEWS, Pakistan, Week no. 20 (13 to 19 May 2012)

This weekly Epidemiological Bulletin is published jointly by the 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

Current week's (20/2012) Outbreaks: Date Disease Province District Area <5M >5M <5F >5F Action Taken

17‐May Measles Sindh Dadu Village Mirzo Khoso, UC Qazi Arif, taluka Mehar

2 5 4 1

Alert for suspected measles was reported from the community, during active surveillance 11 more cases were found, Vitamin(A) drops was given, health education imparted, vaccination status was checked for 23 children, where BCG= 7 (60%), Penta1= 4 (38%), Penta2= 4 (36%), Penta3= 3 (22%), Measles1= 4 (30%), Measles2= 1 (19%). EDOH, THO, FP‐EPI informed and 1 Blood sample collected for lab testing.

17‐May Measles Sindh Thatta

Village Kareem Mallah; Village Juho, UC Gharo, Taluka Ghorabari

2 1 4 5

2 outbreaks from 1 location. Clusters of 10 houses and 15 houses were taken where 20 children were assessed and 6 (30%) of children were found vaccinated for BCG whereas rest of the children found unvaccinated, health education imparted, Vitamin (A) drops provided, 11 blood samples were col‐lected and sent to NIH for labconfirmation. DHO, THO and TSV were informed.

18‐May Measles Sindh Qambar Shahdadkot

Rab Rakhio Lakho , UC Kambar‐3 , Taulka Kambar

5 0 1 0

1 Death due to measles was reported from community. During field investigation 5 more cases were found, Vitamin(A) drops was given to all cases, health education imparted, 10 children were assessed for routine immunization where 2 (20%) found vaccinated against BCG whereas rest of the children found completely unvaccinated. DHMT informed and 3 Blood samples collected for lab testing.

18‐May Pertussis Sindh Tharparkar Village Piyaro jo Tar, UC Satidero, taluka Nagarparkar

9 0 5 5 Alert for probable Pertussis case was notified from THQ Chahchro. During active surveillance 18 more suspected cases were found, health education imparted, Erythromycin tabs supplied and Cough Syr‐ups was distributed, EDOH informed and 5 Nasal Swab were collected for lab confirmation.

18‐May Pertussis Sindh Matiari Village Bhurani, near Vaniyo kot sekhat, taluka Matiari

1 3 4 2

Alert for probable Pertussis case was reported from community. On active search 9 more cases were found. Health education imparted, Erythromycin tabs and Calpol syrups distributed to all cases, vacci‐nation status was assessed for 10 children where BCG= 4 (40%), Penta= 3 (30%), Measles= 2 (20%). Information shared with EDOH and request for vaccination in the area. 2 Nasal Swabs collected for lab testing.

17‐May Measles Punjab Bhakkar Mohallah Shia Eid Gah, UC Urban I, Tehsil Darya Khan.

4 1 5 1

7 Suspected cases of measles reported from a Private Clinic. All cases belongs from the same location. On active Surveil‐lance 4 more cases were found making total number of suspected cases 11. all the suspected cases found unvaccinated. The families with measles cases were REFUSALS. Total 51 Children ( >1 year to < 15 years ) in the location ( apart from suspects ) were checked for vaccination ( BCG+ Measles). 80 % of children in the location were found vaccinated. 2 Blood samples were collected and sent to NIH for lab confirmation. Vit A drops provided to all cases. All children <5 yrs (50) in neighborhood were given single dose of Vitamin A. Health education session conducted for highlighting the importance of vaccination against all EPI diseases. General hygiene and isolation measures were demonstrated to the community. EDO(H) was informed.

17‐May Measles Punjab Rajanpur Basti Gopang, Moza Marri, UC Shikarpur, Tehsil Rajanpur

4 2 2 4

Alert for suspected measles was reported by a School Teacher of Govt Primary school.On active surveillance visit to the locality with the district health department team revealed that there were 12 cases of measles from the same Basti.Blood sample drawn and sent to NIH for lab testing. Vit. A drops provided to all the cases. Vaccination status of 16 children were assessed. All 16 children had BCG scar while only 2 children had been vaccinated fully as per EPI schedule. HE session conducted regarding importance of immunization. Findings shared with the EDOH, DDOH, DSC, DSV and ASV. Intensified outreach activity planned. UNICEF and Save the Children were mobilized for carrying out social mobili‐zation campaign for sensitization of local community for getting their children vaccinated.

14‐May BD Khyber Pakhtunk‐hwa

Haripur Kot Najibullah, UC Kot Najibullah, CD & RHC Kot Najibullah

5 1 4 2

12 suspected cases of Bloody Diarrhea reported. Stool sample was taken and sent to NIH. Water samples from source, homes were taken and assessed for contamination. Health and hygiene sessions were conducted for affected families. Aqua tabs and soaps distributed in community through LHWs. Environmental interventions will be carried out depending on water sample results

16‐May AJS Khyber Pakhtunk‐hwa

Kohat College town colony, Urban V 1 6 0 6

22 cases of AJS were reported from a private clinic. 3 Blood Samples were collected for lab confirma‐tion. Water samples were collected from different households and were found Unfit for drinking by EHE. Health education imparted for personal and environmental hygiene of the community. Informa‐tion shared with EDOH

16‐May Measles Khyber Pakhtunk‐hwa

Swat

Village Sarkhazana Khwar kote kandero, UC Qalagay, Tehsil Kabal

3 1 2 4

6 cases of suspected measles were reported from Saidu group of teaching hospital. WHO Swat team responded to the alert and went to SGTH, all the cases were belonging to the same UC. On active surveillance in the locality, four more cases were found. Outreach vaccination was conducted in the area in which 38 children were vaccinated for measles, 5 for Pentavalent and 5 for OPV.

14‐May Measles FATA Mohmand Agency Nijar kor 2 2 4 3

Alert for measles was reported. On active search 10 more suspected cases found, Blood samples were collected & sent to NIH for lab testing. Outbreak declared, Line listing done, Vaccination status were assessed for 140 children. 125 (89%) children found unvaccinated against measles, health education imparted, Vit A drops provided to all cases. Intensified outreach for measles done in the area, covered 128 children. Agency Surgeon & EPI Coordinator informed.

14‐May Malaria Balochistan Lasbela Sukkan, UC Wayaro, Tehsil Uthal 10 19 12 15

56 Cases of suspected of Malaria were reported. All cases were tested in RDTs and out of them 32 cases were positive (SPR 57%), pf=6(FR=19%), pv=27.Cases were treated by anti‐ malarial drug. Infor‐mation was shared with DHO.

15‐May Malaria Balochistan Harnai Peir sher, UC Spin‐tangi, Tehsil Harnai 0 7 0 2

Alert for Malaria was generated through weekly DEWS data. Total 9 slides were tested and 9 came out to be positive (SPR=100%). P. Falciparum=5(55%), P. Vivax=4. Cases were from the same location. Cases are under treatment by anti‐malarial drugs. Information shared with the District Health Officer.

15‐May Malaria Balochistan Jaffarabad CD Manjhi Pur (Manjhi Pur) 3 11 4 7

25 cases of malaria were reported and were tested on RDTs. 15 were positive (SPR=60%). PF=3 (FR=20%), PV=8, Mix=4. Antimalarial drug + RDT were distributed. Bed nets were not available and fogging and insecticide sprays cannot be done because of non‐availability of insecticides.

15‐May Measles Balochistan Chagai BHU Taftan (Killi Essa Khan) 3 4 1 3

11 cases of measles were reported. All of the cases were unvaccinated. The parents of the children were sensitized for the importance of vaccines. 35 children less then five years were assessed for routine immunization out of which 5 found fully vaccinated (in Iran) whereas rest of the children found unvaccinated. Health education imparted regarding routine immunization. General hygiene and isola‐tion measures were also demonstrated. District Heath department was informed. 03 Blood samples were taken and sent to NIH for lab testing.

18‐May Measles Balochistan Lasbela Jam Yusuf colony, UC Pathra, Tehsil Hub

3 1 2 0

6 cases of measles were reported through LHW network. Vit A drops and symptomatic treatment was provided. Health and hygiene session conducted. 2 blood samples were collected and sent to NIH for lab confirmation. 23 children were assessed for routine immunization, out of which, BCG 20(87%),with scar 18,(78%),P1,4(17%) P2,1(4%) P3,2(9%) M1,10(43%) M2,0. Information shared with DHO for inten‐sified outreach vaccination in the area.

15‐May CCHF Balochistan Quetta Jinnah town; Satelite town; Kharotabad; Khuchlak

0 0 5 1 6 new suspected cases of CCHF reported from Quetta, 3 cases including one death confirmed positive by PCR, while 3 samples pending. Two of the suspected cases are contacts of confirmed cases and all others have history of handling animals or skins.



Province Khyber Pakhtunkhwa: 484 health facilities from 19 districts of Khyber Pakhtunkhwa reported to DEWS with a total of 135,465 patients consultations reported in week 20, 2012. Total 60 alerts were received while 3 outbreaks were identified and appropriated measures were taken in week 20, 2012. Altogether 47 alerts for Measles; 6 for Leishmaniasis; while 1 each for AJS, Bloody diarrhoea, Pertussis, Rabies and Typhoid.

Figure-5: Trend of priority communicable diseases, province KPK

Province Sindh:

Figure‐3: Number of alerts received and responded, week 20, 2012 Figure‐4: Number of consultations by age and gender, week 20, 2012

Province Punjab:

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Figure-6: Number of alerts received and responded week 20, 2012, province KPK

Figure-7: Trend of priority communicable diseases, province Sindh

630 health facilities from 23 districts in province Sindh were reported to DEWS with a total of 323,820 patients consultations in week 20, 2012. Total 71 alerts received while 6 outbreaks were identified and appropriate measure were taken in week 20,2012. Altogether 45 alert for Measles; 8 for Ty‐phoid; 6 for AWD; 5 for Pertussis; 3 for AFP; 2 for NNT; while 1 each for AJS and Leishmaniasis.

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Figure-8: Number of alerts received and responded week 20, 2012, province Sindh

Figure-9: Trend of priority communicable diseases, province Punjab Figure-10: Number of alerts received and responded week 20, 2012, province Punjab

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429 health facilities from 8 districts in province Punjab reported to DEWS with a total of 206,467 patients consultations in week 20, 2012. Total 52 alerts were received while 2 outbreaks were identified and appropriate measures were taken in week 20,2012. Altogether 32 alerts for Measles; 7 for AWD; 5 for Typhoid; 3 each for Acute diarrhoea and Dengue fever; while 1 each for Acute flaccid paralysis and Acute jaundice syndrome.

< 1 yr 1‐4 yr 5‐14 yr 15‐50 yr 50 + yr

Male 27174 62801 82013 125207 57270

Female 26002 57918 84788 203420 63689

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State of Azad Jammu and Kashmir:

Province Gilgit Baltistan:

FATA:

Province Balochistan:

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Figure-11: Trend of priority communicable diseases, province Balochistan Figure-12: Number of alerts received and responded week 20, 2012, province Balochistan

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382 health facilities from 19 districts in province Balochistan reported to DEWS with a total of 61,455 patients consultations in week 20, 2012. Total 35 alerts reported while 6 outbreaks were identified in week 20, 2012. Altogether 13 alerts for Measles; 8 for Leishmaniasis; 7 for suspected Malaria; 3 for CCHF; 2 for AFP; while 1 each for Acute viral hepatitis and Typhoid.

32 health facilities from 4 districts in Gilgit Baltistan reported to DEWS with a total of 14,794 patients consultations in week 20, 2012. No alerts reported or outbreak identified in week 20, 2012 from any area in Gilgit Baltistan.

Figure-13: Trend of priority communicable diseases, province Gilgit Baltistan

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Figure-14: Number of alerts received and responded week 20, 2012, Gilgit Baltistan

Figure-15: Trend of priority communicable diseases, FATA

52 health facilities from 3 agencies in FATA reported to DEWS with a total of 14,078 patients consultations in week 20, 2012. Total 6 alerts reported while 1 outbreak identified in week 20, 2012. Altogether 5 alerts for Measles; while 1 for Leishmaniasis were reported and appropriated measures were taken.

Figure-16: Number of alerts received and responded week 20, 2012, FATA

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Figure-17: Trend of priority communicable diseases, AJ&K

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Figure-18: Number of alerts received and responded week 20, 2012, AJ&K

124 health facilities from 9 districts in AJ&K reported to DEWS with a total of 31,330 patients consultations in week 20, 2012. Total 8 alerts reported in week 20, 2012. Altogether 5 alerts were for Leishmaniasis; while 3 for Measles were reported and appropriate measure were taken.



Distribution of Wild Polio Virus cases Pakistan 2011 and 2012

In this week 20, 2012, no new polio case was reported. As of 21 May 2012, the total number of polio cases confirmed by the laboratory is 16 from 10 districts/towns/tribal agencies and areas.

Province Cases 2011 Cases 2012

P1 P3 P1 P1+P3

Punjab 9 ‐ 1 ‐

Sindh 33 ‐ 2 ‐

Khyber Pakhtunk‐hwa

23 ‐ 4 ‐

FATA 57 2 4 1

Balochistan 73 ‐ 2 ‐

AJ&K ‐ ‐ ‐ ‐

Gilgit‐Baltistan 1 ‐ ‐ ‐

Islamabad ‐ ‐ ‐ ‐

Total 196 2 13 1

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Table‐1: Total number of alerts and outbreaks reported and investigated with appropriate response Disease

2011 2012 (up till week 19) Current week 20, 2012

A O A O A O A O

Acute watery diarrhoea 1350 543 148 10 14 0 162 10

Acute jaundice syndrome 51 17 56 6 3 1 59 7

Bloody diarrhoea 98 20 64 5 1 1 65 6

Dengue fever 785 111 34 2 3 0 37 2

Measles 1708 110 1787 142 145 10 1932 152

Pertussis 287 81 228 85 6 2 234 87

NNT + tetanus 399 0 245 0 2 0 247 0

Malaria 131 88 34 13 7 3 41 16

Leishmaniasis 298 33 378 35 21 0 399 35

Others 645 69 637 54 30 0 667 54

Total 5752 1072 3611 352 232 17 3843 369

Total for 2012 (week 1‐20, 2012)

The chart above and table to the right show the weekly number of con‐firmed cases reported by surveillance focal points in the Departments of Health in Sindh and Punjab in 2012. Total number of confirmed dengue cases to date in 2012 is 50 in Sindh and 56 in Punjab. Month of peak incidence in 2010 was November while peak incidence in 2011 was in September and October.

Distribution of Dengue cases in Pakistan, 2012

Epi‐week Punjab Sindh 1 0 2 2 0 1 3 0 4 4 0 5 5 1 1 6 2 1 7 3 5 8 5 3 9 4 3 10 8 4 11 3 1 12 1 2 13 2 1 14 7 1 15 5 4 16 5 3 17 4 3 18 3 1

Weekly reported Dengue cases

19 2 0 20 1 5

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Focus on: Measles

The global burden of measles has remained a public health challenge. Worldwide, measles is the fifth leading cause of death among under‐five children with an estimate of 197,000 deaths in 2007. One in 15 people have complications with mea‐sles, and one in 1000 will die of it, but two doses of measles vaccine will protect children against the disease. WHO has set the target for measles elimination for 2015 which would require that more than 95% of the world’s children are vaccinated against measles. In Pakistan, measles is an important cause of child‐hood morbidity and mortality. Measles outbreaks have been increasingly common in the country. From 1st January to 19th May 2012, DEWS team have reported 1937 Alerts and identified and responded to 156 outbreaks (clustering of more than 5 cases in a locality) of Measles. During this period 4324 clinical cases and 49 deaths due to Measles have been reported. In 2011, for the same period, 655 alerts and 75 outbreaks were jointly investigated and responded by the WHO‐DEWS team and the department of health. This year, peak of measles cases all over the country has been noticed in the month of April and May especially in the prov‐inces of Sindh, KPK and FATA where maximum number of cases and deaths were reported. While last year uptil 20 week majority of the cases were from Sindh province. First graph at right shows the weekly trend of Measles cases in 2011 and 2012, notably dramatic increase of measles cases has occurred since the 1st week of April. Measles data for week 20 of 2012 by each prov‐ince / territory is shown in table at right. The age distribution of measles cases is illustrated in the 3rd chart at right for the last three weeks. Majority of cases are under five years indicates need for improving measles immunization coverage in this age group.

In order to cope with the situation, the DEWS teams, District Health Departments and the EPI programme are jointly organizing intensified outreach vaccination ac‐tivities to vaccinate unimmunized children in the areas af‐fected. In addition, the community is also being educated on the routine immunization schedule and when to vaccinate their children in order to prevent the childhood life‐threatening diseases. Sindh Department of Health has recommended that:

• The Vaccinators should do Routine Immunization between the NIDS & SIADS. • The LHS when go for Visiting Health Houses should be provided the vaccine & Defaulter Lists, so that she can get them

covered through LHWs. • Every month the Defaulter lists be prepared and get the same covered.

Province Epi‐week 20, 2012

# of Alerts # of Outbreak # of Cases # of Deaths

AJ& K 3 0 3 0

Balochistan 13 2 37 0

FATA 5 1 17 0

Gilgit Baltistan 0 0 0 0

ICT 0 0 0 0

Khyber Pakhtunkhwa

47 1 65 0

Punjab 32 2 62 0

Sindh 45 4 88 1

Total 145 10 272 1

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Alerts and outbreaks, week 20, 2012

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