Weekly Epidemiological Flood Response in Pakistan...2010‐40 2‐Oct‐10 AWD Punjab Muzaffargarh...

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 41 (9 - 15 October 2010) • Between 9 - 15 October 2010 (epidemiological week no. 41), 38 of the 78 flood-affected districts pro-

vided surveillance data to the DEWS system. Of these 38 districts, 90% reported 6-7 days of the week.

• 575 fixed health and 128 mobile medical outreach centers provided surveillance data for this week.

• 306,799 consultations were reported through DEWS of which 19% were acute respiratory infections (ARI), 10% were acute diarrhoea, 11% were skin disease, and 8% were suspected malaria.

• 11 alerts were received and responded to this week: 6 alerts were for Dengue hemorrhagic fever (DHF), 3 were for Acute watery diarrhoea, 1 each for Bloody diarrhoea (BD) and suspected Measles (MS).

• Malaria outbreak control in collaboration with the Malaria Control Program is being implemented in districts Layyah, Rajanpur, DG Khan and Muzaffargarh in Punjab; Jacobabad, Larkana, Thatta and Khairpur in Sindh; Naseerabad, Sibi, Zhob and Jhal Magsi in Balochistan.

• Five of the 10 cases of poliomyelitis confirmed this week were from the flood-affected districts

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 9 Monday 17 October 2010

Table-1: Priority diseases reported during the week 31 - 40, 2010 (29 July - 8 October 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 Week‐31 Week‐32 Week‐33 Week‐34 Week‐35 Week‐36 Week‐37 Week‐38

Acute Diarrhea 25,689 (13%) 94,288 (11%) 182,548 (14%) 199,607 (14%) 138,644(13%)

68,909 (12%)

57,072 (14%)

64,925 (13%)

Bloody Diarrhea 1,449 (1%) 4,566 (1%) 7,907 (1%) 11,024 (1%) 10,839 (1%) 9,228 (2%) 6,705 (2%) 6,411 (1%)

ARI (URTI & LRTI) 25,335 (13%) 92,134 (11%) 185,546 (15%) 217,071 (15%) 187,226(18%)

96,607 (17%)

69,969 (17%)

89,949 (18%)

Suspected Malaria 3,954 (2%) 17,348 (2%) 27,453 (2%) 45,542 (3%) 45,652 (4%) 40,441 (7%) 32,692 (8%) 42,759 (9%)

Skin Diseases 36,383 (19%) 115,080 (14%) 246,959 (20%) 296,441 (21%) 202,630(19%)

92,039 (16%)

56,844 (14%)

60,704 (12%)

Total consultation 194,552 845,353 1,265,912 1,424,260 1,053,827 559,006 414,437 486,376

Week‐39

54,404 (13%)

5,896 (1%)

81,583 (19%)

36,514 (8%)

57,020 (13%)

433,890

Week‐40

37,624 (12%)

5,253 (2%)

65,216 (20%)

25,625 (8%)

41,664 (13%)

326,071

Week‐41

29,570 (10%)

4,426 (1%)

56,991 (19%)

24,768 (8%)

33,293 (11%)

306,799

Figure-1: Weekly trend of leading diseases in flood affected districts of Pakistan, 29-July to 15 October 2010 (Epi week 31 - 41, 2010)

Epidemiological Bulletin: Flood Response in Pakistan Figure-2: Number of fixed and mobile reporting units by province (Week 41, 2010)

• 64 districts have DEWS in place and 38 districts re‐ported to DEWS this week; 6 in Balochistan, 5 in KPK, 11 in Punjab and 16 in Sindh. Not all districts are re‐porting regularly.

• The average number of districts and health facilities reporting per week are shown in the table 2 and fig‐ure 2 above.

• Almost 90% of reporting districts reported 6‐7 times during the last reporting period, 7% reported between 3‐5 times, 3% reported 1‐2 times.

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

Province Wk 33 Wk 34 Wk 35 Wk 36 Wk 37

Balochistan 6 6 6 6 6

KPK 8 8 8 8 8

Punjab 8 8 9 9 9

Sindh 18 18 18 18 18

Total 40 40 41 41 41

Table‐2: Average number of reporting districts per week Wk 38

6

6

10

18

40

Wk 39

6

6

11

18

41

Wk 40

5

15

11

17

48

Wk 41

6

5

11

16

38

Table-3: Leading causes of seeking health care in the flood affected districts as of 15 Oct 2010

Figure-4: Leading causes of seeking health care in the flood affected districts by province, 29 July to 15 October 2010

Diseases Total

Skin Diseases 1,243,346 (17%)

Acute Respiratory Infection 1,177,886 (16%)

Acute Diarrhoea 963,326 (13%)

Bloody Diarrhoea 74,033 (1%)

Suspected Malaria 343,481 (<5%)

Unexplained Fever 367,488 (5%)

Total Consultations 7,357,826

732,232

367,508

126,373

17,233

589,768

381,785

177,648

28,685

449,162

329,947

146,510

37,707

343,843

17,974

5,671

44,976

244,190

11,539 42,776

825

60,762

3,741 8,705

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

Punjab Sindh Khyber Pakhtunkhwa Balochistan

Number of cases

Skin Ds.

ARI

AD

UF

S. Mal

BD

Table-4: Follow-up alerts reported in week 40, 2010. Epidemiological Bulletin: Flood Response in Pakistan

Table-5: Alerts and Outbreaks (Week 41, 2010)

03

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

2010‐40 2‐Oct‐10 AWD Punjab Muzaffargarh DHQ Muzaffargarh (Sharif Shajra P.O) 50 M Stool sample positive for V. Cholera Ogawa. Active surveillance ongoing.

2010‐40 3‐Oct‐10 AWD Punjab Multan THQ Shujabad 12 F Stool sample negative for pathogens. Active surveillance revealed no further cases

2010‐40 4‐Oct‐10 Measles Punjab Multan Rasheed Hospital ‐ Private 4,6 M,F Blood sample was negative for measles and rubella.

2010‐40 4‐Oct‐10 AWD Sind Jacobabad DHQ Jacobabad (UC Dashti) 35 F Stool sample negative for pathogens. Active surveillance revealed no further cases

2010‐40 4‐Oct‐10 AWD x 5 KPK Mardan DHQ Mardan (Toot Kaley, Guli Bagh, Kochian, Sikandari, Janday Takhtbhai)

4m, 6m, 60y, 6m, 45y

M,F,F,F,F

Cases admitted to DTC, stool samples were negative for pathogens. No further cases were found during active surveillance

2010‐40 4‐Oct‐10 Measles KPK Swabi Bacha Khan Medical Complex 2.5 F Blood sample was positive for measles. Further investigation planned

2010‐40 4‐Oct‐10 AWD x 3 Punjab Muzaffargarh Australian Medical Camp (Nigad abad, Chah Langar Wala, Khoo Kukanwala)

32, 26, 25 M,

M, M Stool samples were negative for pathogens, active surveillance revealed no further cases

2010‐40 5‐Oct‐10 AWD x 2 KPK Lower Dir RHC Munda (Ganderey‐Mayar, Gambir‐Mayar)

40, 46 M, M Stool sample was positive for V. Cholera Ogawa. Active surveillance carried out, health education was given and IEC material was provided. DTC health staff, hygiene promotors were trained on case management.

2010‐40 5‐Oct‐10 AWD KPK D.I. Khan Madina Colony 5 F Stool sample was positive for V. Cholera Ogawa. Active surveillance ongo‐ing

2010‐40 6‐Oct‐10 AWD KPK D.I. Khan Chah Faqir Wala 25 F Stool sample positive for V. Cholera Ogawa, active surveillance ongoing

2010‐40 6‐Oct‐10 AWD x 14 Punjab Muzaffargarh

DTC‐MSF Kot Addu (Chowk Munda, Ward # 8, Kot Addu, Mirpur Bhagal), Village Sinawan, Village Rakhpattan, Pnora, Mouza Chaudry, Manhan, Village Gourmani, Rojewala, Village Kita Lonwala, Pul88, Village Sheikh Umah

8m to 25 years

11M, 4F

10 positive Ogawa patients treated at DTC. Active surveillance ongoing. Response in collaboration with WASH Cluster. Distributed filters and soaps to affected families

2010‐40 7‐Oct‐10 AWD KPK Swat THQ Matta 40 M Stool sample positive for V. Cholera Ogawa, active surveillance is under progress for the two UCs.

2010‐40 7‐Oct‐10 DHF KPK Swat SGTH (Mian Bela) 60 M Blood sample negative, no further cases found during active surveillance

2010‐40 7‐Oct‐10 DHF KPK Haripur Muhalla Syed Abad 18, 28 M, F Blood sample collected and active surveillance is under progress .

2010‐40 7‐Oct‐10 AFP Punjab RY Khan UC Nawazabad 3 F Stool sample collected and sent to NIH, Active surveillance is under process

2010‐40 8‐Oct‐10 DHF KPK Swat SGTH (Topseen Village) 18 M Blood sample negative, active surveillance revealed no further cases

2010‐40 8‐Oct‐10 DHF KPK Swat SGTH (Aspand‐Lower Dir) 13 M Blood sample negative, active surveillance revealed no further cases

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

2010‐41 9‐Oct‐10 DHF KPK Mansehra Khaki 38 M Blood sample collected and active surveillance is under progress .

2010‐41 10‐Oct‐10 DHF KPK Mansehra UC Jallu 65, 42 M,F Blood sample collected and active surveillance is under progress. Health education was provided, Mosquito Nets were provided. MS DHQ Mansehra was informed.

2010‐41 10‐Oct‐10 AWD Punjab Muzaffargarh AMT (KAPCO‐Wapda Office) 5 M Stool sample collected and sent to NIH, active surveillance is under process.

2010‐41 10‐Oct‐10 DHF KPK Charsadda Harichand Bangla (IPD‐Malakand) 18 F Blood sample collected and found negative. Active surveillance was done.

2010‐41 10‐Oct‐10 Measles KPK Nowshera IDP Camp Jalozai Phase V 5 M Blood sample collected and active surveillance is under progress .

2010‐41 11‐Oct‐10 DHF KPK Swat Mangarkot Charbagh 18 M

Blood sample collected and found negative. Active surveillance was done. Patient was isolated, bed net was provided and health education was given. WHO, Merlin & DoH combined response is planned. EDO Health was informed.

2010‐41 12‐Oct‐10 AWD KPK Nowshera IDP Camp Jalozai Phase III‐Pabbi 3,5,10 M,F,M

Stool sample collected and found positive, active surveillance was done.

2010‐41 12‐Oct‐10 DHF KPK Swat Sersenai Village‐Kabal 55 F Blood sample collected and active surveillance is under progress . Patient is isolated, ITNs were given and health education was provided. Medical camp was established and active surveillance was done.

2010‐41 12‐Oct‐10 BD Punjab Muzaffargarh AMT (Basti Ghurki) 18 M Stool sample collected and sent to NIH, active surveillance is under process.

2010‐41 13‐Oct‐10 AWD Punjab Muzaffargarh AMT (Kot Addu) 25 F Stool sample collected and sent to NIH, active surveillance is under process.

2010‐41 14‐Oct‐10 DHF KPK Swat Shahdam Kaley 13 M Blood sample collected and sent to NIH, active surveillance is under proc‐ess. Patient is isolated, ITNs were given and health education was provided.

Table-6: List of confirmed Polio Cases from flood affected districts, week 41-2010

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

1 Sindh Ghotki Female 72 22‐09‐2010 NSL1

2 KPK Lakki Marwat Female 20 20‐09‐2010 NSL1

3 Sindh Kamber Female 16 25‐09‐2010 NSL1




Epidemiological Bulletin: Flood Response in Pakistan

Figure-6: Proportional morbidity of priority diseases, KPK province

Figure-8: Proportional morbidity of priority diseases, Punjab province

Province KPK

Diseases Number % of total consul-tations

Acute Diarrhoea 3,928 6%

ARI 12,256 17%

Skin Diseases 3,090 4%

others 47,575 68%

Total Consultations 70,046

• This week 5 out of 17 flood affected districts reported to DEWS from KPK province

• 36 fixed health centers and 14 mobile medical outreach centers reported to DEWS

• 70,046 patient consultations were reported during the reporting period of 9 – 15 October, week 41, 2010

• 8 alerts were received and investigated this week; 6 were for DHF, 1 was for Measles, and 1 was for AWD.

• Regarding Dengue Fever (DF) and Dengue Hemor-rhagic Fever (DHF), from early September up until 15th October 2010, DEWS teams have identified 188 sus-pected cases of DF in the districts Haripur, Mansehra and Abbotabad. Of the suspected cases, 131 were male and 57 were female. No case was under age five years. During this time, there were nine confirmed deaths of cases with fever and hemorrhagic signs but only one was confirmed positive for DF.

Province Punjab • 11 out of 12 flood affected districts reported data to

DEWS from Punjab province


• 96,624 patient consultations were reported during this reporting period

• 3 alerts were received and investigated this week; 2 were for AWD, and 1 was for BD. DEWS officers are follow-ing up the AWD cases in Kot Addu reported last week.

• In Punjab, a higher proportion of suspected malaria was reported this week (10% to 11%), although a peak of malaria in October reflects seasonal trend of diseases, DEWS officers are collaborating with Malaria Control Program to investigate areas of increased malaria.

Diseases Number % of total consulta-tions


ARI 19,132 20%


Suspected malaria 8,732 9%

Total consultations 96,624

Others 33,157 34%

Figure-5: Trend of priority communicable diseases, province KPK (31-July - 15 October 2010)

Figure-7: Trend of priority communicable diseases, province Punjab (3 August - 15 October 2010)


05


Figure-10: Proportional morbidity of priority diseases, Sindh

Figure-12: Proportional morbidity of priority diseases, Balochistan

Province Sindh • 16 out of 22 flood affected districts reported to

DEWS from Province Sindh


• 115,903 patient consultations were reported during the reporting period of 9 - 15 October, week 41, 2010

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

• No alerts were received this week

• A Dengue surveillance and response cell has been established in Hyderabad to address in-creasing numbers of cases of Dengue Fever.

Province Balochistan

• 6 out of 19 flood-affected districts reported to DEWS from province Balochistan


• 24,226 patient consultations were reported during the reporting period of 9 - 15 October, week 41, 2010

• Suspected malaria has declined as a proportion of total consultations across the province but certain hot spots are still experiencing out-break levels of malaria cases. Malaria outbreaks in districts Naseerabad, Sibi, Zhob and Jhal Magsi are being addressed in collaboration with the Malaria Control Program.

• No alerts were received from Balochistan

Diseases Number % of total consul-tations


ARI 4,257 18%

Suspected Malaria 3,358 14%

Unexplained Fever 1,173 5%


Diseases Number % of total consultations


ARI 21,346 18%


Suspected malaria 11,834 10%


Others 41,257 36%

Figure-9: Trend of priority communicable diseases, province Sindh (6 August - 15 October 2010)

Figure-11: Trend of priority communicable diseases, province Balochistan (6 August - 15 October 2010)


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.

Since July 29, 2010, approximately 7,357,826 patient consul‐tations have been reported to DEWS from the flood affected provinces in Pakistan. DEWS is currently in place in 64 (82%) of the 78 flood affected districts and reporting is received from 38 (59%) of these 64 districts.

The major causes for seeking healthcare by the affected communities continue to be diarrheal diseases, acute respi‐ratory infections, skin diseases and suspected malaria.

In KPK, ARI increased from 12% to 14% also AD continues to decline, however, it remains proportionally higher compared to the corresponding reporting period from 2009. (Please see Fig.13)

So far about 2,443 cases of suspected Dengue Fever (DF) have been reported in Pakistan with about 1,082 confirmed cases. Karachi in the south and Haripur in the north are the endemic areas. Control of mosquitoes is the only primary prevention strategy. Four different dengue viruses, spread by the bite of the urban Aedes aegypti mosquito, can cause the headache or flu‐like symptoms with fever called Dengue Fever. When DF cases are infected another year with a different dengue virus, Dengue Hemorrhagic Fever (DHF) is a potentially deadly complication. DHF often begins with a sudden rise in temperature accompanied by facial flush and other flu‐like symptoms. The fever usually continues for two to seven days and can be as high as 41°C, possibly with convulsions and other complications. In moderate DHF cases, all signs and symp‐toms abate after the fever subsides. In severe cases, the patient's condition may suddenly deteriorate after a few days of fever; the tempera‐ture drops, followed by signs of circulatory failure, and the patient may rapidly go into a critical state of shock, or quickly recover following appropriate medical treatment. WHO currently estimates about 2/5 of the world’s population is at risk for Dengue Fever (DF) with about 50 million dengue infections world‐wide every year and about 500,000 (1%) hospitalized for Dengue Hemorrhagic Fever (DHF). In a recent study of DF in Pakistan from 2003‐2007, there were 15,040 patients with suspected DF during that time with 3,952 (26%) testing positive for dengue IgM antibody, and 209 hospitalized of whom 45 were diagnosed as DHF. In this review, 63% of suspected DF cases were male and 37% were female. The median age declined over the study period from 32 in 2003 to 24 in 2007. The first confirmed outbreak of DF in Pakistan was in 1994 and found due to DF virus serotype DV‐2. The current annual epidemic trend be‐gan in September to December 2005, when a sudden rise in DHF patients was noted at major hospitals in Karachi apparently due to introduc‐tion of serotype DV‐3 in the country. During the outbreak of DHF in 2006, both DV‐2 and DV‐3 serotypes were found to be circulating. All dengue patients must be carefully observed for complications for at least 2 days after recovery from fever because life threatening com‐plications often occur during this phase. Patients and households should be informed that severe abdominal pain, passage of black stools, bleeding into the skin or from the nose or gums, sweating, and cold skin are danger signs. If any of these signs is noticed, the patient should be taken to the hospital. Please use only paracetamol for pain and fever as other medicines may increase the bleeding tendency. Due to rises in incidence of DF and DHF, WHO‐Geneva has established a unit for prevention and control of Viral Hemorrhagic Fevers. WHO‐EMRO and Pakistan Country Office are in coordination with them to bring resources to Pakistan to address the issues here such as improving case management of DHF in hospitals and improving vector control in community level. Khan E, Kisat M, Khan N, Nasir A, Ayub S, Hasan R. Demographic and Clinical Features of Dengue Fever in Pakistan from 2003–2007: A Retrospective Cross‐Sectional Study. PLoS One. 2010; 5(9): e12505. Published online 2010 September 13. doi: 10.1371/journal.pone.0012505. PMCID: PMC2938342 World Health Organization. Dengue and Dengue Hemorrhagic Fever. Fact Sheet No. 117. March 2009. http://www.who.int/mediacentre/factsheets/fs117/en/. Accessed on 17 October 2010.

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

Focus on: Dengue Fever and Dengue Hemorrhagic Fever

Summary of Health Event in Flood affected districts

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 crisis and hosting districts, Khayber Pakhtunkhwa (2009‐2010)

2009 2010

Alerts of Acute watery diarrhoea (31 July to 7 October 2010)



08

Positive Cases of Malaria reported from flood affected districts (Aug 1 to Oct 7, 2010)

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