Epidemiological Week No. 31 (4-10 Aug) August 20/ Vol. 90/ DEWS

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1 Epidemiological No. 31 (4-1 Aug) August 2/ Vol. 9/ DEWS Reporting Units...2 Total number of consultations...2 DEWS Data, Epidemiological No. 32, DEWS Data, Monthly Summary (Epidemiological No )...4 Acute Watery Diarrhoea... Acute Jaundice Syndrome...6 Malaria...7 Acute Respiratory Infection...8 Other Reportable Diseases and Conditions...8 Outbreak Alert and Response...9 Number of reported cases and deaths per District, AJK...1 Number of reported cases and deaths per District, NWFP...11 Bagh: Polio vaccination campaign Pictured by: Dr. Fawad Khan The number of bloody diarrhoea cases decreased by 2% from week 31 (W31=34 & W32=42) Five suspected cases of acute watery diarrhoea were reported from DHQ hospital, Bagh district. Malaria cases decreased by 1% from week 31 (W31=721 & W32=613) Acute watery diarrhoea cases decreased by 17% from week 31 (W31=12,62 & W32=1,44) One case of suspected measles was reported from Mansehra district. The ly Morbidity and Mortality Report (WMMR) is published by the Ministry of Health of Pakistan (MOH) and the World Health Organization (WHO). The WMMR is built on surveillance data that health service providers and NGOs transmit on a weekly basis from health facilities and hospitals in those areas affected by the earthquake that struck Pakistan on 8 October 2. The WMMR objectives are to monitor the trend of health conditions over a period of time and provide vital information to all health partners. The WMMR is only a snapshot of the health conditions in those facilities where events are registered and data collected and does not necessarily reflect the situation from other health facilities. The WMMR is a publication that has been developed for emergencies and previously used in other areas such as the Darfur Crisis. The WMMR is produced with the financial support of AAI Australia, Americares, CIDA, Denmark, DFID, ECHO, Ireland, Italy, Japan, Korea, Monaco, Norway, SIDA, Slovak Republic, Switzerland, Turkey, USAID The WMMR is published by the World Health Organization (WHO), Health Emergency Operation Centre, National Park Road, Chak Shehzad, Islamabad, Pakistan. For More Information, please contact: Dorcas Taylor, Epidemiologist, WHO/EHA/Pakistan; taylord@pak.emro.who.int or Dr. Birjees Mazher Kazi, Chief, Public Health Laboratories Division, NIH MOH; kazis@isb.paknet.com.pk or WHO Webpage:

2 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS Reporting Units The number of reporting sites able to report this week was 28; the reporting timeliness of the DEWS system has decreased by 1% at current epidemiological week 32 compared with previous week (epidemiological week 31). Many facilities were unable to report due to an ongoing measles vaccination campaign. See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 14 July to 1 Aug 27. Area Population Reporting Health Facilities 14-2 July July 28July- 3 Aug 4-1 Aug Bagh 42, Battagram 92, Mansehra 1,14, Muzaffarabad 894, Poonch 633, Total 3,727,668 32(9%) 32(9%) 311(93%) 28(8%) Total number of consultations In week 32, there was 8% decrease in the number of reporting sites, and the number of consultations has also decreased from 99,12 to 89,13. The highest number of consultations was reported from Muzaffarabad, with 29,896, and the lowest from Battagram district, at,77. The weekly trend of reporting units participating in the DEWS and the number of consultations is shown in figure 1. No. Unit 3 Reporting Unit Reporting Units and Consultations Consultation No. Consult W31 W28 W2 W22 W19 W16 W13 W1 W7 W4 W1 W W47 W44 W41 W38 W3 W32 W29 W26 W23 W2 W17 W14 W11 W8 W W2 W1 W48 W4 W42 Figure 1. ly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 1 October 2-1 Aug 27. 2

3 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS DEWS Data, Epidemiological No. 32, 27 During the last week (4 to 1 Aug, 27), 89,13 consultations were reported through DEWS. Acute Respiratory Infections (ARI) accounted for 2% (17,892) of consultations, which was 4 percentage points higher compared to the same week last year. Acute Watery Diarrhoea (AWD) made up 12% (1,44) of consultations, 8% (7,38) were due to Fever of Unknown Origin (FUO) and less than 1% (278) due to Injuries (INJ). The AWD cases in patient under five years were percentage point lower in week 32 of 27 compared to the same week last year. In patients aged five and above, AWD was 1% of consultations, which was three percentage points lower than that reported in the same week last year. All other reportable conditions each represented less than 1% of the total consultations in week 3. AWD 19% ARI 2% AWD 1% ARI 19% AWD 12% ARI 2% OTH* 46% FUO 9% INJ <1% FUO 8% INJ <1% OTH* OTH* 62% 9% < yrs (n=16,876) yrs (n=72,637) All Ages (n=89,13) Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan,4-1 Aug 27. *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance FUO 8% INJ <1% DEWS Data, Epidemiological No. 32, 27: Consultations by age The rate of AWD in both age groups was almost the same in week 29 and 3 in 27 compared with the same weeks in 26, however in weeks 31and 32 AWD there was a downward trend in the rate of AWD in 27 for both age groups when compared to the same weeks of 26. This trend was more pronounced in patients under five. See figure 3. AWD as percentage of all consultation with in age group yrs 27 yrs 26 < yrs 27 < yrs Figure 3: AWD as a percent of all consultations, by age group, Earthquake Affected Areas, Pakistan, 1July - 11 Aug 26 to 14 July - 1 Aug 27 3

4 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS DEWS Data, Monthly Summary (Epidemiological No ) During the period, 4 to 1 Aug, 27 (Epidemiological weeks 29 to 32 inclusive), 18,664 consultations relating to health conditions under surveillance were reported, out of the total of 383,621 consultations. 2% (74,97) of consultations were due to acute respiratory infection (ARI), 13% (48,79) acute watery diarrhoea (AWD), 8% (28,8) unexplained fever (FUO) and less than 1% (1,113) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 14 July 1 Aug 27. WEEK 29 WEEK 3 WEEK 31 WEEK 32 TOTAL Event C D C D C D C D C D CFR% AWD BD AFP 1 1. MAL ARI MES MEN JAU TET. AHF. FUO INJ OTH TOTAL RU C Cases, D Deaths, AWD - Acute Diarrhoea, BD - Bloody Diarrhoea, AFP - Acute Flaccid Paralysis, MAL Malaria, ARI - Acute Respiratory Infection, MES Measles, Men - Meningitis, JAU - Acute Jaundice Syndrome, TET - Neonatal Tetanus, AHF Acute Hemorrhagic Fever, FUO Unexplained fever, INJ Injuries, OTH Others, RU Reporting Units. Please note data from late reporting in previous weeks has been updated. During the same reporting period, 71,34 consultations were reported in children less than years of age, (19% of the total consultations), of which ARI was 26% (18,4), AWD 2% (14,74), FUO 8% (,832) and INJ was less than 1% (2). Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than years old, Earthquake Affected Areas, Pakistan 14July 1Aug 27. WEEK 29 WEEK 3 WEEK 31 WEEK 32 TOTAL Event C D C D C D C D C D CFR% AWD BD AFP 1 1. MAL ARI MES MEN JAU TET. AHF. FUO INJ OTH TOTAL RU

5 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS There was a 17% decrease in the number of AWD cases from 12,62 to 1,44 since last week, and there was also a decrease in the number of ARI cases from 2,246 to 17,892 since last week. The weekly proportion of ARI and AWD is shown in figure 4. % Consultation ARI and AWD percent of total consultations ARI AWD W31 W28 W2 W22 W19 W16 W13 W1 W7 W4 W1 W W47 W44 W41 W38 W3 W32 W29 W26 W23 W2 W17 W14 W11 W8 W W2 W1 W48 W4 Figure 4. ly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 1 October 2 1 Aug 27. Acute Watery Diarrhoea During week 32, there were 1,44 cases of AWD reported which was 4 percentage points lower when compared with same week last year. There was one death of a patient less than five years old reported from Muzaffarabad district. See figure. AWD as percentage of all consultation Figure : Trend in AWD as a percent of all consultations, 27, Earthquake Affected Areas, Pakistan, 14 July - 1 Aug 27

6 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS Bloody Diarrhoea In week 32, there were 42 cases of bloody diarrhoea reported, which was 2% lower than week 31. There were no associated deaths reported from any district. The percentage of BD in 27 has been lower than that seen in 26 for the last four weeks. See figure BD as percentage of all consultation Figure 6: Trend in bloody diarrhoea as percentage of all consultations, 26 and 27, Earthquake Affected Areas, Pakistan, 1 July - 11 Aug 26 to 14 July - 1 Aug 27 Acute Jaundice Syndrome In week 32, there were 21 cases of suspected hepatitis reported. There were no associated deaths reported from any district. In 27 the rate of hepatitis climbed significantly in week 29, but has remained lower than that seen the same weeks of last year. See figure 7. AJS number of cases with in age group yrs 27 yrs 26 < yrs 27 < yrs Figure 7: Trend in suspected hepatitis cases per reporting site, Earthquake Affected Areas, Pakistan, 1July - 11 Aug 26 to 14 July to 1 Aug, 27. 6

7 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS Malaria In week 32, there were 613 cases of suspected malaria reported, 1% lower than last week, out of which 33 suspected cases were in patients over five years of age and 8 in patients less than five years of age. There were no associated deaths reported from any district. The number of malaria patients was higher in week 3 and 31 of 27 compared to the same weeks last year but in week 32 has declined to a level below that seen in the same week of 26. See figure 8. Malaria as percentage of all consultation Figure 8: Trend in malaria as a percent of all consultations within age group, Earthquake Affected Areas, Pakistan, 1July -11 Aug 26 to 14 July to 1 Aug, 27. Measles There were 2 suspected cases of measles reported in week 32, one case over five years of age reported from Mansehra and one case less than five years of age was reported from Muzaffarabad district. There were no associated deaths reported. A measles vaccination campaign is being undertaken in several of the earthquake affected districts, and it is hoped that the rate of measles will drop even further. See Figure Measles number of cases Figure 9: Trend in measles cases as a percent of all consultations, Earthquake Affected Areas, Pakistan, 1 July -11 Aug 26 to 14 July 1 Aug, 27 7

8 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS Acute Respiratory Infection In week 32, there were 17,892 consultations for ARI reported through the DEWS system. There were four deaths in patient less than five years of age was reported in week 32 out of which two deaths reported from Mansehra, third death was reported from Poonch and fourth death was reported from Bagh district. The rate of ARI has been slowly rising in the past four weeks, and has been consistently higher than that seen in the same weeks of 26. See Figure 1. ARI as percent of all consultation Figure 1: ARI as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 1July- 11 Aug 26 to 14 July - 1 Aug 27 Other Reportable Diseases and Conditions There were no cases of suspected meningitis reported from any district in week 32. There were 7,38 cases of Fever of Unknown Origin (FUO) and 278 injuries in week 32. There were no cases of tetanus and acute hemorrhagic fever reported from any district. See figure 11. Meningitis number of cases Figure 11: Total number of meningitis consultations, Earthquake Affected Areas, Pakistan, 1July-11 Aug 26 to 14July- 1 Aug 27 8

9 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS Outbreak Alert and Response 1 Acute watery diarrhoea Bagh On 4 th of August 27, DHQ Bagh reported one case of acute watery diarrhoea. The patient was a 2 year old female resident of Kharal Abbassian, with sudden onset profuse watery diarrhoea and vomiting. The patient was admitted in the Diarrhea Treatment Centre (DTC) with severe dehydration and shock. A stool sample was taken and sent to NIH for laboratory confirmation. During Active surveillance there was no case with similar symptoms found in the family and surroundings. On th of August 27, DHQ Bagh reported one case of acute watery diarrhoea. The patient was a 48 year old male resident of Islamabad who came to Bagh a day before the onset of illness. He was staying at a hotel in Bagh city, where took a meal and an hour later developed profuse watery diarrhoea and vomiting. The patient was admitted in the DTC with severe dehydration and shock. A stool sample was taken and sent to NIH for laboratory confirmation. Hygiene education i.e. benefits of the boiled drinking water, proper storage of the water, proper segregation of cooked and uncooked food, thorough washing of vegetables before cooking was given to the hotel staff and authorities. DHQ hospital Bagh reported 2 cases of acute watery diarrhoea on 6 th of August 27. The patients were a 1 year old male and 3 year old female, residents of village Jhir, Ghaniabad. Both patients experienced a sudden onset profuse watery diarrhoea and vomiting one day before admission to the DTC. Both the patients were from different families but the water source was common. Two stool samples were taken and sent to NIH for laboratory confirmation. On 9 th of August 27, DHQ hospital Bagh reported a case of acute watery diarrhoea. The patient was a 4 year old female resident of village Bahunth Kohna, Bagh. The patient was admitted in the DTC with severe dehydration and shock. A stool sample was taken and sent to NIH for laboratory confirmation. The drinking water sources of the local people were two inadequately protected natural springs. Both springs were used simultaneously for washing clothes, bathing and collecting water for drinking. Active hygiene promotion and education i.e. benefits of boiled drinking water, proper storage of the water and safe disposal of waste was given to the family members and local community. Measles Mansehra An alert for suspected case of measles was received from BHU Bherkund, Mansehra. The patient was a 6 year old male resident of village Dabi Humsherian complaining of cough and rashes for three days followed by fever, conjunctivitis and runny nose for one day. A blood sample was taken and sent to NIH for laboratory confirmation. On active surveillance no more cases with similar symptoms found from the area. 1 Outbreak Investigation and response of Suspected Viral Hepatitis, Malaria, and Bloody Diarrhoea and Watery Diarrhoea would only take place when a cluster of cases is identified or there is an increase in the incidence of the disease. (Note: Single death due to Diarrhoea and single case of reported severe dehydration among > years would be investigated) 9

10 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9/ DEWS Number of reported cases and deaths per District, AJK Table 6. Number of reported cases and deaths, Bagh District*, Earthquake Affected Areas, Pakistan, 14 July -1 Aug 27. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH C D C D C D C D C D C D C D C D C D C D C D C D C D Total Table 7. Number of reported cases and deaths, Poonch District*, Earthquake Affected Areas, Pakistan, 14 July -1 Aug 27. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH C D C D C D C D C D C D C D C D C D C D C D C D C D Total Table 8. Number of reported cases and deaths, Muzaffarabad District*, Earthquake Affected Areas, Pakistan, 14 July -1 Aug 27. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH C D C D C D C D C D C D C D C D C D C D C D C D C D Total

11 WMMR ly Morbidity and Mortality Report Pakistan 2 August 27 / Vol. 9 DEWS Number of reported cases and deaths per District, NWFP Table 9. Number of reported cases and deaths, Battagram District*, Earthquake Affected Areas, Pakistan, 14 July -1 Aug 27. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH C D C D C D C D C D C D C D C D C D C D C D C D C D Total Table 1. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 14 July -1 Aug 27. AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH C D C D C D C D C D C D C D C D C D C D C D C D C D Total