Weekly Epidemiological Bulletin

Transcription

1 Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan Volume 2, Issue 22, Monday June, Highlights Epidemiological week no. 22 (2 May - 2 June, ) 92 districts in provinces, FATA, AJK, and ICT provided surveillance data to the DEWS. This system is gradually expanding to provide information about communicable disease threats in all parts of Pakistan. Currently DEWS surveillance officers are responding to alerts in 4 districts and agencies. 3,1 fixed health facilities and mobile medical outreach centres provided surveillance data for this week. A total of 9,939 consultations were reported through DEWS of which % were acute respiratory infections (ARI), % acute diarrhoea, 9% skin disease, and % were suspected Malaria. A total of alerts were reported in week-22, : Altogether alerts were for Measles; 33 were for AWD, were for Pertussis, 2 each were for Acute Diarrhoea, Leishmaniasis, Meningitis, Neonatal Tetanus and Tetanus, while 1 each for Acute Jaundice Syndrome, Bloody Diarrhoea, Monkeypox, Scabies and Typhoid. National Polio Eradication Initiative reported six confirmed polio cases this week, 1 each from Killa Abdullah, Khuzdar and Pishin districts in Balochistan, 1 each from Bannu and Peshawar districts in Khyber Pakhtunkhwa, while one from district Diamer in Gilgit Baltistan. Total 49 cases have been reported in from 23 districts. Priority diseases under surveillance in DEWS Acute Flaccid Paralysis (AFP) Acute Jaundice Syndrome (AJS) Acute Respiratory Infections (Upper and Lower) (ARI) Acute Watery Diarrhoea (AWD)/ Suspected Cholera Acute Bloody Diarrhoea (BD) Other Acute Diarrhoeas (AD) Suspected Viral Hemorrhagic Fever (VHF) Suspected Malaria (Mal) Suspected Measles (MS) Suspected Meningitis (MG) Others Figure-1: Weekly trend of leading priority diseases in Pakistan, 29 July to 2 June (Epi week 31, to week 22, ) wk 31 wk 33 wk wk 3 wk 39 wk 41 wk 43 wk wk 4 wk 49 wk 1 wk 1 3 wk 9 Table-1: Priority diseases reported during the week to week 22, Diseases Wk- Wk-1 Wk-1 Wk-1 Wk-19 Wk- Wk-21 Wk-22 Skin Disease 3,93 (9%) 4,4 (9%) 9, (9%),13 (9%) 9, (9%),9 (9%) 9,239 (%) 91,9 (9%) ARI (URI and LRI) 224,1 (24%) 22,1 (23%) 2,343 (24%) 1,13 (22%) 199,121 (22%) 3,32 (21%) 2,4 (%) 199,4 (%) Other Acute Diarrhoea (Not Watery), (9%) 92,39 (%) 9, (%),43 (%) 94,42 (%) 2,9 (%), (%) 1,43 (%) Bloody Diarrhoea,12 (1%), (1%),24 (1%), (1%), (1%),9 (1%) 9,41 (1%),439 (1%) Suspected Malaria 4, (%),23 (%) 4, (%) 3, (%), (%),41 (%) 1,9 (%),322 (%) Total consultation 92,9 9,31 93,1 4,932 94, 9, 1,,1 9,939 Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int. 1

2 Epidemiological Bulletin: DEWS, Pakistan, Week no. 22 (2 May - 2 June, ) Table-2: Leading causes of seeking health care in the disaster affected districts, 29 Figure-2: Weekly number of reporting health units (Week 33- to week 22-) July to 2 June Diseases Total Mobile Fixed Skin Diseases 3,13,3 (%) Wk 33 Wk Wk 3 Wk 39 Wk 41 Wk 43 Wk Wk 4 Wk 49 Wk 1 Wk 1 Wk 3 Wk Wk Wk 9 Wk Wk 13 Wk Wk 1 Wk 19 Wk 21 Acute Respiratory Infection,32,39 (24%) Other Acute Diarrhoea (Not Watery) 2,2,32 (9%) Bloody Diarrhoea,31 (1%) Suspected Malaria 1,, (%) Unexplained Fever 1,14,9 (4%) Total Consultations,19,394 Focus on: Polio In the past week six new type 1 polio cases were confirmed by the laboratory; three from Balochistan (Killa Abdullah, Pishin and Khuzdar districts), two from Khyber Pakhtunkhwa (Peshawar and Bannu districts) and one from Gilgit Baltistan (Diamer district). As of 29 th May, Pakistan has reported a total of 49 polio cases (all type 1) from 23 districts/ towns/ tribal agencies/ areas. The next sub national immunization days (s NIDs) will be conducted from 13th to th June targeting approximately 1 million children; a mix of bopv and mopv1 will be used. Gilgit Baltistan has reported a polio case after over 12 years. The child belongs to a family originally from Mohmand agency in FATA, which is a known high risk population group, although they have settled in Gilgit Baltistan for about 4 years. As per recommendation of the Technical Advisory Group (TAG) on polio eradication in Pakistan, a focused case response vaccination campaign is being planned in Diamer district and neighboring areas. This would be followed by another vaccination campaign within 2 weeks. Moreover, bopv will also be added to the measles follow up campaign already scheduled for the whole Gilgit Baltistan in early July. A special mission is leaving today for district Diamer to perform in depth investigation and quick assessment of the components of Polio Eradication and devise any interventions, if further needed. The first meeting of the National Task Force on Polio Eradication was held on 1st June, chaired by His Excellency, the Prime Minister of Pakistan Syed Yousuf Raza Gilani. The inaugural meeting was attended by the Governor Khyber Pakhtunkhwa, the Chief Ministers of Punjab, Sindh and Khyber Pakhtunkhwa and the parliamentarians. The meeting was also joined by the Director General WHO Eastern Mediterranean Region (EMR), the WHO Assistant Director General and Director Global Polio Eradication Initiative, country representatives of WHO and UNI CEF, and representatives of other partner agencies. The Prime Minister called on FATA, K P, Sindh and Balochistan provinces to intensify their efforts and ensure comprehensive implementation of the National Emergency Action Plan. Distribution of Wild Polio Virus cases Pakistan and Year : The total number of polio cases reported in is 144 including 1 type-1 cases and 24 type-3 from infected districts/towns/agencies. Year : The total number of new type-1 polio cases confirmed by the laboratory is 49 till date from 23 districts. Province Cases Cases P1 P3 P1 P3 Punjab Sindh Khyber Pakhtunkhwa 19 - FATA Balochistan 13 - AJK Gilgit Baltistan Islamabad Total Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , 2 Fax : , wr@pak.emro.who.int.

3 Province Khyber Pakhtunkhwa: This week districts reported to DEWS from KP province 19 health facilities reported 1,9 patients consultations to DEWS. ARI cases reported were 44, (%), an increase by 2% in proportional morbidity as compared with last week. AD is showing a consistent upward trend and accounted for 13% - 14% of the total consultations in last 4 weeks. alerts were reported in this week from Khyber Pakhtunkhwa, were for Measles, were for AWD, while 1 each for Bloody diarrhoea, Monkeypox, Pertussis and Typhoid. Date Disease District Area <M >M <F >F Action Taken 2 May. AWD Lower Dir Village Charingo Lajbook 1 2 May. AWD Buner Gor Adda, Kheran Kanda 1 31 May. AWD Shangla 31 May. Measles Tank Vill Chinni, Machan Khel June. Measles Swat Village Madyan 1 Vill Jabba Battagram 2 June. Measles Battagram Bannian 2 June. Measles Haripur Khalabut Township, Union Council Khalabut June. Measles Tank Pai 1 1 June. Monkeypox Abbottabad Achrian 1 Afghan Refugee camp, 2 June. Pertussis Charsadda Rajjar 2 May. Typhoid Haripur DHQ Daggar Buner(2 Kotkay, UC Aloch) Kheweshgi Payan & Bala 2 June. AWD Nowshera UC Kheweshgi; Mohallah Sabzagan, Dagai Khel 3 June. AWD Mardan 1 June. BD Haripur 2 May. Measles Haripur Buner (Vill Shergarh, UC Amazai) Afghan Refugee Camp 14, Union council Panian Padhinna camp, Union Council Khalabut Village Kokarai, Tehsil 2,2 May Measles Swat Babuzai; Village Tatal, Tehsil Bahrain Village College Doraha, May. Measles Mohallah Syedabad, UC Mansehra Labarkot; Village Sharka, UC Battal Afghan Refugee Camp Bassu Mera UC Gudwalian May. Measles Hangu Hangu Epidemiological Bulletin: DEWS, Pakistan, Week no. 22 (2 May - 2 June, ) Figure-3: Trend of priority communicable diseases, province KP (31-July to 2 June ) Field investigation conducted. Sample was collected and found positive for V.c. Ogawa. Source of drinking water protected Tube well. Poor household and personal hygiene and water handling practice. Provided aqua tabs, soap units and IEC material to the affected families and Health education was given. Sample was collected and found negative for V. Cholera. Active surveillance was carried out in the area, no other case was found. One AWD case presented to DHQ Dagar, district Buner, The case was investigated by surveillance Officer WHO Buner and sample was taken and sent to NIH and found positive for Non1 VC. Active surveillance was carried out in the native village of the case in Shangla by DEWS SO Shangla. No other case was found in the same area. Water source identified and committee for cleanliness, health and hygiene message conveyed to the community, outreach activity started. Aqua Tabs and Hygiene kits were distributed. Two AWD cases were found during active surveillance of female medical ward of DHQ hospital. 2 stool samples were collected and found negative for Cholera. Briefing session were conducted with the Ward health staff and Family members. During field investigation houses were checked, no other cases found. One case of AWD was reported from Private clinic in Sawarai, District Buner. The case was investigated and sample was taken and sent to NIH. Active surveillance was carried out in the native village of the case. No other case was found in the area. Water source identified is pond and spring in the area. Health and hygiene messages conveyed to the community, outreach activity started. Aqua Tabs and Hygiene kits were distributed. 3 Suspected case were reported from BHU STC2 from Camp 14. On investigation and active surveillance 2 more cases were found. Stool samples were taken from 2 cases and sent to NIH and found negative for Shigellosis. Environmental assessment done and water supply schemes found contaminated. EDOH was informed. Health and Hygiene sessions have been conducted for the affected population and health promotion campaign with Save the Children for all the Afghan refugee camps has been planned. 1 Suspected case was reported from BHU STC4. On investigation and active surveillance 1 more case was found. 2 Blood samples were taken and sent to NIH. Vit A given to the suspected cases. Cluster of houses was taken to assess the vaccination status of the surrounding area. 4 children were assessed only out of them had complete measles vaccination. This area was missed in recent mass measles campaign. EDOH and EPI team was informed about the cases. 2 suspected cases were reported from two different locations. 2 blood samples were collected and sent to NIH. Vit A given, health education and importance of vaccination conveyed to the community. EDOH and EPI team were informed. 2 suspected measles cases reported from 2 different locations. Vit A and health education session Provided. EDOH and EPI team requested for further action and vaccination. 31 children vaccinated in the area. Case investigated, serum and throat swab sent to NIH, Active surveillance done, Routine outreach vaccination session is going on in the area. Vit A was given to the patient. Case coordinated with EDOH and EPI. 1 Suspected case was reported from private. On active surveillance 2 more suspected cases were also found in the same house. One blood sample collected and sent to NIH. Vit A given to the suspected cases. Cluster of houses was taken to assess the vaccination status of the surrounding area and was found very poor. EPI coordinator who was with the team assured vaccination of unimmunized children in the area. EDOH was informed about the cases. Suspected case was reported from CH Madyan. On investigation and active surveillance no other case was found. Blood sample was taken from case and sent to NIH. Vit A given to the suspected case. Health education conducted and importance of vaccination highlighted to the community.. EDOH and EPI team was informed about the case. 1 suspected case was reported from DHQH. On investigation and active surveillance no more cases were found. Blood sample was taken and sent to NIH. Vit A given to the suspected case. Cluster of houses was taken to assess the vaccination status. 32 children < years of age were checked in houses and only were found to have BCG scar. Only one child had routine measles vaccination. Vaccination status found very poor. EDOH and EPI team was informed about the finding. Vaccination campaign planned to strengthen routine immunization. Suspected case was reported from WCH Abbottabad. On investigation and active surveillance no more cases were found. Blood sample was taken and sent to NIH. Vit A given to the suspected cases. EDOH and EPI team was informed about the case. Vit.A given, health education sessions conducted, EDO H Informed, < Measles Vaccination done in the Relevant houses, Active Surveillance done. A suspected case of Monkeypox was reported from Bach Christian Hospital in Qalandarabad, Abbottabad. The case is years old child admitted with signs of hemorrhagic rash on the face and body along with lymphadenopathy. Case is under close observation in isolation. Throat Swab, Blood for serology and swab from pustular secretions was taken and transported to NIH with all biosafety protocols. Active surveillance was carried out in the area and it was found that there were cases of chicken pox in the village where the patient lives, and it was now also revealed that a juggler came to the village with his pet monkey and displayed some feats to the children. The case had also fed the monkey with some sweets and candies. The EDO office was informed about the case and a specialist dermatologist of the district is now treating the case with antiviral and antibiotics. There are signs of improvement in the case. One suspected Pertussis case reported from DHQH, case investigated and on active surveillance three more children in the same house were found with similar sign and symptoms. Nasopharyngeal and throat swab taken and sent to NIH for analysis, Erythromycin given to patients and close contacts. EDOH and EPI coordinator informed. confirmed cases of enteric Fever/Typhoid fever were reported from BHU Bassu Mera. On investigation and active surveillance 3 more positive cases were found. Blood samples were taken from 2 cases for typhoid and they also reported positive. Environmental assessment was carried out, 2 out of 4 water samples were contaminated including source. Aqua tabs distributed. EDOH and Save the Children were informed and conducted Health and Hygiene sessions for the affected population. Health promotion campaign for all the Afghan refugee camps has been planned. Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int wk 9 wk 41 wk 43 wk wk 4 wk 49 wk 1 3 wk 9

4 Province Punjab 12 districts reported data to DEWS from Punjab province, health facilities reported a total of 2, patient consultations during this reporting period ARI cases reported were 4,2 (1%) still leading cause of consultations. 23 alerts were reported in this week from Punjab; 13 were for Measles, 4 were for AWD, 2 were for AD, while 1 each for Leishmaniasis, Malaria, Meningitis and Pertussis. Increased number of confirmed malaria cases from districts. 139 from Muzaffargarh, 4 were from DG Khan, 4 from Rajanpur, from Layyah, 1 were from Sargodha, while 42 from Jhang. Date Disease District Area <M >M <F >F Action Taken 31-May AD 2-Jun AD Mianwali 2-May 2-May -May Sheikh Wahan Rahim Mianwali Qureshian Yar Khan AWD Multan AWD Rajanpur AWD Multan DHQ Hospital - Moch Gulshan-e Mehr Colony, Zikriya Town Near Sabzi Mandi, Ahmadani Town Chongi No., Gulgasht; Rasheedabad 2-Jun Leishma niasis Mianwali UC Vanjaree Tehsil Esa Khel 2-May Malaria Layyah Basti Kot sultan, Union council Kot sultan Epidemiological Bulletin: DEWS, Pakistan, Week no. Week no. 22 (2 May - 2 June, ) Figure-4: Trend of priority communicable diseases, province Punjab (3 August to 2 June ) 1 3 wk 9 wk 41 wk 43 wk wk 4 wk 49 wk 1 3 wk 9 1 specimen was collected and found positive for V.c. Ogawa. The water sources were examined thoroughly and samples were collected for bacteriological contamination. A medical relief camp was established (1 Doctor, 2 LHVs and one paramedical staff deployed) in Basti M. Buksh, Mouza Sikandarabad where 3 AD patients treated on the first day. Staff of RHC Mianwali Qureshian trained in management of Acute diarrheal diseases and stocks of essential medicine were moved to RHC. Aqua tabs, Jerry Cans, Life straws and Soaps were distributed among residents of all the 3 villages. Health Education sessions were conducted on Safe Drinking Water, use of ORS, use of life straws, and general health and hygiene. Stool sample was collected and found positive for V.c.Ogawa. Drinking water samples were collected from water sources for analysis. Nearest RHC was visited and briefed on the situation, control measures and importance of awareness among general masses about safe drinking water, food and personal hygiene. EDO(H) Mianwali and MS of DHQ Hospital Mianwali were informed about the situation and provision of rehydration medicine and support during the patient s stay in hospital was ensured. In the locality/area no more cases of AWD were found. Stool sample was collected and sent to NIH. In the locality/area households were interviewed but no more cases or suspects were found. Water samples were tested for bacteriological contamination. Chlorination of water was performed. HE Session was conducted. MD WASA was met and requested for arrangement of Filtration plant at the locality. Distribution of soaps, Aqua Tabs and IEC among them. Stool sample sent to NIH for laboratory confirmation was reported negative. Active surveillance was carried out in the area, no other case was found. Two samples were found positive for V.c. Ogawa. Water samples were tested for bacteriological contamination from different sources. Health education session were conducted. MD WASA was met and requested for arrangement of filtration plant in the locality. During filed investigation houses were investigated and no more cases found. Soap, Aqua Tabs and IEC distributed in the community. Line listing is ensured, Patient were screened by DDOH for IM and IL injections, EDO H will provide antimony injections. Malaria Program requested for fogging and IRs of the area. Alert was generated from health facility and Health Facility and Location was visited; 12 samples were found positive for Malaria (P.vivax, P.falciparium 4), RDTs were used to confirm the cases; Health education session was conducted; LHW was involved; bed net among high risk group were distributed in the affected families. Breeding places were destroyed with the help of Malaria Field staff. D. G. 2-May Measles Khan Moza Tarakrri Chak Bahadur Garh Kot Mubarak DG Khan 1 Gave two doses of Vit A to the case. The patient never vaccinated against Measles. Vaccinator was requested to conduct vaccination in the area within this week. Blood sample of the suspected case was sent to NIH. Health Education on vaccination to mothers in the households visited. 2-May Measles Khushab UC Mochiwala 1 Case was investigated properly and these cases were not full filling the criteria of case definition. Hence false alert Haveli Majoka Tehsil Sahiwal; Mubarak hospital, -May Measles Sargodha Johar Town- Lahore; Mubarak Hospiatl Satellite Town. 31-May Measles Muzaffargarh 31-May Measles Rahim Shamasabad- Haroon abad Yar Khan Tehsil Liaqat Pur 1-Jun Measles Jhang 1-Jun Measles Muzaffargarh D. G. 2-Jun Measles Khan City-2 1 Badhoana Shorkot; UC Banga; UC Kaki Nau, Shor Kot City-1 Kotaddu; UC Baseera 1 Three measles alerts received from three different locations. EDO H informed. Hospital investigation conducted Indus Colony 1 2-May Meningitis Layyah DHQ layyah 1 2-May Pertussis Khushab UC Jalalpur Khushab The suspected case has been given 2 doses of vitamin A. Concerned Vaccinator, doctor MS Social Security Hospital were requested to be vigilant incase similar cases are reported again from the same locality. Vaccinator was requested to ensure % EPI vaccination in the area within this week along with Measles. Blood sample was collected and sent to NIH for lab confirmation. HE to mothers in households visited. Distribution of soap and Aqua tabs to patient s family. The suspected case was given 1st dose of vit A. The child was not vaccinated for Measles. Vaccinator was advised to conduct vaccination in the area within this week including Measles. Blood sample sent to NIH for confirmation. Three suspected measles cases were reported from three different locations, during investigation cases found misdiagnosed and not full filling the criteria of case definition. suspected measles cases reported from 2 different locations. Vit A given, history revealed no vaccination against measles. Vaccinator was requested to ensure vaccination in the area. Blood samples collected and sent to NIH. Health education to mothers provided. 1st dose of vitamin A was given to the case. Not vaccinated against Measles. Vaccinator was advised to ensure vaccination in the area. Blood sample was sent to NIH for Measles confirmation. one case was reported, reinforce proper case management, patient isolated, medicine and injectables provided, sample sent to IPH result awaited, close contacts given prophylactic antibiotics, District administration informed, Health education sessions given 1 Case was investigated properly and this case was not full filling the criteria of case definition of WHO. Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int. 4

5 Province Sindh This week 21 districts reported to DEWS from 1,4 health centers with a total of 42, patient consultations during the reporting period of week 22,. In Sindh, ARI cases reported were,9 (%), 1% higher proportional morbidity as compared with last week. 44 alerts were reported from Sindh in this week: 19 were for Measles, 1 were for AWD, 2 each were for Pertussis, Neonatal Tetanus and Tetanus, while 1 Meningitis. Date Disease District Area <M >M <F >F Action Taken Epidemiological Bulletin: DEWS, Pakistan, Week no. Week no. 22 (2 May - 2 June, ) 2-May AWD Jamshoro UC Thano Ahmed Khan-Taluka Active Case Finding, Case Isolation, Health Education, sample collected and found positive for Non1 VC, Chlorine 1 1 Thano Arab Khan Tablet Distributed, serious Patient referred to THQ. Reinforced appropriate case management. Active search of cases, Reinforced Case Management, IEC Material, Aqua Tab, Hygiene Kit and ORS distributed, 2-May AWD Mirpur Khas Old MirpurKhas,Sindhri Road 1 Health Education. Discussed with DD and EDO H about the case. On Job Training Provided to the Health care providers. More Health Education Session planned. 1 Stool and 1 Water sample Collected for testing 29-May AWD Jamshoro Taluka Thano Bhula Khan 2 Active search for other cases, Health Education Provided, Chlorine Tablets and IEC Material Provided, 1 Stool and 4 Water samples collected for laboratory test. EDO H informed. -May AWD Dadu Active search of cases, Reinforced Case management, Health Education with Proper guidelines, 2 Stool samples were Village Khuda Bux Laghari,Near collected and found positive for V.c. Ogawa. 4 Water Sample Collected for laboratory test, Hygiene Kit, Zinc Tab, Hur Pump,UC Bhawalpur Aqua Tabs and ORS distributed, Informed EDO H -May AWD Sukkur Village Hingoro-UC Hingoro 1 1 cases of AWD reported, One sample collected and found positive for V.c. Ogawa. -May AWD -May AWD Thatta 31-May AWD Dadu Tando Allah Village Kevro Lund,UC Dasoori; Yar Village Tharo Laghari,UC 4 Village Juma Jat,UC Darya Khan Soho,Taluka Mirpur Bathoro; Village Khameeso Sameejo,UC Mehar Shah,Taluka Mirpur Bathoro Brihmani Colony, Guhram Gopang; Meerjat Muhalla,Dhamali Muhalla May AWD Karachi Lyari Town DHQ Mirpurkhas; Village Lundoo, 31-May AWD Mirpur Khas Deh, Taluka KGM May AWD Shikarpur Makrani Street, Bhatti Mohalla May AWD Sukkur Village Ali Nawaz Noonari near Bachal Shah Miyani 1 1-Jun AWD Matiari Soomra Mohalla,City Haala 1 2-Jun AWD Mirpur Khas Ahmdani Colony 1 2-May Measles Naushahro Feroze Village Morath, UC Ghulam Shah, taluka Kandiyaro; Village Jaindo Rajper, taluka Mehrabpur 1 2 cases reported from two different locations. 3 Stool samples all found positive for V.c. Ogawa. water sample collected, Health Education, ORS, Zinc Tabs, IEC Material, Life straw filters, Aqua Tabs, Jerry Cans provided in the community AWD cases reported from two different locations, active search for cases, health education, Aqua Tabs, ORS provided, Sensitized about Hand Washing Practice, Inform EDO H and Environment Team, 2 Stool samples were collected and 1 found positive for V.c. Ogawa. 4 water samples taken and sent to NIH. AWD cases reported from two different locations, active search for cases, health education, family sensitized, Aqua Tabs, ORS and Zinc Tab were distributed, 2 Stool samples both found negative, 4 water samples were collected and sent to NIH. Active search of cases, health Education Provided, Aqua Tabs Distributed, 1 stool sample collected and found positive for V.c. Ogawa. Health Staff briefed, health facilities sensitized Three cases from two different locations, active search of cases in the community, reinforced case management, IEC material, Aqua Tab, Hygiene Kit and ORS distributed, health education, DD and EDO H were informed. 2 Stool and 2 water samples were collected and sent to NIH. One found positive for V.c. Ogawa. A years old boy admitted in Civil hospital Shikarpur with severe dehydration and watery diarrhea. One stool sample collected and found positive for V.c. Ogawa. Upon field investigation more cases found with diarrhea but they got treatment from GPs. Water samples collected from affected houses. EHE and EM paid visit for distribution of hygiene kits, aqua tabs and health and hygiene awareness in community. 1 case of AWD, months old boy is shifted to isolation ward of GMC hospital Sukkur, SO DEWS Sukkur in contact for further follow up and necessary support for the child. Active search of cases, Health Education, 1 stool collected and found positive for V.c. Ogawa.3 water sample Collected for lab test. ORS, chlorine Tab and Zinc tab were distributed. Reinforced Case Management, IEC Material, Aqua Tab, Hygiene Kits and ORS Distributed. Health Education, DD and EDO H were Discussed About the case. Training Provided, DOH and SO dews planned Health Education Session, 1 Stool and 2 Water sample collected for lab test and found positive for V.c. Ogawa. 3 suspected cases reported from two different locations. 1 blood sample collected and sent to NIH. Vit A given, Nutritional biscuits distributed, Sensitized LHWs on case definition. 2-May Village Pir Bux Zardari,UC Active search of cases, Reinforced Case Management, gave Vit A, Imparted Health Education, 1 Blood Sample Taken, Measles Nawabshah 1 Bucheri,Taluka Daur EDO H was requested for outreach vaccination 2-May Village Bapuhar,Village Bhakuo,Taluka Mithi lected Active search for cases, health education, advocated immunization activity, informed EDOH,3 Blood Sample Col Measles Tharparkar May Measles Thatta Village Hot Nohri,Taluka Jati Active search for cases, gave Vitamin A, Blood Sample Collected, Health Education, Requested EDO H For Immunization 2-May Measles Karachi C.Area,UC-2, Malir Town 1 1 Active search of cases, Vitamin A Provided, DEWS Team Deliver EH Hygienic Session, Imparted Health Education,1 Blood Sample Collected for lab test -May BHU Norai Shareef,Village Muhammad Fazil Palejo Sample Collected Active search of cases, Vitamin A Provided, Health Education, active surveillance found no other cases, 1 blood Measles Hyderabad 1 -May Measles Shikarpur Village Bambhihar, taluka Garhi 1 suspected cases of Measles reported, Vitamin A given, Date of on set was 24, reported by SO DEWS 1 Yaseen Shikarpur. Village Haji Allah Ditto Peryer, UC Mehar shah; Village Natho Khaskhali, UC Darro, Taluka Mirpur 1 suspected cases reported from 4 different locations. 4 blood samples were collected and sent to NIH. Active,31 May, 1 Measles Thatta 2 2 June Bathoro; Village Lemon Degrahi search for cases, Vit A given, Health Education Provided, Informed EDO H and request for routine immunization. Muhalla, UC Bujora; Village Saeedpur Mallah,UC Ali Bahar 31-May Measles Ghotki Benazir Colony, Soomra Muhalla- UC III; Village Ranwatti UC Ranwatti 31-May Measles Khairpur Mohalla Haji Rajpar Daraza Shareef-UC Gambat 1-June Measles Matiari AD Sand Road; Nomads population, City Matiari Opposite Moulana Anwar Madrassa; 1,2-June Measles Sukkur Barrage Colony, Near Usmania Masjid Village Aqli Hingorja,UC Manjethi,Taluka 31-May Meningitis Tharparkar Mithi 1 1 Figure-: Trend of priority communicable diseases, province Sindh ( August to 2 June ) 1 3 wk 9 wk 41 wk 43 wk wk 4 wk 49 wk 1 3 wk 9 2 suspected cases of measles were reported from two different locations. 1 blood sample was collected and sent to NIH. Vit A given, DHMT inform and requested for vaccination of unvaccinated children in the area more suspected cases found during follow up visit along with DDO preventive, for verifying activity conducted by vaccinators for vaccination of children in affected community suspected measles cases were reported from two different location. Active search of cases, Vit A given, health education provided, family sensitized, 2 blood samples were collected and sent to NIH, EDO H informed suspected cases of measles reported from two different locations. Further information awaited. 1 Verified the hospital record, found no other case in the hospital and community Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int.

6 Sindh: Contd. Date Disease District Area Province Balochistan In this week, 1 districts reported to DEWS from Balochistan province. 4 fixed and mobile medical outreach centers reported a total of 4, patient consultations. ARI reported in, (1%) of the total consultations which is the same proportional morbidity as compared with last week. While AD showing consistent trend and accounted for 14% of patients visits. 19 alerts were reported in this week from Balochistan, were for Measles, were for AWD, 3 were for Malaria, while 1 each was for Acute Jaundice Syndrome, Leishmaniasis, Pertussis and Scabies. Increased number of malaria cases were confirmed in districts Hernai, Jhal Magsi, and Lasbella. A total of 3 number of samples were tested from three districts and 11 found positive for malaria. Date Disease District Area <M >M <F >F Action Taken 1-Jun AJS Kech 2-May AWD Chagai 31-May AWD Lasbela Sangabad, Karki-UC Sami Kech Epidemiological Bulletin: DEWS, Pakistan, Week no. Week no. 22 (2 May - 2 June, ) <M >M <F >F Action Taken Hyderabad 1-Jun NNT Bone Care Hospital 1 Health Education, Informed SO Badin and Jamshoro, Informed EDO H Health Education, EDOH was informed for routine immunization and send LHWs for health education 1-Jun NNT Karachi Neonatal ICU, NICH 1 sessions. Village Yar Muhammad Khoso-UC Active search of cases, Health Education Provided, 2 Throat swab Sample Collected, Isolation, Essential 2-Jun Pertussis Matiari Matiari Medicine distributed. EDOH was informed and requested for routine immunization in the area. Mirpur Active search of cases in the community, Reinforced case management, contacts were given erythromycin, 2-Jun Pertussis Satellite town 1 2 Khas Health Education Provided, Isolation, active surveillance, EDOH informed, 1 Throat swab sample sent to NIH. Village Ramzan Mangi UC Bhetoor, A 2 years girl reported as case of Tetanus, In absence of TIG, ATS is used to save the life of child. TT coverage -May Tetanus Ghotki 1 taluka Khan Gharh and safe delivery practice awareness scheduled for community. 1-Jun Tetanus Karachi ICU Ward NICH 1 1 Health Education, hospital record checking, informed to health authorities for routine immunization. 3 2-June Malaria Jhal Magsi BHU Barija 2-May Measles Chagai killi toor jan agha station Taftan 1 2-May Measles Kalat Chashma-UC Kalat Saddar 2 29/31 May Measles Khuzdar 1-June Measles Jaffarabad 2-June Measles Quetta Killi Malik essa khan station Taftan Mohhala Qasmani, Village Sonmiani Jangi Abad-UC Kahand; Killi Langov Abad-UC Kahand; Civil Colony Khuzdar Tent City, Highway, Tehsil Dera Allah Yar Killi kateer and killi nakhail, Kuchlak June AWD Sibi Village khajjak 1 2-June AWD Jaffarabad Ghot Dur Mohammad Jamali- UC Sameji 3 2 -May Leishmaniasis Lasbela Moza Marhi Uthal 1 2-May Malaria Lasbela Hub May Malaria Harnai RHC Sharigh, BHU Belli, BHU Ghurmai, BHU Sazoo, DHQ Harnai June Pertussis Kech Gazeen Karki-UC Sami June Scabies Sibi Village Luni Figure-: Trend of priority communicable diseases, province Balochistan ( August to 2 June ) 1 3 wk 9 wk 41 wk 43 wk wk 4 wk 49 wk 1 3 wk 9 3 cases of AJS were reported. No other cases were found. Patients were taking treatment. The drinking water stored in underground tanks. Health education was given to patient's family member and community to adopt the practice of safe and hygienic drinking water as well as aqua tab distributed. 9 cases of AWD with severe dehydration and 3 deaths due to AWD were reported. Field investigation was done and finding were shared with DHO + PPHI team. PPHI has initiated the case management and provided ORS and IV fluids to the BHU staff. houses were surveyed and only one more case was found who visited the affected house for condolence. 2 stool samples were taken and found negative for Cholera. The supply line passing through a pond of stagnant water. The community was requested to fill this pond. 1 severely dehydrated case was referred to JGQ (H) hub. IV fluid and ORS was given to Patients of suspected AWD and Patients of AD. Health education was also given in the community about safe drinking water, Sanitation, Food and water proper usage. all the patients were stable. 2 Stool samples were taken and 1 found positive for V.c. Ogawa. One case of AWD with severe dehydration from village khajjak was admitted at DHQ hospital Sibi. Field investigation conducted. No other AWD case was neither reported in BHU Khajjak nor found during house to house search. Source of drinking water is govt. water supply scheme of the village. DHO and DDHO were informed about the case. One stool sample was taken and found negative for Cholera. cases of AWD were reported including 1 death. The DHO was informed about the AWD case. Field investigation conducted, stool sample collected and sent for lab confirmation. Aqua tablets, hygiene kits and buckets were distributed in the affected community. The samples of drinking water was also collected; a mobile medical team was also sent to the affected location. 1 case of suspected Leishmaniasis was reported. After investigation it was declare Leishmaniasis. Patient will seek own treatment. No other cases were found in the area. 24 cases of Malaria were reported. 24 samples were examined and of them found positive for P. falciparum. The District Health officer was informed and requested to provide Bed Nets as well as fogging spray in affected area. 199 samples were tested, 131 came positive. Patients information was collected and Investigation was made. Health Education was also held with HCP to put awareness among community about malaria. A meeting was also conducted with DHO and Focal person for Merlin (NGO) for further preventive measures taken. Further investigation in progress samples for Malaria were tested from two different locations, were found positive. DHO was informed about the malaria cases and positivity rate and requested to take preventive measures. 1 case of suspected measles was reported. During field investigation houses were surveyed but no other case for measles was found. Blood sample was collected and sent to NIH. Gave Vit A to the patient. The matter was also discussed with DHO. Alert for 2 suspected cases of Measles. Both the cases were given Vit A. 2 blood samples were collected and sent to NIH Islamabad for further investigation. During house to house search no other cases was found. DHO and EPI was informed. suspected measles cases reported from 3 different locations. All the cases were investigated. Vit A and health education were given to the affectees. 3 blood samples were taken and sent to NIH. On house to house search no other cases was found. DHO and EPI coordinator was informed. One case of measles was reported from Tent city. The field examination was done on time. In critical observation, only one child with old history of sign and symptoms of Measles was found, whom the Vit.A was given. While no sample was collected as it was a clear case of measles. 2 cases of suspected measles were reported from Kuchlak. The blood sample was taken and sent to NIH for further investigation. The early field investigation was also made and gave Vit.A to the patients. The DHO was also informed about the measles alert. 3 cases were reported within a short interval of time. The patients were being treated by the health care provider at the nearest health facility. the patient's family was given the Health education and on patient care and vaccination. DHO and EPI team was informed for vaccination in the area. cases of scabies were reported from RHC Luni. All the patients were residing in two nearby houses and had observed close routine gathering. The index case who was the elder of the home caught that infection from district Naseerabad a month ago and now members of his family had got the same skin problem. Treatment was given to all the affectees as well as Health Education was also given to the family members. The DHO and DDHO were also informed about the alert and further necessary action such as medicine supply to the affected population was made. during house to house search more cases were found Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int.

7 Gilgit Baltistan In this week, health centers from Gilgit Baltistan sent weekly report with a total of 12,9 patient consultations. ARI cases reported were 2,93 (23%), while Acute Diarrhoea (Not Watery) 1,39 (12%). The DEWS network has been recently introduced in Gilgit Baltistan and is being established. Four alerts for Measles received and responded this week. Epidemiological Bulletin: DEWS, Pakistan, Week no. Week no. 22 (2 May - 2 June, ) Figure-: Trend of priority communicable diseases, Gilgit Baltistan ( March to 2 June ) Date Disease District Area <M >M <F >F Action Taken Village Pari Bangala; Amphary Qadirgi Mohallah; 31-4 suspected cases were reported from 4 different locations, gave Vit A, 4 sample collected May,1,2 Measles Gilgit 1 3 and sent to NIH, DHO Gilgit and EPI ASV informed, during field surveillance no other cases Barmas Kote; Village Kargah June found, plan made for strengthening routine vaccinations, EPI Vaccinator informed and Jut FATA This week 3 health centers reported from FATA, with a total of 9,492 patient consultations. ARI cases reported were 1,9 (21%), while Acute diarrhoea reported 1,1 cases (12%) Three alerts for Measles were received and responded this week. Date Disease District Area <M >M <F >F Action Taken 2-May Measles Khyber Haji Soorat Khan Killi Pindi Agency Lalm Molagori 2-Jun Measles Bajaur Village Smassai- Loesam & Village Kamar Sar- Agency Mamoond 1 2-Jun Measles TANK Khirgai wk 9 wk wk 22 Figure-: Trend of priority communicable diseases, FATA (4 February to 2 June ) wk wk wk suspected case of Measles reported, active surveillance in the field conducted, no other case found. All activities coordinated with Agency surgeon office and EPI coordinator. Vit A given to the 2 suspected Measles cases were reported from two different villages. Throat swabs and blood samples taken, health education session conducted in one of the two areas was visited for active Vit A given, health education session conducted, EDO H Informed and requested to initiate response through the relevant staff and strengthen routine vaccination. 3 4 wk 9 wk wk 22 State of Azad Jammu and Kashmir In this week, weekly report received from health centers with a total of 2,1 patient consultations. ARI cases reported were 3,94 (%), while Acute diarrhoea reported 1,3 (%) cases Two alerts one for AWD and another for measles were received and responded this week. Figure-9: Trend of priority communicable diseases, AJK ( March to 2 June ) 3 4 wk 9 wk wk 22 This week's alerts Date Disease District Area <M >M <F >F Action Taken 2-Jun- AWD Poonch 2-Jun- Measles Poonch village Batti ne raha UC Rehara village Batti ne raha UC Rehara case of AWD was reported from Sheikh Zaid Hospital, Rawalakot. Stool sample was collected and found positive for V.c. Ogawa. Field investigation was carried out jointly with DOH team and no other active case of AWD was found. Health hygiene sessions were conducted, water sample was taken for testing. A suspected case of measles was found during field visit for AWD alert investigation. Upon field investigation no more suspected case was found blood sample was taken and sent to NIH. Vit. A was given to active case and his contacts < of age. Health education session was conducted. House were visted for vaccination coverage and found good coverage Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int.

8 Islamabad Capital Territory This week 4 health facilities are reporting through DEWS with a total of 4,2 patient consultations. ARI cases reported were 1,12 (24%), while Acute Diarrhoea (Not Watery) (13%). Fluctuation in rates was due to difficulties in collecting reports as the system is being established. Two alerts for Measles received and responded this week. Date Disease District Area <M >M <F >F Action Taken -May; 2 June Measles Islamabad CH PIMS; RHC Tarlai 2 Table-3: Total number of alerts and outbreaks received and responded Epidemiological Bulletin: DEWS, Pakistan, Week no. Week no. 22 (2 May - 2 June, ) Figure-: Trend of priority communicable diseases, Islamabad (1 January to 2 June ) wk 2 wk 4 wk wk wk wk wk 9 wk wk 22 2 suspected cases of measles reported from two different locations, Vit A given, patient fully immunized, field investigation underway. The second case reported from RHC Tarlai was misdiagnosed. During field investigation no other cases found. Disease Post Flood Early Recovery Current Week Total A O A O A O A O AWD AJS BD Measles Pertussis NNT + Tetanus Malaria Leishmaniasis Others Total * Post Flood (29 July, to 2 Feb, ) ; Early recovery (1 Mar to 2 May, ); Current Week, 22 (2 May - 2 June, ); A= Alerts ; O= Outbreaks. Figure-: Three years trend of Acute Diarrhea, Pakistan 9, and Focus on: Proportional Morbidity The figure on the left and the one on the front page are representing trends of "proportional morbidity." On the Acute Diarrhea chart, this is the number of new consultations for acute diarrhea divided by the total number of consultations. When the number of health facilities, emergency teams and mobile units available varies a lot, the actual numbers of consultations vary a lot, and the ratio or proportion is the most stable number to understand the incidence of a disease or syndrome in a population. The stability of the proportional morbidity calculation is evidenced in the lines following the same "track" each year, as noted in the above Epi week figures, because these diseases have seasonal trends diarrhea increasing in the summer and respiratory infections increasing in the winter. By plotting the trend week by week, we take note when there is a peak of cases different from previous years. The very dramatic peak starting about week 31,, demonstrates the increase in acute diarrhea cases from the flood affected areas starting in KP the first week of August. The line also answers the question of whether there was really an increase in diarrhea or just an increase in surveillance. We have increased the number of surveillance officers in as we have tried to cover more districts, but the "proportional morbidity" of diarrhea follows the seasonal trend of 9 and early. While the overall diarrhea trend so far this year is following the usual proportional morbidity, the cholera cases and outbreaks are above the usual and starting earlier than usual. This year we have confirmed outbreaks in March and April which is unheard in previous years. We also have a mixing of the new and the old districts: Mirpurkhas District of Sindh is the site of the first outbreak this year in March known also to have had a previous outbreak in September, while Dadu District also of Sindh is a flood affected district with first outbreak in November and now in April. Positive cases have also been detected in Bolan, Baluchistan, and Multan and Bahawalpur, Punjab, as well as Jamshoro, Naushahro Feroze, Thatta, Tando MK and Tando AY of Sindh. Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int.

9 Epidemiological Bulletin: DEWS, Pakistan, Week no. Week no. 22 (2 May - 2 June, ) Acute Watery Diarrhoea outbreaks Islamabad and World Health Organization (WHO), Pakistan. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : , wr@pak.emro.who.int. 9