Epidemiological Week No. 48 (25 Nov- 1 Dec 2006) 8 Dec 06/ Vol. 54/ DEWS

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1 Epidemiological No. 48 (25 Nov- 1 Dec 2006) 8 Dec 06/ Vol. 54/ DEWS 48 Reporting Units...2 Total number of consultations...2 DEWS Data, Epidemiological N DEWS Data, Monthly Summary (Epidemiological s N )...4 Acute Watery Diarrhoea...5 Bloody Diarrhoea...6 Acute Jaundice Syndrome...6 Malaria...7 Measles...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...10 Number of reported cases and deaths per District, NWFP...11 Muzaffarabad: Picture by Omid Mohit In the past month (Epidemiological weeks inclusive), 140,570 health events under surveillance were reported including 75 deaths This week, there were 251 reporting units contributing to the report. In week 48, Total 70,019 consultations were reported, with 15 deaths In week 48, there were five deaths from acute respiratory infection. Five suspected cases of meningitis reported this week, all cases were from Muzaffarabad district In this week 48, Malaria cases were increased by 13% (from 519 to 594 cases). 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 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, House #6, Street #20, F-7/2, Islamabad, Pakistan For More Information, please contact: Dorcas Taylor, Epidemiologist, WHO/EHA/Pakistan; taylord@eqpak.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 8 Dec 2006 / Vol. 54/ DEWS Reporting Units The number of sites able to report decreased by 71 this week, with Bagh district unable to report, and severe weather hampering reporting sites in other districts from submitting data. Reporting timeliness of the DEWS systems has also decreased in the current epidemiological week compared with week 47. Bagh data will be added when received, and reflected in the week 49 report. See Table 1 for summary statistics. Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 25 Nov-1 Dec Reporting Health Facilities Area Population 4-10 Nov Nov Nov 25Nov-1Dec Muzaffarabad 894, Bagh 452, Unavailable Poonch 633, Mansehra / Balakot 1,154, Battagram / Shangla 592, Total 3,727, (95%) 313(96%) 322(99%) 251(77%) Total number of consultations In week 48, there was a decrease in the number of reporting sites, and the number of consultations also decreased to 70,019. The highest number of consultations by district was in Muzaffarabad, with 26,751 and the lowest was in Battagram, at 7,143. No. Unit 300 Reporting Unit Reporting Units and Consultations Consultation No. Consult W48 W47 W46 W45 W44 W43 W42 W41 W40 W39 W38 W37 W36 W35 W34 W33 W32 W31 W30 W29 W28 W27 W26 W25 W24 W23 W22 W21 W20 W19 W18 W17 W16 W15 W14 W13 W12 W11 W10 W9 W8 W7 W6 W5 W4 W3 W2 W1 W52 W51 W50 W49 W48 W47 W46 W45 W44 W43 W42 0 Figure 1. ly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October December

3 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS DEWS Data, Epidemiological No. 48, 2006 Between 25 Nov and 1 Dec 2006, 70,019 consultations were reported through DEWS. Overall, 28% (19,363) were due to acute respiratory infections (ARI), 6% (4,471) due to acute watery diarrhoea (AWD), 8% (5,440) due to fever of unknown origin (FUO), and 5% (3,233) due to injuries (INJ). ARI accounted for 35% and 25% of consultations in the less than 5 years old and 5 or more years old respectively. All other reportable conditions each represented less than 1% of the total consultations in week 48. AWD 11% ARI 35% AWD 5% ARI 25% AWD 6% ARI 28% OTH* 42% FUO INJ 8% 3% < 5yrs (n=18,871) OTH* 56% INJ 5% 5yrs (n=51,148) FUO 8% OTH* 52% FUO 8% INJ 5% All Ages (n=70,019) Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 25 Nov-1 Dec *OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance DEWS Data, Epidemiological No. 48, 2006: Consultations by age The weather condition in the earthquake affected districts has declined markedly in the last two weeks, with snow in many districts and heavy rains in others. As expected, the rate of ARI continues to increase, and over 1 in 3 consultations in children under five are currently for ARI. Though lower in than the rate in children under five, the rate of ARI consultations in patients five years and over has increased in the last week, from 21.5% of all consultations to 25%. See figure 3. ARI as a percent of all consultations within age group <5 >=5 Figure 3: ARI as a percent of all consultations, but age group, by week, Earthquake Affected Areas, Pakistan 14 October 1 December

4 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS DEWS Data, Monthly Summary (Epidemiological s No ) In the past four weeks, between 4 Nov to 1 Dec 2006 (Epidemiological weeks inclusive), 140,570 consultations for health conditions under surveillance were reported, out of a total 321,733 consultations. 24% (78,648) of consultations were due to acute respiratory infection (ARI), 6% (20,249) acute watery diarrhoea (AWD), 7% (21,597) unexplained fever (FUO) and 5% (15,978) Injuries (INJ). Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 25 Nov-1 Dec WEEK 45 WEEK 46 WEEK 47 WEEK 48 TOTAL Event C D C D C D C D C D CFR% AWD BD AFP 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 82,262 consultations were reported in the less than 5 years old group, (26% of the total consultations), of which 33% (27,110) were due to ARI, 11% (8,813) due to AWD, 7% (5,977) due to FUO and 4% (3,253) were reported as injuries (INJ). Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 25 Nov-1 Dec WEEK 45 WEEK 46 WEEK 47 WEEK 48 TOTAL Event C D C D C D C D C D CFR% AWD BD AFP MAL ARI MES MEN JAU TET AHF FUO INJ OTH TOTAL RU

5 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS In the current week, there was a decrease in the number of cases of AWD with 5,322 last week and 4,471 this week, however, as Bagh district could not report, this decline is not necessarily indicative of a decline in the overall rate. In the current week, ARI decreased in the total number of cases as compared with the previous week, (21,199 last week and 19,363 this week). Despite the decline in the number of cases, the rate of ARI increased. The weekly proportion of ARI and AWD is shown in figure 4. % Consultation ARI and AWD percent of total consultations W48 W47 W46 W45 W44 W43 W42 W41 W40 W39 W38 W37 W36 W35 W34 W33 W32 W31 W30 W29 W28 W27 W26 W25 W24 W23 W22 W21 W20 W19 W18 W17 W16 W15 W14 W13 W12 W11 W10 W9 W8 W7 W6 W5 W4 W3 W2 W1 W52 W51 W50 W49 W48 W47 W46 W45 ARI AWD Figure 4. ly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 5 November December Acute Watery Diarrhoea In week 48 there were 4,471 cases of AWD reported, with no associated deaths. The rate of AWD differs by district, with Poonch having the highest rate in week 48, at 8.6% of all consultations, and Mansehra the lowest, at 4.5% of all consultations. See Figure 5. AWD as a percent of all consultations BATTAGRAM MANSERA MUZAFFARABAD POONCH District Figure 5: AWD as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, November 25 December 1,

6 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS Bloody Diarrhoea I week 48, there were 345 cases of bloody diarrhoea reported. There were no associated deaths. The trend in bloody diarrhea differs by district, with Battagram both having the highest rate, and increasing in the past week. Poonch as consistently had the lowest rate of bloody diarrhea over the last four weeks. See figure BAGH* BATTAGRAM MANSERA MUZAFFARABAD POONCH Bloody diarrhea as a percent of all consultations Figure 6: Trend in bloody diarrhoea cases as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, 5 November 1 December 2006 *Data unavailable in week 48 Acute Jaundice Syndrome In week 48 there were 44 cases of suspected hepatitis, with one associated death in a patient five years or over in Muzaffarabad. Suspected hepatitis is one of three waterborne diseases tracked by the DEWS, the others being bloody diarrhea and acute watery diarrhea. The share of consultations for waterborne diseases that is suspected hepatitis varies by district, with Battagram having the highest proportion in the past three weeks, and Bagh having the highest proportion in week 45. Poonch has had a consistently low proportion of waterborne diseases that are suspected hepatitis, and Mansehra and Muzaffarabad have very similar proportions for most weeks. See figure 7. Suspected hepatitis as a percent of all consultations for waterborne diseases under surveillance** BAGH* BATTAGRAM MANSERA MUZAFFARABAD POONCH Figure 7: Suspected hepatitis cases as a percent of all waterborne diseases under surveillance, by district, Earthquake Affected Areas, Pakistan, 5 November 1 December, 2006 *Data unavailable in week 48 **Waterborne diseases include AWD, bloody diarrhea, and suspected hepatitis 6

7 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS Malaria In week 48, there were 594 malaria cases reported, with no associated deaths. Poonch has had the highest rate of malaria in the last two weeks, and the rate is rising. Battagram and Mansehra also have seen a rise in malaria, however, the rate is low. See figure 8. Malaria as a percent of all consultations BAGH BATTAGRAM MANSERA District MUZAFFARABAD POONCH Figure 8: Malaria as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, November 18 December 1, 2006 Measles There were 6 cases of measles reported in week 48, all in Battagram. After a decline, measles is starting to reappear in the earthquake affected districts, particularly Battagram. However, when seen compared to the trends in the last year, the weekly number of cases reported is still comparatively low. See figure Measles cases Figure 9: Trend in measles cases, Earthquake Affected Areas, Pakistan, 15 October December

8 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS Acute Respiratory Infection In week 48, there were 19,363 consultations for ARI. There were five associated deaths, 3 in Mansehra (2 patients under 5, 1 five or over) one in Poonch, and one in Muzaffarabad; both of these deaths were of patients five years or older. This winter is perceived as more harsh than last winter, and the much higher ARI rates seen in week 48 of 2006, compared to week 48 of 2005 would support that assertion. However, there are also many more reporting sites this winter, so the differences may reflect a more complete reporting more than a more serious trend in disease. See figure 10 ARI as a percent of all consultations BAGH BATTAGRAM MANSERA District MUZAFFARABAD POONCH Figure 10: ARI as a percent of all consultations in weeks and 48, Earthquake Affected Areas, Pakistan, 26 November 2 December 2005 and 25 November 1 December 2006 Other Reportable Diseases and Conditions There were 5 cases of suspected meningitis reported in week 48, all in Muzaffarabad, with 4 in patients five years or older, and one in a patient under 5. There were no cases of acute flaccid paralysis, tetanus or hemorrhagic fever. There were 5,440 cases of fever of unknown origin, and 3,233 injuries. Unexplained fever has been attributed to failing to diagnose both malaria and ARI. Though more common than malaria and less common than ARI, the trend of unexplained fever more closely follows the trend of malaria. See figure 11. Number of consultations Malaria Unexplained fever ARI Figure 11: Trend in unexplained fever, malaria, and ARI, Earthquake Affected Areas, Pakistan, 15 October December

9 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS Outbreak Alert and Response 1 Measles: Battagram An increasing number of measles cases reported from THQ Alpuri led the investigation team to visit the facility. One case was found at the THQ; a 3 ½ year old girl, who developed the disease on 28 th November. On investigation, four further cases were found in relatives of the girl, all from Banda Dolat Kalay village, UC Bailay Baba. Ages ranged from 22 months to 6 years. No further cases were found outside the family. Blood samples were taken for confirmation. Vaccination coverage was found to be very low in the village due to its isolation, and a vaccination campaign was planned to begin within two days. Acute Jaundice Syndrome: Poonch An alert for suspected hepatitis was received from BHU Rehara, in a ten year old child. Symptoms developed on 19 th November. No other family members were currently ill, but a cousin had the same symptoms 3 months previously. The family received hygiene education materials, and a blood sample was taken for confirmation. One death due to hepatitis was reported from Upper Jarooth, near Paniola. The patient, an adult male, was admitted on 23 rd November, and died within two hours. He had had jaundice three years previously, but it was not properly diagnosed. His wife was advised to be tested for hepatitis C. No family members had any symptoms. Meningitis: Bagh An alert for meningitis was received from DHQ hospital, Bagh, on 28 th November. The lumbar puncture was undertaken within two hours of receiving the alert, and the sample sent for confirmation. The patient is a 16 year old male from Bagh city who presented with fever, nausea, and neck stiffness. He had no travel history, and there was no sign of symptoms in any family member. He received antibiotics, and was making a recovery. The sample tested negative for meningitis. 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 >5 years would be investigated) 9

10 WMMR ly Morbidity and Mortality Report Pakistan 8 Dec 2006 / Vol. 54/ DEWS Number of reported cases and deaths per District, AJK Table 6. Number of reported cases and deaths, Bagh District, Earthquake Affected Areas, Pakistan, 25 Nov - 1 Dec 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, 25 Nov - 1 Dec 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, 25 Nov - 1 Dec 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 8 Dec 2006 / Vol. 54 DEWS Number of reported cases and deaths per District, NWFP Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 25 Nov - 1 Dec 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 10. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 25 Nov - 1 Dec 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