Weekly Epidemiological Bulletin

Transcription

1 Weekly Epidemiological Bulletin Disease early warning system and response in Pakistan Highlights Volume 3, Issue 46, Wednesday 21 ember 212 Figure1: 8 districts reported to DEWS in week 46, 212 Epidemiological week no. 46 ( ) : 99 alerts investigated this week, responding to 19 outbreaks involving 29 measles cases. Vitamin A was provided to cases and EDOsH took action to improve vaccination in affected areas (Page 7) : alerts investigated this week, involving 7 cases. Alerts/Outbreaks were controlled by timely measures and by case management and infection control at health facilities (Page 7) One new suspected CCHF cases reported; (Page 6) 8 districts have reported to DEWS in week 46, ,4 health facilities have shared weekly data to the Disease Early Warning System (DEWS) in this week 86,873 patients consultations were reported in week 46 compared to 888,767 consultations reported in week 4, 212. Altogether 27 alerts were investigated and response were provided to 26 outbreaks. Priority diseases under surveillance in DEWS Pneumonia Acute Watery Diarrhoea Bloody diarrhoea Other Acute Diarrhoea Suspected Enteric/ Fever Suspected Malaria Suspected Meningitis Suspected Dengue fever Suspected Viral Hemorrhagic Fever Suspected Suspected Diphtheria Suspected Pertussis Suspected Acute Viral Hepatitis Neonatal Tetanus Acute Flaccid Paralysis Scabies Cutaneous Cumulative number of selected health events reported in Epiweek 1 to 46, 212 (1 Jan ) Disease # of Cases Acute diarrhoea 2,876,12 8% Bloody diarrhoea 8,22.% ARI 6,281,41 18% S. Malaria 1,788,821 % Skin Diseases 1,66,338 % Unexplained fever 1,22,178 4% Total (All consultations) 34,4,961 Figure2: Weekly trend of Acute diarrhoea in Pakistan; Week1, 211 to week46, 212. Major health events reported during the Epiweek 46 ( ) Disease # of Cases Acute diarrhoea 62,19 8% Bloody diarrhoea 3,214 <1% 1 ARI 211,334 24% S. Malaria 2,6 6% Skin Diseases 3,734 4% Epiweek Unexplained fever 29,844 3% Total (All consultations) 888,767 The graph (Figure2) shows the comparison of weekly trend of Acute diarrhoea as proportional morbidity (percentage of cases out of total consultations) reported to DEWS each week in year 211 and 212. Overall weekly trend of acute diarrhoea is stable in all provinces. Districts in Sindh and Khyber Pakhtunkhwa are investigating alerts for acute watery diarrhoea/suspected cholera. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int. 1

2 Current week's (46/212) Outbreaks: Date Disease Province District Area <M >M <F >F Action Taken Weekly Bulletin: DEWS, Pakistan, Week no. 46 (11 to ) 12 Balochistan Muslim Bagh Killa Saifullah town area, Tehsil Muslim Bagh cases were reported. Cases were investigated and found lesion on face and arm. None of the cases had travelling history. Health session taken and Treatment as per disease protocol was given to all patient. All information was shared DHMT. 16 Balochistan Killi Gawal Ismailzai, UC Musfar Killa Saifullapur, Tehsil KSF cases for reported. Patients were investigated and examined. During investigation found lesion on different parts of body. None of the cases had travelling history. Health session taken. Treatment as per disease was given. 14 Malaria UC Cattle farm, Balochistan Jaffarabad Tehsil Jhat Pat Malaria alert was observed. 48 cases reported of which 22 slides tested through RDT. 17 slides verified positive for PF=8, PV=4 and mixed=. The cases were reported from different locations. DHO office provided RDTs and anti malarial to response more properly. Though no preventive measures was taken due to budget constraints. Malaria Balochistan Nasirabad BHU Allah Dad, Tehsil Manjhoo Shori 61 cases reported which all were tested by RDT. 27 slides verified positive of Falciparum. Merlin is already working in the district. Treatment was provided through Merlin (INGO) resources. All information was shared with DHO for further prevention. Goraki, UC Mashkai, Tehsil Mash 12 Balochistan Awaran kai 4 1 case reported for measles and investigation was done by DEWS Focal person. All cases were presented with typical sign & symptoms. Symptomatic treatment was already provided. No more case reported. household were checked. kids seen which all were unvaccinated. Information shared with DHO and requested to send outreach team for immunization. Balochistan Nasirabad Ghot Missari Khan, UC Golawah, Tehsil Tamboo Outbreak was reported by DHO. Few days earlier 3 children were expired due to measles in the same location. Presently cases more cases observed in the location. Cases were presenting with typical sign & symptoms. As per disease protocol, treatment and VitA dosage is given. Parents were guided to give next dose accordingly. 3 kids were referred to DHQ Hospital for further treatment. campaign was done in the community. Patient are treating by Medical camp. Followup has planned daily. AJS Khyber Pakhtunkhwa Haripur Village Noordi, UC Rehna suspected Acute Viral Hepatitis cases reported from Village Noordi. Epidemiological and Environmental assessments were carried out. Field investigation found possible source as contaminated water supply which is an unprotected spring. No shared food intake history. Water samples were assessed for contamination. Active case finding was carried out in the area. 12 more cases were identified with having AVH in past one month. Blood samples were taken and sent to NIH. LHWs were also asked to identify and notify cases of AVH and especially referrer pregnant ladies to nearest health facility. EDO H was informed of the outbreak. Health and hygiene campaign is planned for coming week. Soaps were distributed among the families. 13 Khyber Pakhtunkhwa Mardan Village Shindey Charbanda, UC Babenei A suspected alert was reported from BHU Charbanda, tehsil Mardan. patient was found unimmunized for measles vaccination. Epidemiological assessment was carried out in the area and surrounding. 6 more clinical cases from among two families were identified, most of them were unimmunized for measles vaccination. Vitamin A capsule was given. Outreach vaccination activity was carried out by district EPI team in the area with available antigens. Health education session was conducted with the family members and community, LHW's working in the area was involved. EDO H Focal person & EPI Coordinator were informed. 12 Laloo Machi Goth, Sindh Sabzi Mandi, Hale Hyderabad road, taluka Hyderabad 1 One case of was found during active surveillance at civil hospital Hyderabad with severe dehydration. Case was investigated along with focal person and WHO EHE. Active surveillance was done. Tap water is the source for drinking water. Health education regarding importance of Boiling of water and health and hygiene was imparted. Aqua tabs and soaps were provided. Information shared with DHO, DO Preventive and Focal person and 1 Stool sample collected which was found positve for Cholera, 2 water (Tap and Drinking water cooler) samples also collected and are under process. Village Jummo 16 Sindh Dadu Jamali, UC T.R Khan, taluka Johi Village Moosa 16 Sindh Dadu Jamali, UC T.R Khan, taluka Johi Suspected case of was reported by pediatrician of city Johi. During active surveillance 8 more cases were found. All cases has sign and symptoms of Fever, Cough, Rashes, coryza and conjunctivitis. Vitamin (A) dose given. Health education imparted. Vaccination status of 24 children were assessed. BCG=14(8%), Penta1=9(37%), Penta2=6(2%), Penta3=(2%), 1=1(41%), 2=8(33). Information shared with EDOH and 1 Blood sample collected. Suspected case of was reported by pediatrician of city Johi. During active surveillance 4 more cases were found. Out of them only 3 cases were BCG+ve only, 2 cases were 1 and 2 were 2 vaccinated. Vitamin (A) dose given. Health education imparted. Vaccination status of children were assessed. BCG=11(73%), Penta1=1(66%), Penta2=7(46%), Penta3=(33%), 1=9(6%), 2=7(46). Information shared with EDOH and 1 Blood sample collected. Sindh Ghotki Village Jamal Chachar UC Mithri Taluka Khan Garh Suspected measles case notified by WMO RHC Adilpur, during active search in the village four more cases were found, 2 doses of Vitamin A was given to all cases, 2 blood samples were taken and sent to NIH, only one child has BCG scar, information was shared with DHO, DEWS focal person & PPHI DSM and requested fro vaccination in the area. Sindh Ghotki Village Panjo Bag UC Hussain Beli suspected measles case was notified by Lab Technician from MCH centre Ghotki, during active search in the village total cases were found, Vitamin A doses were given to all cases, 4 blood samples were taken and sent to NIH, poor routine immunization status were observed almost all the children were not vaccinated with measles doses. Information was shred to DHMT and requested for vaccination in the area. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int. 2

3 Cont d current week's (46/212) Outbreaks: Date Disease Province District Area <M >M <F >F Action Taken Khosa Muhalla, 12 Sindh Jamshoro UC Sehwan2, taluka Sehwan Weekly Bulletin: DEWS, Pakistan, Week no. Week no. 46 (11 to ) 4 cases of were reported from a private clinic. Hospital investigation was carried out. During active surveillance 4 more case were found. Out of them 1 case was not vaccinated and other were all vaccinated. Vitamin (A) dose was given. Health education imparted. Vaccination status of 13 children were assessed. BCG=13(1%), Penta1=12(92%), Penta2=12(92%), Penta3=11(84%), =11(84%). Information shared with EDOH and Blood samples collected. Village Hakim Ali, 13 Sindh Kashmore Nandhroo Khan, UC Rasaldar Village Gul Mohammed Brohi, 13 Sindh Larkana UC Pathan Village Usman 13 Sindh Larkana Abro, Taluka Larkana Village Ali Buksh Sindh Matiari Mari, UC and taluka Matiari Village Sarangh Khuawarh, UC Rawanti, taluka Qambar Thari Hashim, UC wagan, taluka Warah Village Khero Jatoi, UC Wagan, taluka Warah Suspected Case was notified by MT GD 27 Mile (PPHI), on investigation with PPHI team & vaccinator 1 Death due to Post complications & 14 cases were found. No any Case had BCG scar, Vitamin (A) given to cases. Two Blood sample collected. EPI status of 17 children were assessed where no any child was found vaccinated. Information shared with DHMT. Suspected case was notified from private clinic. Active search done and found more cases. Vitamin (A) given also sensitized for isolation of patients. Symptomatic treatment assured for case. Health education imparted. Routine cluster taken from 8 children. BCG= 4=(%), Penta1=4(%), Penta 2=2(2%), Penta 3=(%), Mealses1=3(38%), Mealses2=(%) Informed DHO office and 2 Blood sample collected. Suspected 1 case was notified from private clinic. During active search 9 more cases were found. Vitamin (A) doses given to all cases and sensitized for isolation of patients, symptomatic treatment assured for cases. Community sensitized about rouitne immunization. Four blood samples collected and send to NIH. DHO informed to take action about Strengthening of vaccination, routine immunization status was taken from 11 children. BCG=(4%), Penta1=4(36%), Penta2=3(27%), Penta 3= (%), Mealses1=4(36%). Mealses2=(%). Suspected case of was reported from THQ Matiari. Active surveillance was done. Case was BCG +ve only and not vaccinated for other antigen. Vitamin (A) dose given. Health education imparted. Vaccination status of the area was taken. BCG=(7%), Penta=(4%), (4%). Information shared with EDOH and 4 Blood samples collected. Two cases of suspected were reported by MO BHU Gazi khan Khuawarh. Both children were found according to case definition. During field investigation 4 more cases were found from same village, no any travel history was provided by parents. Routine immunization status was taken. BCG=(%), Penta1=2(22%), Penta2=2(22%), Penta3=(%), 1=4(44%), 2=(%), Vitamin(A) given to all cases. Health education imparted. DHO informed about the cases and 3 Blood samples collected. Suspected case of was notified by private Practioner. During filed investigation by SO DEWS Larkana found 4 more cases. Children having BCG scar to 3 children and Parents were not sure about other antigens. Blood sample was collected and sent to NIH. Vitamin A (2 doses) were given, health education imparted regarding importance of routine immunization. Informed to DHMT for containment measures. Two cases of suspected, during field investigation 3 more cases were found. Out of them 3 cases were BCG +ve and 2 were not vaccinated for any antigens. Routine immunization status was taken. BCG=6(7%), Penta1=3(37%), Penta2=2(28%), Penta3=(%), 1=4(%), 2= (%), Vitamin(A) given to all cases. Health education imparted. DHO informed about the cases and 2 Blood samples collected. Qambar 13 Sindh Shahdadkot Qambar Sindh Shahdadkot Qambar Sindh Shahdadkot Shaheed Sindh Benazir Abad Village Lal Khan Brohi, UC Suhailo 3 2 One case was notified from a private clinic. During field investigated 4 other cases were found in the area. all the Children were found unvaccinated. Blood sample collected from 2 patients. Vitamin A provided. Cluster for routine immunization taken from 12 houses where 14 children were checked. have BCG scar, 4 have penta1, 3 have Penta23, 2 have 1 and have 2. Two Blood samples collected and all information shared with DHMT. 12 Sindh Shikarpur Village Budhani soomra, UC Rahimabad, taluka Khanpur 4 3 alert was notified by MS RHC Rahimabad. During field investigation total 12 cases were found. Four Cases had BCG scar. two Blood sample was collected. Vitamin (A) drops given to cases. Health education imparted on importance of routine immunization. EPI status: 14 children were assessed & only 6=(42%) children had BCG scars. Information shared with DHMT for Mop Up the area and 2 Blood samples collected. 13 Sindh Sukkur Sindh Sukkur Pertussis Sindh Dadu Asif Colony, Bachal Shah Miyani, taluka New Sukkur Oadh Muhalla, UC Bachal Shah Miyani, taluka New Sukkur Village Mehar Channa, UC Khan jo Goth, taluka Mehar One Death due to and 1 case were reported from GMCH. During field investigation along with vaccinator 7 more suspected cases were found. 2 doses of vitamin A provided to cases. Health education imparted to affected families & contacts. On examination 2 cases had no BCG scar & all were not vaccinated for vaccine according to parents. Cluster of routine immunization checked out of 12 children. BCG=(8%), 12=(%) according to parents. All information shared with DHO & DHMT. 1 case of Suspected was reported at Paeds OPD. During field investigation along with vaccinator 1 more cases found. Two doses of vitamin (A) given. One blood sample collected and send to NIH. Health education imparted to affected families & contacts. Nine Children had BCG scar & not received vaccine. Cluster of routine immunization checked. Out of children BCG=(1%), 12=(%) according to parents history. All information shared with DHO & DHMT. Two cases of suspected Pertussis were reported by BHU Saeedpur. Both cases were suffering from coughing from 1 month and treated at BHU Saeedpur but not get cured. Symptomatic treatment was given. During field investigation at village 3 more cases were found. Routine immunization status was not satisfactory in the area. Erythromycin was given to cases and contacts. One Nasopharyngeal swab was collected. Nineteen children were assessed for routine immunization status. BCG=14(73%), Penta1=9(47%), Penta2=(26%), Penta3=4(21%), 1=11(7%), 2=8 (42%). EDOH informed about the cases and request for mop up the area. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int. 3

4 Weekly Bulletin: DEWS, Pakistan, Week no. Week no. 46 (11 to ) Figure3: Number of alerts received and responded, week 43 46, 212 Figure4: Number of consultations by age and gender, week 46, # of consultations Pertussis Malaria Wk43 Wk44 Wk4 Wk46 CCHF < 1 yr 14 yr 14 yr yr + yr Male Female Province Khyber Pakhtunkhwa: 461 health facilities from 16 districts of Khyber Pakhtunkhwa sent reports to DEWS with a total of 132,2 patients consultations reported in week 46, 212. Total 3 alerts were received and appropriate measures were taken. Altogether 2 alerts for ; 3 for ; 2 AJS; while 1 each for ARI,, BD, DF and Meningitis. Acute diarrhoea trend showing decrease as compared with last week. Figure-: Trend of acute diarrhoea diseases, province Khyber Pakhtunkhwa 2 Figure-6: Number of alerts received and responded week 43-46, 212, province KPK Wk43 Wk44 Wk4 Wk46 CCHF Province Sindh: 926 health facilities from 23 districts in Sindh province reported to DEWS with a total of 431,37 patients consultations in week 46, 212. Total 78 alerts received while 18 outbreaks were identified and appropriate measures were taken. Altogether 4 alerts for ; 11 for NNT; 4 for ; 3 for Pertussis; 2 each for BD and ; while 1 each for DF and. Acute Diarrhoea shows minor decreasing as compared with last week. Figure-7: Trend of trend of acute diarrhoea, province Sindh Figure-8: Number of alerts received and responded week 43-46, 212, province Sindh Pertussis Wk43 Wk44 Wk4 Wk46 CCHF Province Punjab: 48 health facilities from 9 districts in province Punjab reported to DEWS with a total of 191,417 patients consultations in week 46, 212. Total 39 alerts were received and appropriate measures were taken. Altogether 9 each alerts for and ARI; 8 for ; 4 for AD; 3 for Scabies; 2 each for and NNT; while 1 each for BD and Malaria. AD shows a minor decreasing as compare with last week. Figure-9: Trend of acute diarrhoea, province Punjab Figure-1: Number of alerts received and responded week 43-46, 212, province Punjab Malaria Wk43 Wk44 Wk4 Wk46 For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int. 4

5 Province Balochistan: Weekly Bulletin: DEWS, Pakistan, Week no. Week no. 46 (11 to ) 428 health facilities from 21 districts in province Balochistan reported to DEWS with a total of 67,861 patients consultations in week 46, 212. Total 4 alerts reported and 6 outbreaks were identified and appropriate measures were taken in week 46, 212. Altogether for ; 9 for ; 7 for BD; 4 for ARI; 3 each for Malaria and ; 2 for NNT and tetanus while 1 each for CCHF, Scabies. AD showing minor decreasing as compared with last week. Figure-11: Trend of acute diarrhoea, province Balochistan Figure-12: Number of alerts received and responded week 43-46, 212, Balochistan Malaria Pertussis Wk43 Wk44 Wk4 Wk46 CCHF Province Gilgit Baltistan: 32 health facilities from districts in Gilgit Baltistan reported to DEWS with a total of 21,18 patients consultations in week 46, 212. No alert for any disease was reported in week 46, 212. but AD showing decrease from last few weeks. Figure-13: Trend of acute diarrhoea, province Gilgit Baltistan Figure-14: Number of alerts received and responded week 43-46, 212, Gilgit Baltistan Wk43 Wk44 Wk4 Wk46 FATA: 62 health facilities from 3 agencies in FATA reported to DEWS with a total of 13,33 patients consultations in week 46, alerts; each for and ; while 1 for NNT were reported in week 46, 212 and appropriate measures were taken. An increase in AD is noted this week. Figure-: Trend of acute diarrhoea, FATA Figure-16: Number of alerts received and responded week 43-46, 212, FATA Pertussis Wk43 Wk44 Wk4 Wk46 State of Azad Jammu and Kashmir: 121 health facilities from 9 districts in AJ&K reported to DEWS with a total of 26,491 patients consultations in week 46, alerts, 2 for ; and 1 for were reported in week 46, 212. AD showing a decreasing trend from last few weeks. Figure-17: Trend of acute diarrhoea, AJ&K Figure-18: Number of alerts received and responded week 43-46, 212, AJ&K Wk43 Wk44 Wk4 Wk46 For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int.

6 Weekly Bulletin: DEWS, Pakistan, Week no. Week no. 46 (11 to ) Table1: Number of alerts and outbreaks reported and investigated with appropriate response Disease (up till week 4) Current week 46, 212 Total for 212 (week 146, 212) A O A O A O A O Acute watery diarrhoea Acute jaundice syndrome Bloody diarrhoea CCHF Dengue fever Diphtheria Pertussis NNT + tetanus Malaria Others Total Distribution of Wild Polio Virus cases Pakistan 211 and 212 As of 17 ember 212, Pakistan has reported a total of 4 polio cases including 1 type1, 2 type3 and 1 mixture type1 and 3 polio cases from 27 districts/ tribal agencies. Province Cases 211 Cases 212 P1 P3 P1 P3 P1+P3 Punjab 9 2 Sindh 33 4 Khyber Pakhtunkhwa FATA Balochistan 73 4 AJ&K GilgitBaltistan 1 1 Islamabad Total Follow up of CCHF, and Dengue CCHF: CCHF is a serious viral hemorrhagic fever with up to % case fatality rate, caused by an RNA virus of family Bunyaviridae, genus Nairovirus, carried by Hyalomma species of ticks. Human beings become infected by tick bites or crushing the ticks, which are usually found on sheep, cattle, goats or camels, and their slaughtered skins. They may also be exposed to the virus in blood or tissues of a viremic animal during its slaughter and butchering; or by contact with infected blood or secretions of acute human cases in home or hospital setting. On ember, 212, one new suspected case of CCHF was reported from Balochistan. In 212, So for a total of 6 suspected cases have been reported throughout the country with 41 confirmed to date and 17 deaths; (CFR is 36.96%). 23 confirmed cases have been reported from Balochistan; 7 from Sindh; 6 from Khyber Pakhtunkhwa and from Punjab. Chart at right illustrates current situation of CCHF cases in 212. # of cases Number of CCHF cases (week 1 to 46, 212), Pakistan Suspeceted Positive Deaths Approximately all the cases have contact history with animal trading/handling, tick bite, contact with patient, tannery worker, butcher/animals slaughtering, a traditional practice of wearing fresh animal skin (posti) to treatment ailment. These animals and their skins have continuous movement!intra Pakistan and between neighboring countries (Afghanistan and Iran). Any contact of a CCHF patient should monitor his/her temperature for 14 days and see a doctor if fever develops. The anti viral medicine Ribavirin has been effective in saving lives of patients who report early to the health facility. For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int. 6

7 Weekly Bulletin: DEWS, Pakistan, Week no. Week no. 46 (11 to ) : As of 1 ember 212, more measles cases and deaths have been reported in Pakistan than in 12 months last year. Table 1 summarizes the situation of measles in 212 up to 17 ember; and table 2 illustrates the alerts and outbreaks in week 46 (11 to 17, 212). Table1 212 (Week 1 46) Table2 Epi week 46, 212 Province # of Alerts # of Outbreaks # of Cases # of Deaths Province # of Alerts # of Outbreaks # of Cases # of Deaths AJ&K 24 Balochistan FATA Gilgit Baltistan 26 3 ICT Khyber Pakhtunkhwa Punjab Sindh Total AJ&K 1 1 Balochistan FATA 8 Gilgit Baltistan ICT 1 1 Khyber Pakhtunkhwa Punjab 9 11 Sindh Total As it is shown in the above table that majority of the measles cases have been reported from Sindh and Khyber Pakhtunkhwa provinces. Both of these provinces have announced the EPI facilities will be providing measles vaccine twice a week for all children under age. Dengue: The chart at right showing the weekly number of confirmed Dengue cases reported by surveillance focal points from the Departments of Health in Sindh and Punjab in 212. Total number of confirmed dengue cases to date in 212 is 42 in Sindh and 3 in Punjab. Month of peak incidence in 21 was ember while peak incidence in 211 was in September and October. # of cases Weekly trend of positive Dengue cases reported from Sindh and Punjab, week 1 to 46, 212 Punjab Sindh Malaria: The chart at right shows the Malaria slide positivity and Falciparum rate reported in week 46, 212. Total number of malaria cases tested in this week is,1, out of which 29 were found positive; 1223 for P. Vivax; 62 for P. Falciparum; while 316 for Mixed (SPR = 13.93%; F. R = 43.3%) Malaria slide positivity and falciparum rate, week 46, 212 SPR FR : The surveillance definition for a case of Acute Watery Diarrhoea () or suspected cholera in an endemic area, is any case over age 2 years with severe dehydration or death due to diarrhoea of 3 or more stools in 24 hours. An outbreak is defined as a cluster of 6 or more cases of or any number of cases with at least one confirmed case of Vibrio cholera. The table at right summarizes the situation of in last four weeks, 2 October to 17 ember 212. During the period, a total of 26 alerts were reported and 3 confirmed out breaks were identified and were responded very efficiently and in systematic manner. The Surveillance Officers in the districts with the close coordination of trained rapid response teams from Department of Health and partners address the outbreaks. Province Sindh Balochistan FATA Punjab KPK GB AJK ICT Week 43 46, 212 Outbreaks # of Alerts # of Outbreaks with confirmed # of Cases # of Deaths V. cholera AJ&K Balochistan FATA Gilgit Baltistan ICT Khyber Pakhtunkhwa Punjab 1 3 Sindh Total For Correspondence: NIH: eic.nih@gmail.com; WHO: Tel : , Fax : ; wr@pak.emro.who.int. 7

8 Weekly Bulletin: DEWS, Pakistan, Week no. Week no. 46 (11 to ) Alerts and outbreaks, week 46, 212 For Correspondence: NIH: WHO: Tel : , Fax : ; wr@pak.emro.who.int. 8