Weekly Morbidity and Mortality Report (WMMR) IDP Hosting Districts, NWFP, Pakistan Week # 36 (29 Aug 4 Sep), 2009

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1 Weekly Morbidity and Mortality Report (WMMR) IDP Hosting s, NWFP, Pakistan Week # 36 (29 Aug 4 Sep), 29 Emergency Humanitarian Action (EHA) Islamabad, Pakistan A child with Acute Diarrhoea is being treated at the Diarrhea treatment center DHQ hospital Mardan Highlights: During the Epidemiological week 36, 29, five alerts, were received and responded. Three alerts for suspected acute watery diarrhea (2 in district Buner, 1 in Swat and in 1 in Jalozai IDP camp) and one alert for suspected Pertusis from Khyber Teaching Hospital, Peshawar were investigated and responded accordingly. During this week, 234 health facilities reported 7,95 patients consultations through the DEWS network Acute Diarrhoea reported in 5,859 (8%) of the total consultations in all age groups, Diarrhoea accounts for 16% of the consultations in the children below 5 years age and 6% of the consultations in the patients above 5 years age Acute Respiratory Infections (ARI) continues to be the leading cause of morbidity, with a total of 14,37 consultations (2% of total consultations) in the IDP hosting districts of NWFP. In children less than 5 years of age, ARI accounts for 4,227 (27%) of the total consultations in the age group. Nineteen DEWS sites reported; 574 Ante Natal visits, 7 pregnancy and delivery related referrals, 617 consultations for chronic non communicable diseases and 181 injuries. The WMMR is published by the World Health Organization (WHO), Emergency Humanitarian Action (EHA) unit, National Park Road, Chak Shahzad, Islamabad, Pakistan. For More Information, please contact: Dr. Ahmed Farah Shadoul, Chief of Operations, EHA, WHO, Pakistan; Shadoula@pak.emro.who.int Dr. Fazal Qayyum, Director Health Services, Department of Health NWFP, Pakistan Dr. Musa Rahim Khan, Senior Public Health Officer (DEWS Coordinator), WHO, EHA, Pakistan; khanm@pak.emro.who.int

2 1. Alert and outbreak investigations and response: During the epidemiological week 36 (29 Aug to 4 Sep 29) five alerts, were received from different locations, investigated by the DEWS teams and responded in collaboration with the Health and WASH cluster partners. Four alerts were received for suspected acute watery diarrhea and two of the alerts identified as outbreaks after investigation and control measures initiated. One alert for suspected Pertusis, received from Khyber Teaching Hospital, Peshawar which was declared negative after laboratory investigation. 1. Pertussis: One 2 nd of September 29, a one and half year old female child was reported as a suspected case of Pertusis from Khyber Teaching Hospital, Peshawar. The DEWS team conducted field investigation and no other suspected case with the similar signs and symptoms was found among the contacts of the patient and in the locality. Throat swab sample was taken from the child for laboratory investigation and reported negative for the pathogen causing Pertusis from NIH laboratory Islamabad. 2. Acute Watery Diarrhea: 1. During the week two alerts; one from village Barkaley and another from the DHQ hospital Dagar district Buner were reported for suspected Acute Watery Diarrhoea. DEWS team conducted field investigation in collaboration with DoH and the health cluster partners working in the area. From the health facilities data four different locations: Mohalla Bara Hujra village Barkally; Mohalla Kuza Hujra, village Cheena; Mohalla Shamsher and Mohalla Hasan Khel, were identified from where the suspected cases were being reported mostly. The DEWS team visited all the areas did field investigation and collected stool samples from 6 patients for laboratory investigation. No clustering of the cases was found in all these locations. All the 6 stool samples were tested at NIH laboratory and reported negative for the pathogen causing AWD. 2. On 27 th and 28 th September, 29, an unusual increase in the number of Acute Diarrhoea cases noticed in the casualty department of the Saidu Group of Teaching hospital in Swat. WHO has deployed a team comprised of a Surveillance officer and Environmental Health Engineer to investigate the situation and to support the DoH in Swat. The investigation revealed that it is an outbreak of Acute Watery Diarrhoea. The patients are mainly coming from Mingora, Saidu Sharif, Manglawar, Shagai, Spalbandai and Slamapur. Contaminated water is suspected as the cause of the outbreak and control measures have been started with dissemination of messages on hygiene promotion and clean drinking water. Aqua tabs have been supplied to affected population through TMA Swat. Supplies for the treatment of Diarrhoea have been provided at the hospital and EDO health Swat. The situation is being monitored vigilantly. Swat is still security risk area and access to the area is limited. A formal DEWS network for weekly reporting is not in place yet, however the early warning system has been introduced. 3. An alert for AWD was generated from the Jalozai 2 health facility in the Jalozai IDP camp district Nowshera. The alert was promptly responded and investigated and the control measures reinforced jointly in collaboration with the health and WASH cluster partners. The situation is contained and improving. 2. DEWS reporting units and consultations Table 1: Weekly number of reporting units and total consultations from health facilities in IDP camps and outside camp in IDP hosting districts of NWFP from week 33 to 36, 29 Week 33 Week 34 Week 35 Week 36 Consultations Consultations Consultations Consultations Buner 1 3, ,25 8 5,857 Charrsada , , , ,474 Swabi ,46 Mardan 52 1,369 25, ,2 27, , ,69 Nowshera 38 8,642 9, ,591 8, ,169 8, ,7 7,431 Peshawar 59 2,681 1, ,929 12, ,13 14, ,152 11,186 Total 23 13,35 52, ,75 59, ,19 59, ,887 61,63

3 During the week 36, 29, total 234 sites shared the weekly DEWS reports on due time. A total of 7,95 patient consultations have been reported in this week reflecting an increase of consultations by 1,58 (1%) as compared to the previous week. Out of the total reported consultations, 4,484 (57%) patient visits were reported for females and 3,466 (43%) for male patients. During this week 15,481 (22%) of the total consultations were reported in children less than 5 years age. Nineteen DEWS sites reported; 574 visits for Ante Natal care, 7 pregnancy and delivery related referrals, 617 consultations for chronic non communicable diseases and 181 injuries. With the return of IDPs from Swat and Buner to their native places, the weekly patient consultations at the health facilities in the IDP camps have dropped significantly (table 2). Table 2: Weekly total consultations in IDP camps by district, from weeks 33 to 36, 29 Consultations IDP camp Week 33 Week 34 Week 35 Week 36 Buner Karapa 932 Charsadda Palosa Mardan Jalala Nowshera Benazir Complex Jalozai 1, 2, 3, Peshawar Kacha Garhi 1 & Total Morbidity pattern of the seven most common communicable diseases in the IDP hosting districts and one conflict affected district (Buner) of NWFP, during week 36 of 29: Figure 1: Pattern of the seven most common communicable diseases reported in the 5 IDP hosting districts, and Buner the confect affected district, in NWFP as number of consultations during week 36, 29 Number of consultations URTI AD SCB UF LRTI MAL BD Mardan Peshawar Nowshera Charsadda BUNER Swabi The number of consultations for the most common communicable diseases is compared to get an idea about the most common currently prevailing communicable diseases under surveillance in the IDP hosting districts of NWFP. During the epidemiological week 36 of 29; Upper Respiratory Tract Infection (URTI) was reported as the most common disease (17%) amongst all the consultations reported and was also the leading cause of morbidity in the IDP camps as well as outside the camps in all the 6 districts (Figure 1). Acute Diarrhoea (AD) was the second common disease (8%) in all the districts with a highest number of consultations in district Mardan, followed by Scabies (SCB) (5%) with highest number of consultations in district Mardan, Un explained fever (4%) and Lower Respiratory tract Infection (3%). Suspected Malaria was reported in 1,821 (3%) of the cases of the total consultations and compared to the other IDP hosting districts Mardan, Nowshera and Buner report more cases of suspected Malaria; Bloody Diarrhoea was reported in 664 (1%) patients with higher number of cases from district Mardan, Peshawar and Nowshera. As district Mardan is still hosting a

4 large number of IDP populations with the host community therefore the number of consultations for all the reportable communicable diseases is high. 4. Morbidity pattern of the five most common communicable diseases by number of consultations in the IDP camps of NWFP during week 36 of 29 Figure 2: Pattern of five most common communicable diseases in the IDP camps NWFP, week 36, 29 Number of consultations URTI AD SCB MAL LRTI UF BD Jalozai 3 Jalozai 2 Jalozai 1 Jalozai 4 KG II KG I Palosa Jalala B.Complex During week 36, health facilities in most of the IDP camps (except Jalozai 2) reported URTI as the leading cause and acute diarrhea as the second common cause of consultations. The health facilities in Jalozai 2 IDP camp where an AWD outbreak has been identified reported acute diarrhea as the leading cause of consultation and URTI as the second common cause of patient visits. An increasing number of consultations for Scabies have been reported in Jalozai 1, 2, 3 and 4 health facilities of the IDP camp in Jalozai, district Nowshera. Intensive hygiene promotion and water and sanitation interventions are recommended in these camps for the prevention of these waterborne and water related diseases. 5. Weekly Trends of the five most common communicable diseases in the IDP hosting districts NWFP: Figure 3: Weekly morbidity pattern of five most common reported communicable diseases by number of cases per 1 consultations in IDP hosting districts of NWFP from week 1 to week 36 of 29: Number of cases per 1 consultations URTI AD LRTI UF SCB The morbidity trend is proximally represented by the number of consultation of each disease as per 1 consultations during each week. Generally the upper respiratory tract infection (URTI) is the leading cause of consultation throughout the period. Overall both upper and lower respiratory tract infections remained stable during the recent weeks except a slight increase in URTI during the last two weeks where an upward trend was noticed. With a slight weekly fluctuation the overall consultations for Acute Diarrhoea (AD) remained steady during the recent weeks. The rest of the commonly reported communicable diseases (unexplained fever and scabies) are also showing a steady trend with a little weekly fluctuation.

5 6. Weekly morbidity pattern of Acute Diarrhea and LRTI among <5yrs population of IDP hosting districts of NWFP from week 1 to week 36 of 29 Figure 4: Weekly morbidity pattern of Acute Diarrhea and LRTI among <5yrs population as per 1 consultations in the age group, in the IDP hosting districts of NWFP from week 1 to week 35 (1 st January to 4 th September) 29 Number of cases per 1 consultations AD <5 LRTI <5 Acute Diarrhea (AD) and Lower Respiratory Tract Infections (LRTI) are the known most common cause of morbidity and leading causes of death among children less than five years age. During week 36, a total of 15,481 consultations reported in the children Under Five years age, out of those, 2,465 (16%) consultations were for Acute Diarrhea and 659 (4%) for LRTI. When the weekly trends of both the diseases were analyzed among children under five years age, as per 1 consultations in the age group in the IDP hosting districts of NWFP; consultations for AD is shows a weekly fluctuation trend while LRTI reflecting a more steady trend in the recent weeks in children under 5 years age (fig 4). 7. Water and Sanitation: Regular water and sanitation monitoring and evaluations are being done by WHO Environmental Health Engineers in all the remaining IDP camps routinely and in the host community from where alerts or outbreaks for the waterborne disease are reported. Key water and sanitation intervention during week 36, 29 WHO EH team Responded to AWD outbreak alerts in villages Cheena and BarKaley of Buner. Detail WATSAN investigation was carried out including water quality testing from main source and households. WHO provided 14 aqua tabs to BHU Cheena for distribution in affected community for household water treatment. WHO EH team conducted a training session for health staff in Pabbi satellite Hospital on hospital ward disinfection and preparation of Chlorine solution of different concentration for use in DTC at the hospital. In Jalozai IDP a joint hygiene promotion activity was conducted by WHO and Merlin. Eighteen hygiene promoters and 4 hygiene supervisors were briefed on Diarrhea prevention and management and IEC material was provided to hygiene promoters for their reference and use in community health education and awareness session. The WASH camp coordination meeting in Jalozai camp decided to review the WASH services provided in the camp so far and the missing links for improvement. WHO EH team provided refresher training on chlorination to the Tube well operators in Phase 3 of Jalozai camp. WHO requested WASH partners to remain on board in follow up of AWD outbreak in Nowshera WHO EH team responded to AWD outbreak in swat. The Outbreak was thoroughly investigated. The unclean storage reservoir and shortage of TMA water supply is causing the people to use water from the unprotected water sources in the area. WHO collected 7 water samples (4 household and 3 unprotected spring sources) for quality test. WHO also distributed 2 aqua tabs and 5 leaflets on clean drinking water initially. UNICEF has been requested for further support to TMA swat for immediate Water quality improvement intervention at source and household level. UNICEF is processing the request on priority basis.

6 As a follow up of establishing a provincial water quality testing lab in Peshawar, the Peshawar Development Authority (PDA) has formally allocated two Rooms in its Quality Control Section Hayat Abad Phase 6. WHO is in the process of hiring builders for renovation of the lab site according to standard laboratory design specifications. The chlorinator at Palosa 1 camp is still out of order and manual Chlorination is being done in the camp. Four water samples were tested for residual chlorine at the tap ends and three of the samples were found with residual chlorine level within.2.5ppm limits. HDOD requested WHO for donation of soap to be distributed in Palosa 1 IDP camp, WHO is processing the request to provide 5 units hand washing soaps to HDOD next week. Site for Water testing laboratory in Swabi has also been finalized with TMA Swabi. The site will be renovated for establishing water quality testing laboratory. WHO EH team monitored the water treatment process in Jalala IDP camp where all the samples were found with residual Chlorine level within.2.5 ppm limit. The WHO EHE and MERLIN team conducted a joint Hygiene session in Kacha Ghari IDP. Fifty (5) female participants and 2 children attended the session. A meeting was conducted with Prime Minister Program for Hepatitis control. It was decided that WHO will work in collaboration with this program for health care waste management of the targeted seven health facilities in the IDP host districts. During the epidemiological week 36, a total of 22 water samples were tested for biological contamination and 8 samples for residual Chlorine from the five IDP hosting districts 12 water samples were found unfit for drinking and appropriate actions were taken in collaboration with the WASH partners. Table 3: Biological test results of the water sample tested in the IDP hosting districts of NWFP Bacteriological test result Total No of water sample Water sample fit for drinking Water samples unfit for drinking tested No % No % Buner % 4 67% Peshawar 4 2 5% 2 5% Swat % 6 86% Action Taken WHO provided Aqua Tabs to DoH for distribution in affected households Chlorination restarted in Kacha Garhi, Peshawar, WHO and Merlin conducted health education sessions WASH cluster provided 8, Aqua Tabs to DoH and TMA Swat for household treatment Nowshera 5 5 1% Table 4: Results of the water sample tested for the residual Chlorine level, IDP hosting districts NWFP Residual Chlorine (.2mg.5mg) Total No of water sample tested Water samples chlorine detected and within permissible limit Action Taken No % Charsadda % Mardan 4 4 1% 9. Number of reporting/non reporting Health Facilities by type and department (Week 36, 29): During the Epidemiological week 36, 29, 234 (66%) of all the assigned DEWS reporting sites reported to the system, reflecting an increase in the weekly reporting units as compared to the previous week. The weekly reports from the IDP camps in Lower Dir, Malakand and Upper Dir are not received. With the collaborative efforts of DoH, PPHI and health partners the DEWS trainings have been conducted in district Swabi and Charsadda recently. The Weekly DEWS reporting from district Swabi has started now. DEWS reports from district Buner are being received

7 through the health partners who have started services in the district. Soon the DEWS network will be extended to district Swat also. Table 5: DEWS reporting by type of facility, IDP hosting districts NWFP for week 36, 29 Number of DEWS Reporting Health Department Health Facility Implemented Health Facilities Facilities Percentage PPHI BHU % RHC % DHQ % Dept. Of Health THQ 1 % IDP s % Mobile, CD and CH % Total % 1. Maternal health care and <5 year Children, Nutrition surveillance: Some indicators on maternal health care and <5 children nutrition surveillance were recently introduced in selected facilities. Some of these sites in the camps have been closed now. Nineteen DEWS sites reported 574 Ante Natal visits, 7 pregnancy and delivery referrals, 617 consultations for chronic non communicable diseases and 181 injuries. The information on Maternal Health Care and <5 children nutrition surveillance by each district during week 36, 29 is presented in the table below. No of Pregnant women received Antenatal Care Inside Total Pregnancy and delivery related Referrals Inside Total Moderate Acute Malnutrition in children <5 Inside Buner Charsadda Mardan Nowshera Peshawar Swabi Total Total