A. Situation update on the outbreak of Dengue Fever in Khyber Pakhtunkhwa (KP) Provinces of Pakistan

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1 14th Oct 17th Oct 20th Oct 23rd Oct 26th Oct 29th Oct 1st Nov 4rth Nov 7th Nov 10th Nov 13th Nov 16th Nov 19th Nov 22nd Nov 25th Nov Wr Pakistan (Centre) Dr. Mohammad Assai ARDAKANI visits KP province (Oct 2017) to support response to the outbreak of Dengue fever in the region Pakistan Health Cluster Bulletin # 1 November 2017 Highlights There is an ongoing outbreak of Dengue fever in Khyber Pakhtunkhwa (KP) province of Pakistan. The outbreak was first notified on 19th July As of 24th November 2017 over 122,807 suspected cases were registered of which 25,770 cases tested positive and 69 deaths were recorded. Preliminary findings from Vulnerability Assessment the assessment has been released by OCHA Health Cluster funding against Humanitarian Strategic Plan 2017 for Pakistan is 90% funded A. Situation update on the outbreak of Dengue Fever in Khyber Pakhtunkhwa (KP) Provinces of Pakistan There is an ongoing outbreak of Dengue fever in KP. The first case was notified on the 19 th July As of 24 th November 2017, over 122,807 suspected cases were registered, 25,770 cases tested positive and 69 deaths recorded. The most affected district is Pishawar. In Peshawar 114,182 suspected cases were registered, 23,708 cases tested positive and 64 death were recorded. The outbreak has been contained with on average 5 cases being recorded daily in the last 4 days. See Figure I; below showing daily incidence of confirmed Dengue fever cases. # Daily incidence of confirmed cases of Dengue fever in Peshawat (14th October to 27th November 2017) Date Burden of disease 56% (995) of the cases are coming from Sarband (273), Sufaid (184), Tehkal Bala (176), University town (149), Pawakal (115) and Achini bala (98). 62 percent of the cases being admitted in the ward are male and are aged between the ages of 15 to 63 years Response to date The health cluster is supporting the province of KP through recruitment of one epidemiologist and four medical entomologists to provide technical support and mentoring of the provincial and district health staff. Other support included; training of clinicians on case management, training of surveillance officers on disease surveillance and training of medical entomologist on vector control. A five day campaign was conducted in late October in 14 Union Councils in Peshawar. This campaign led to drastic reduction in the daily incidence of Dengue fever.

2 Challenges; Water storage practices were poor. Covering the water holding containers are not being done. There is need to enforce proper water supply and proper storage practices. Environmental management of drainage system is not developed there is need to improve environmental management. Health staff of new affected areas is not properly trained and there is need to strengthen surveillance B. Funding for the Health Cluster The health cluster is supporting the government of Pakistan to respond to the humanitarian situation in line with the Humanitarian Response Plan (HRP) 2017 for Pakistan. The objective of the health component of Pakistan HRP is to contributes to SO1 and SO4 of the Pakistan HSP 2017 which reads as follows Strategic Objective 1; women, men, girls, boys, elderly and disabled persons in host and return areas have enhanced access to essential life-saving health services aimed at reducing avoidable morbidity and mortality in the targeted areas of return and displacement Strategic Objective 2 to Strengthen the capacity of Government health officials in FATA and KP to develop multi-hazard preparedness and response plans to predict, prepare for, respond to and manage emerging public health threats and risks posed due to diseases and/or natural and man-made disasters Target population 1.2 million people in FATA and KP. Total requirement in 2017 is USD million. As of 14th November 2017, 13.5 million have been mobilized to support health response (1.3 million was mobilized through Pakistan Humanitarian Pool Fund (PHPF) and 12.2 million by WFP). Note that they are 25 active health cluster partners in Pakistan. C. Assessments findings Vulnerability Assessment in FATA This assessment was conducted by UNOCHA with financial support from World Bank and technical support from the various clusters. Preliminary report of the Vulnerability Assessment in Federal Administered Tribal Areas (FATA) and Frontier Regions (FR) has been released. This assessment was conducted in August and September The overall goal of the Vulnerability Assessment is to ensure that the transition from humanitarian to development in FATA is seamless and is cognizant to the vulnerabilities of the people of FATA. The objective of the assessment is to identify actionable information to use in the prioritization, design and budgeting of urgent and time sensitive interventions in 2018 only. Four distinctive thematic areas were covered in the assessment. The areas are; Basic service delivery, Livelihood and inclusive growth, Social capital, governance and security and Resilient recovery households were interviewed during this assessment. Below is a brief highlight of the findings from the health perspective; Access to community health services was 3% in FATA and 16% in Frontier Regions (FR) Access to Basic Health Unit (BHU) was 36% FATA and 36% in FR Access to Maternal and Child Health unit was 0% in both FATA and FR The average distance travelled by the population wto the nearest health facility was 7Km for FATA and 19.3 Km for FR. Regarding responders perception of quality of health care services, most of the responders rated quality of health services being provided as poor (FATA only 23% rated the quality of health services as good and in FR 21%. Of the ladies who had a child in the last three years only 6% in FATA and 16% in FR seek medical care 4 times during pregnancy. 59% of the women in FATA and 19% of the women in FR delivered their last child at home 70% of the women in FATA and 69% of the Women in FR had their children immunized after delivery 69% of the women in FATA and 59% of the women in FR said that their children have been vaccinated under routine EPI activities 2 Pakistan Health Cluster Bulletin # 1

3 11% of the household in FATA and 22% of the household in FR said that they have ever been visited by Lady Health Worker in the last three months 44% of the households in FATA and 45% of the household in FR did not get the prescribed medicine when they last visited the nearest heath centre (the medication was not there or they could not afford the price). D. Community involvement in elimination of Dengue Highlights On 18th of October, 2017 a provincial event for House to House Elimination of Dengue was held in town hall 3 in Peshawar Khyber Pakhtunkhuwa. The event was attended by the DG Health Provincial Government, DCO, Representatives of WHO Provincial & Country Offices, Water and Sanitation Department, KP Health Department, UNICEF, Red Cross Society of Pakistan and LHWs. The event was followed by the official launch by the Provincial Health Department, KPK in collaboration and partnership with the WHO and UNICEF for the largest-ever community based larval source identification and elimination campaign in 14 highest-endemic Union Counsels of Peshawar; During the campaign more than 190,000 households in various union councils of Peshawar were sprayed with thermal fog. Larval breeding site identification and elimination was also conducted in 90,000 households. A clear decline in dengue has been observed in the month of November 2017 with only 10 confirmed cases of Dengue fever registered by 20th November 2017 as compared to 139 cases registered on 18th October Findings The field experience during the campaign clearly highlighted the following communication gaps that need to be addressed for ensuring an effective community participation and response for the fight against Dengue: Poverty, poor living conditions of the people in slum areas; Non availability of running water in most of the visited UCs requiring household water storage. Storing water without covering is the main source of dengue larval growth in the households; Lack of general awareness on health related issues; People are not properly familiar with Dengue larvae which are considered water insects; Old beliefs - because of lack of awareness people are not receptive to the idea of larva being the cause of a dangerous disease; Lack of education is the biggest barrier which compromises the efforts made by many sectors such as health, education and sanitation. Addressing the Gaps To fill these gaps "Education over information" is the utmost need of the hour. Government is doing its best to come out of this epidemic, but, participation of masses is equally important for the success of Dengue control interventions. Healthy environment requires equal participation and is a collective responsibility of the policy makers, implementers and the community. Participation from every sphere of life and every relevant sector such as health, education, water & sanitation, environment is the only way to create healthy, clean and safe way of living. Lady Health Workers, as the front warriors for this door to door campaign, must be well facilitated, catered and trained to provide health education to the community for prevention and readiness on Dengue and other diseases. The focus is to ensure that people are educated and well aware of the potential danger of Dengue with stress on prevention and preparedness to counter any future outbreaks. E. UNICEF Contribution to HSP 2017 During 2017, UNICEF support focused on provision of health services to returning families in FATA by revitalizing and strengthening the Government s primary healthcare systems including Mother and Child Health (MNCH) and reproductive health services. UNICEF s strategic approach to leverage Government resources and strengthen health systems resulted in good progress. UNICEF supported the Mother and Child

4 Days and community based MNCH interventions, in partnership with FATA Health Directorate & civil society, and benefitting a population of 400,000 in KP & FATA. The low cost high impact intervention package included antenatal care, deworming of 2 to 5 year children, identification and vaccination of defaulter children (children not vaccinated or missing vaccination routine immunization), multiple micro-nutrient supplementation for children (aged 06 to 59 months), social mobilization and health education and provision of life saving commodities (clean delivery kits, new-born kits). Through MNCH interventions, 8,428 women were provided with ANC, and 4,316 pregnant women benefitted from clean delivery kits, and 4,284 were supplied with newborn kits. In addition to support for rebuilding health facilities in FATA, UNICEF and partner's supported provision of lifesaving services to 8,428 women and 326,348 children. UNICEF also focused on building capacity on disaster risk management to enhance communities and governments' understanding on disaster risk reduction. In total, 40 health care providers were trained on Community Based Disaster Risk Management (CBDRM) in FATA and 15 male & female Master Trainers trained in Gilgit Baltistan. Furthermore, to address limited neonatal service delivery in FATA two Sick New-born units were established in Kurrum and Bajaur agencies in Government s existing health facilities. These units provide high quality and timely services to sick newborns in addition to fulfilling critical equipment gaps. UNICEF s support to Government and NGO partners resulted in vaccination of 326,348 children for measles. UNICEF provided 8600 long lasting insecticide treated nets in response to dengue outbreak. IEC material i.e, posters, brochures and 1000 banners were provided by UNICEF. F. UNFPA Contribution to HSP 2017 UNFPA in collaboration with FATA Health Directorate, the project is delivering critical lifesaving maternal and reproductive health information and services and strengthen the protective environment to women, men, boys and girls in three agencies, Kurram, Orakzai and Khybar through the application of Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Crises under PHPF and Denmark funding. MISP, a sphere Deliveries by THQs standard, is a set of priority activities to be implemented in emergency situations with the goal of reducing maternal mortalities, morbidities and disabilities. 100 UNFPA through its partner, FATA Health is providing health 29 facilities with basic family planning, and emergency obstetric care, in three districts of FATA covering 4 health facilities with female health providers. In Kurram, three, Orakzai two and Khyber two health facilities are being May June July August Alizai September Sadda October supported with human resources, supplies, medical equipment to deliver life-saving sexual and reproductive health services to returnees and host communities. Under PHPF funding, in Kurram only, in total 19,944 have been reached, out of which 19,421 were women and 523 were men who received sexual and reproductive health services. Moreover, 758 births were attended by skilled health workers; 2,221 clean delivery kits; 1,428 new born baby kits were distributed, 7,671 women and 361 men were also reached through various awareness raising activities regarding reproductive health issues including family planning. During August 2017, Psycho social support services were also delivered to women and girls amongst FATA returnees through establishing three WHFS and strengthening four health facilities in Khyber and Orakzai. Psycho-social support, legal, protection and RH related services to vulnerable women and adolescent girls comprised the main interventions. During this period, 430 women and 85 adolescent girls accessed WHFS for various multisectoral services; 345 women received psychosocial support, 357 women were referred to and facilitated from WFHS for specialized RH services. Awareness rising sessions on women protection concerns, birth spacing and health related issues reached 1,723 women and 139 men. 4,222 women received various medical treatment; 235 women received hygiene kits, and whereas 24 women were trained on MISP Pakistan Health Cluster Bulletin # 1

5 Minimum Initial Service Package (MISP) for Reproductive Health in Humanitarian Settings, for the FATA staffs was conducted. A total out of 24 participants from various backgrounds agreed to move forward with the mainstreaming of MISP in contingency and preparedness plans of the province by inclusion of minimum SRH and GBV actions in emergencies. Clinical management of rape survivors (CMRS) training was conducted for the health staff of health facilities in three agencies. Out of 25 participants only 3 of the participants were not health Practitioners while 22 were practicing health staff from government and non-government facilities.