Weekly Epidemiological Bulletin Flood Response in Pakistan Volume 1, Issue 21 Monday 10 January 2011 Highlights Epidemiological week no 1 (31 Dec 2010 to 6 Jan 2011) Between 31 Dec 2010 to 6 Jan 2011 (epidemiological week no. 1, 2011), 57 districts in 4 provinces provided surveillance data to the DEWS system. 2,159 fixed health and 11 mobile medical outreach centres provided surveillance data for this week. A total of 603,266 consultations were reported through DEWS of which 32% were acute respiratory infections (ARI), 8% skin disease, 6% acute diarrhoea, and 6% were suspected Malaria. Total 22 alerts in past two weeks were received and responded: 9 were for Measles, 4 for suspected Influenza, 3 for Meningitis, 2 for diphtheria, while 1 each for Neonatal Tetanus, Pertussis, Pneumonia and Viral Hemorrhagic Fever. There were no case of confirmed poliomyelitis reported this week from any area of flood affected district. Note: All presented data are based on the number of patient consultations and include information on priority diseases under surveillance as well as major health events reported through DEWS. Priority diseases under surveillance in the flood affected areas Acute Flaccid Paralysis (AFP) Acute Jaundice Syndrome (AJS) Acute Respiratory Infections (ARI) Acute Watery Diarrhoea/ (AWD) Suspected Cholera Bloody Diarrhoea (BD) Acute Diarrhoea (AD) Suspected Hemorrhagic Fever (VHF) Suspected Malaria (Mal) Suspected Measles (Ms) Suspected Meningitis (Mg) Others Figure-1: Weekly trend of leading priority diseases in flood affected districts of Pakistan, 29 July to 30 December 2010 (Epi week 31, 2010 to week 1, 2011) Table-1: Priority diseases reported during the week 45-52, 2010 Diseases Wk 46 Wk 47 Wk 48 Wk 49 Wk 50 Wk 51 Skin Disease 23,784 (8%) 29,056 (8%) 38,022 (9%) 40,533 (8%) 35,686 (8%) 42,813 (8%) Wk 52 41,434 (8%) Wk 1 50,529 (8%) ARI (URI and LRI) 79,391 (28%) 98,719 (27%) 126,265 (29%) 156,168 (30%) 132,185 (30%) 166,801 (31%) 157,965 (31%) 190,913 (32%) Acute Diarrhoea 20,138 (7%) 27,007 (7%) 34,377 (8%) 33,188 (6%) 27,989 (6%) 37,100 (7%) 32,931 (6%) 36,470 (6%) Bloody Diarrhoea 2,578 (1%) 3,422 (1%) 2,972 (1%) 3,943 (1%) 3,098 (1%) 3,925 (1%) 3,074 (1%) 3,902 (1%) Suspected Malaria 21,726 (8%) 27,198 (7%) 30,633 (7%) 31,780 (6%) 27,111 (6%) 35,266 (6%) 25,791 (5%) 34,862 (6%) Total consultation 280,676 364,543 428,159 522,284 444,112 544,147 509,488 603,266 01
Fig-2: Weekly number of reporting health units (Week 33-2010 to week 1-2011) Table-2: Leading causes of seeking health care in the flood affected districts, 29 July 2010 to 6 January 2011 Diseases Total Skin Diseases 1,606,107 (13%) Acute Respiratory Infection 2,714,016 (22%) Acute Diarrhoea 1,324,520 (11%) Bloody Diarrhoea 128,863 (1%) Suspected Malaria 717,447 (6%) Unexplained Fever 567,064 (5%) Total Consultations 12,458,458 Figure-3: Leading causes of seeking health care in the flood affected districts by province, 29 July 2010 to 6 January 2011 Number of cases 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000-884,455 927,126 557,863 380,403 145,780 537,482 1,034 837,654 435,600 34,080 397,538 76,401 133,229 785,171 248,471 164,065 130,177 103,874 70,255 82,586 50,941 29,453 22,404 21,975 Punjab Sindh Khyber Pakhtunkhwa Balochistan Skin Ds. ARI AD UF S. Mal BD Figure-4: Acute Diarrhea trends, Disaster affected districts, Pakistan 2009 and 2010 Since July 29, 2010, a total of 1,324,520 acute diarrhea patient consultations have been reported to DEWS from the flood affected districts of 4 provinces in Pakistan. In the graph at right, DEWS reports received in 2010 are compared to the reports of 2009 from disaster affected districts. This week, DEWS received 36,470 reports of acute diarrhea, 6% of total consultations. This is the same proportional morbidity reported by DEWS in January 2010 and slightly lower than in January 2009. Percentage 20 18 16 14 12 10 8 6 4 2 0 2009 2010 2011 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epi-week Figure-5: Acute Respiratory Infection trends, Disaster affected districts, Pakistan 2009 and 2010 Since July 29, 2010, approximately 2,714,016 Acute Respiratory Infection patient consultations have been reported to DEWS from the flood affected districts of 4 provinces in Pakistan. In the graph In the graph at right, DEWS reports received in 2010 are compared to the reports of 2009 from disaster affected districts. This week, DEWS received 190,913 reports of acute diarrhea, 32% of total consultations. This is the same proportional morbidity reported by DEWS in January 2010 and in January 2009. Percentage 40 35 30 25 20 15 10 5 0 2009 2010 2011 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 Epi week 02
Table-3: Alerts reported in week 52-2010 and week 1-2011. Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes 24-Dec-10 Diphtheria KP Lakki Marwat Lady Reading Hospital (UC Baraam Khel) 8 F Probable diphtheria case was found. Contacts treated prophylactically with antibiotics. Phase 2 mass immunization campaign is underway to cover the affected area. 27-Dec-10 Diphtheria KP D.I. Khan Lady Reading Hospital (Kotjai - Paharpur) 12 M Probable diphtheria case was found. Field investigation located 3 contacts 8y, 4y, and 2.5 y. All samples were negative for diphtheria. Contacts treated prophylactically with antibiotics. Further investigation about vaccination coverage in the area is ongoing. 24-Dec-10 Measles KP Swabi BKMC (Panjpir Village) 3 M Upon field investigation 1 suspected case was found. Sample was negative for Measles. Active surveillance found no new cases. 28-30 Dec 2010 Measles KP Lower Dir DHQ Timergara (UC Toor Mang), BHU Toormang (Siar Village) 9, 4 M, F Upon field investigation 2 suspected cases, one positive, were found in area missed by vaccination campaign one month ago. Two doses vit A megadose 24 h apart treatment for cases; scattered population now planned to be vaccinated by outreach vaccinator in UC Toor Mang and mop up campaign in Siar Village. 31-Dec-10 Measles KP Swat THQ Matta 2, 5 M, M 2 suspected case were reported from the health facility. 1 sample was positive for Measles. Active surveillance was done. No more cases found. 31-Dec-10 Measles Sindh Jacobabad RHC Mirpur (UC Ranjhapur) 3, 2.5, 6, 1.5 M, F, M, M Upon field investigation 9 suspected Measles cases were found. 4 Sample were collected and all found positive for Measles. Phase 2 measles campaign has started. 1-Jan-11 Measles Sindh Jamshoro JSB Bank IDPs Camp - Sehwan 3.5, 4, 6, 6, 2.5 M, M, F, F, M Upon field investigation 7 suspected cases were found and sampled. Two doses vit A megadose 24 h apart treatment for cases; Area had been missed during vaccination campaign. 650 children vaccinated as mop up response.. 3-Jan-11 Measles KP Swat CH Barikot 6 M Upon field investigation 1 suspected case was found. Sample was collected and sent to NIH. Active surveillance is ongoing. 4-Jan-11 Measles Punjab Multan UC Durana (Zikryia Town - Gulshan Mehar) Cases: 3, 3, 3, 4, 1.5, 4, 3, 4.5, 4, 2, 2, 6, 4; Deaths: 2, 6, 6, 6, 1, 2.5, 4.5 Cases: F, M, F, M, F, M, F, M, F, M, M, M, M; Deaths, M, M, M, M, F, F Upon field investigation, suspected measles 13 cases plus 7 deaths were found. Further 3 deaths under 1m age and serious malnutrition. 5 Blood samples sent to NIH. Medical camp was established; eligible children vaccinated against Measles; two doses vit A megadose 24 h apart treatment for cases; Hygiene kits and other medicines were distributed. Active surveillance and monitoring is on going. 4-Jan-11 Measles KP Nowshera Jalozai IDP Camp VI - Merlin Health Post 3 F Upon field investigation 1 suspected case was found. Sample was collected and sent to NIH. Active surveillance is on going. 7-Jan-11 Measles Sindh Ghotki MCH Center (UC Bhand - Jeewan Kolachi VIllage) 1.5 F Upon field investigation 1 suspected case was found. Sample was collected and sent to NIH. Active surveillance is on going. 24 to 30 Dec, 2010 H1N1 (2009) KP Swabi Kalal Village, Kota Village, Kala Village; Gajai Village, UC Panjpir; UC Gabasni; BHU Chaknodah; Minirin Payan; Chota Lahore 24, 41, 50, 19, 6, 4, 35, 4, 19, 18 M, F, F, F, F, F, F, F, M, M 15 Suspected cases were found with typical flu like symptoms. 12 out of 15 samples tested at NIH were positive for H1N1 (2009). These cases were hospitalized and received oseltamivir. 28-Dec-10 H1N1 (2009) Sindh Sukkur Anwar Paracha Teaching Hospital 20 F Suspected case was found with typical flu like symptoms. Sample tested at NIH showed positive H1N1 (2009). Patient hospitalized and treated with oseltamivir. 1-Jan-11 H1N1 (2009) KP Peshawar KTH (Koocha Kaghaz Kataan - Gunj) 22 M Suspected case was found with typical flu like symptoms. Sample tested at NIH found positive for H1N1 (2009). Patient hospitalized and treated with oseltamivir. 4-Jan-11 H1N1 (2009) KP Swabi BKMC (Zakria Payan Village & Miniri Bala Village); UC Zaida; Parmoli Village 18, 40, 65, 10 M, F, M, F 4 Suspected cases were found with typical flu like symptoms. Samples tested at NIH and reported positive for H1N1 (2009). 29-Dec-10 Meningitis Sindh Ghotki Asha Centre (Sachal Ghoto Village) 7 M Upon field investigation 1 suspected case was found. Active surveillance revealed cases positive for malaria. 29-Dec-10 Meningitis Sindh Qambar Shahdadkot UC Bago Dero (CMC Hospital - Larkana) ** M Upon field investigation 1 suspected case was found. Active surveillance is under process. 30-Dec-10 Meningitis KP Mardan Spogmay Hospital (Hatam Kallay Kotlamey) ** M Upon field investigation 1 suspected case was found. Sample was negative for Meningitis. Active surveillance was done. 31-Dec-10 NNT Sindh Ghotki UC Hussain Beli (Murad Ghoto Village) 7d M 1 suspected case was reported from the health facility. Upon field investigation patient was found in serious condition. TIG was provided by WHO but patient expired due to complications. Further analysis of public health issues is under process. 31-Dec-10 Pertussis Sindh Ghotki UC Bago Daho (Vasti Inayat Shah) 4, 6, 11 F, F, F Active surveillance was conducted and 3 suspected cases were found during field investigation. 1 Sample was collected but found negative for pertussis. 30-Dec-10 Pneumonia Balochistan Sibi DHQ Sibi ** M,M,M,M, F, F Cluster of six deaths presumed due to ARI were reported among infants at a health facility but upon active surveillance patients' families could not be traced out due to lack of information 5-Jan-11 VHF Punjab Muzaffargarh UC Muradabad (Nishtar Hospital-Multan) 35 M Sample was declared positive for DF by Nishtar Hospital, Multan. Appropriate clinical case management at hospital and vector control at community level was instituted. Table-5: List of confirmed Polio Cases from flood affected districts, week 1-2011 There were no case of confirmed poliomyelitis reported this week from any area of flood affected districts. Altogether, polio program has reported a total of 140 confirmed wild polio cases and one death in year 2010. 03
Province Khyber Pakhtunkhwa This week 14 districts reported to DEWS from KP province, 459 health centers reported 105,151 patients consultations to DEWS. ARI is the leading disease in KP province reported 48,093 (46%) 1% higher than last week. Eleven alerts were received and investigated this week; 5 alerts were for Suspected Measles, 3 were for Influenza, and 2 were for probable Diphtheria, while 1 for suspected Meningitis. Figure-6: Trend of priority communicable diseases, province KP (31-July 2010 to 6 January 2011) Diseases Wk-50 Wk-51 Wk-52 Wk-1 Skin Diseases 4,847 (4%) 4,538 (3%) 4,875 (4%) 3,647 (3%) ARI (URI and LRI) 45,234 (39%) 54,654 (42%) 50,120 (45%) 48,093 (46%) Acute Diarrhea 7,904 (7%) 7,822 (6%) 6,850 (6%) 5,981 (6%) Bloody Diarrhea 941 (1%) 911 (1%) 729 (1%) 656 (1%) Suspected Malaria 2,401 (2%) 2,118 (2%) 2,002 (2%) 1,382 (1%) Total consultations 116,054 132,341 112,888 105,151 Province Punjab 11 districts reported data to DEWS from Punjab province 779 fixed health centers and 3 mobile medical outreach centers reported a total of 175,275 patients consultations were reported during this reporting period ARI reported 37,922 (22%) 1% higher than last week. Two alerts were received and responded this week. 1 each for suspected Measles, and Viral Hemorrhagic fever. High number of Malaria cases were reported from flood affected districts. This week a total of 4,064 malaria samples were tested of which 141 were positive (slide positivity rate 3.46%), while falciparum rate was 54.6%. Figure-7: Trend of priority communicable diseases, province Punjab (3 August 2010 to 6 January 2011) Diseases Wk-50 Wk-51 Wk-52 Wk-53 Skin Diseases 13,491 (10%) 16,341 (10%) 17,489 (9%) 15,486 (9%) ARI (URI and LRI) 30,854 (23%) 39,456 (24%) 39,921 (21%) 37,922 (22%) Acute Diarrhea 7,272 (5%) 13,295 (8%) 12,345 (6%) 11,378 (6%) Suspected Malaria 5,437 (4%) 8,473 (5%) 7,265 (4%) 5,160 (3%) Total consultations 135,438 166,799 192,119 175,275 04
Province Sindh This week 21 districts reported to DEWS from Sindh province 608 health centers were reported to DEWS this week A total of 264,631 patient consultations were reported during the reporting period of week 1, 2011. In Sindh, ARI reported 83,766 (32%) remains the same percentage as compared with last week Eight alerts were received and responded this week; 3 were for suspected Measles, 2 for Suspected Meningitis, while 1 each for Neonatal Tetanus, Pertussis, and Influenza Figure-8: Trend of priority communicable diseases, province Sindh (6 August 2010 to 6 January 2011) Diseases Wk-50 Wk-51 Wk-52 Wk-1 Skin Diseases 14,629 (10%) 19,121 (10%) 15,473 (10%) 27,627 (10%) ARI (URI and LRI) 42,351 (29%) 55,771 (29%) 48,288 (32%) 83,766 (32%) Acute Diarrhea 8,641 (6%) 11,604 (6%) 9,394 (6%) 14,974 (6%) Bloody Diarrhea 1,034 (1%) 1,417 (1%) 933 (1%) 1,423 (1%) Suspected Malaria 14,271 (10%) 18,348 (10%) 11,332 (8%) 22,769 (9%) Total consultations 145,293 191,328 150,594 264,631 Province Balochistan In this week, 11 districts reported to DEWS from Balochistan province. 313 fixed and 8 mobile medical outreach centers reported to DEWS A total of 58,209 patient consultations were reported during the reporting period of week 1, 2011. In Balochistan, 21,132 (36%), remains the same as compared with last week. One alert of Pneumonia was received and responded this week. High number of Malaria cases were reported from different areas of Jaffarabad and Kech districts. A total of 659 malaria samples were tested of which 204 were positive (slide positivity rate 30.9%). Falciparum Rate was 60.2%. Figure-9: Trend of priority communicable diseases, province Balochistan (6 August 2010 to 6 January 2011) Diseases Wk-50 Wk-51 Wk-52 Wk-1 Skin Diseases 2,719 (6%) 2,813 (5%) 3,597 (7%) 3,769 (6%) ARI (URI and LRI) 13,746 (29%) 16,920 (32%) 19,636 (36%) 21,132 (36%) Acute Diarrhea 4,172 (9%) 4,379 (8%) 4,342 (8%) 4,137 (7%) Bloody Diarrhea 1,100 (2%) 1,597 (3%) 1,394 (3%) 1,823 (3%) Suspected Malaria 5,002 (11%) 6,327 (12%) 5,192 (10%) 5,551 (10%) Total consultations 47,327 53,679 53,887 58,209 05
Focus on: Vitamin A and Measles Measles is the greatest cause of vaccine-preventable death in the world, and every child should receive two doses of measles vaccine before age two. If a child develops measles disease, vitamin A can reduce the risk of dying from pneumonia. Most people only need one measles vaccination to protect them for a lifetime but about 5 percent to 15 percent of the population don't respond and need a second vaccination to protect them. Vitamin A deficiency puts unvaccinated or under-vaccinated children at higher risk for measles. In turn, measles can contribute to acute vitamin A deficiency. Vitamin A is found in foods like fish oils, liver, butter and egg yolk. Although vitamin A deficiency is often thought to be dietary, Vitamin A deficiency could also be due to inadequate absorption through malfunctions in our bodily system or loss of vitamin A due to infections or diarrhea. A systematic study of vitamin A for treating measles in children in 2005 considered eight trials encompassing 2,574 participants age 15 and under. The review concluded that two mega-doses of vitamin A given on consecutive days reduce the risk of dying from measles for children under age 2 years. Pneumonia was the most common cause of death in children with measles in the four studies that specified cause. Pooling data from studies that used two doses of vitamin A, the reviewers found: 67 percent reduction of mortality from pneumonia (429 hospitalized children), 41 percent reduction of post-measles croup (722 children studied), and 65 percent lower risk of developing diarrhea (474 children). Conclusion: Every measles case should receive two doses of vitamin A given on consecutive days. It is life saving. REFERENCE: Huiming Y, et al. Vitamin A for treating measles in children. (Review). The Cochrane Database of Systematic Reviews 2005, Issue 4, from Health Behavior News Service http://www.docguide.com/news/content.nsf/news/8525697700573e18852570a8006c4039: Influenza Update On 10 August 2010, WHO announced that the world is now in the post-pandemic period, but based on knowledge about past pandemics, the H1N1 (2009) virus is expected to continue to circulate as a seasonal virus for some years to come. While the level of concern is now greatly diminished, vigilance on the part of national health authorities remains important. Surveillance is currently focused on detecting any notable changes in the severity or other epidemiological or clinical characteristics of the H1N1 2009 virus, including changes in the age distribution, the clinical appearance, proportion of cases requiring intensive management, or unexpected increases in numbers of cases are detected. In December 2010, most of the confirmed cases of influenza H1N1(2009) were outpatients detected during routine surveillance of influenza-like illness in sentinel sites. Due to the cost of the test and the new focus of surveillance, most samples are now taken from hospitalized patients or high risk patients. Further investigations are pending regarding the severity of the cases. All persons with influenza like illness and serious disease should start oseltamivir twice daily as early as possible, within the guidance of their physician. The objective of this weekly epidemiological bulletin is to provide a snap shot on selected health events reported from the communities affected by the current flood in Pakistan. While every attempt is made to present the weekly trend of the epidemic prone diseases, the information presented in the bulletin needs to be interpreted in the context that precise information on the reference populations is not always available, The bulletin also includes information collected by DEWS teams established during earlier emergencies, including 2005 earthquake, 2007 floods and 2008 ID crises. The primary focus of DEWS is the early detection of epidemic prone diseases, to facilitate a rapid public health response. We would like to thank all the numerous national and international partners who have contributed to the Disease Early Warning System. 06
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