Weekly Morbidity and Mortality Report (WMMR) IDP Hosting s, NWFP, Pakistan Week # 37 (5-11 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 37, 29, no new alerts/outbreak reported from any area of IDPs hosting districts, NWFP. During this week, 224 health facilities reported 72,437 patients consultations through the DEWS network Acute Diarrhoea reported in 6,275 (9%) of the total consultations in all age groups, Diarrhoea accounts for 17% 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 17,229 consultations (24% of total consultations) in the IDP hosting districts of NWFP. In children less than 5 years of age, ARI accounts for 5,59 (31%) of the total consultations in the age group. Nineteen DEWS sites reported; 498 Ante Natal visits, 5 pregnancy and delivery related referrals, 678 consultations for chronic non-communicable diseases and 26 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
1. Alert and outbreak investigations and response: During the epidemiological week 37 (5 to 11 Sep 29) no new alerts/outbreak reported from any area of IDP s hosting districts, NWFP. The situation of AWD outbreak in Swat is improving Acute Watery Diarrhea Swat update: Acute Diarrhoea is a common health cause of consultation during this season in district Swat but on 27 th and 28 th August, 29, an increase in the daily number of Acute Diarrhoea cases noticed in the casualty department of the Saidu Group of Teaching hospital in Swat. The DEWS team conducted field investigation and found that majority of the patients are coming from Mingora, Saidu Sharif, Manglawar, Shagai, Spalbandai and Slamapur and few other places in the surroundings of Saidu Sharif and Mingora city. From the investigation it was suspected as an AWD outbreak and interventions initiated. The hospital data reveals that from 23 rd August to 14 September a total of 5492 patients with Diarrhoea have been attended at the hospital. Out of the total, 255 patient had mild diarrhea and treated with ORS, 2987 patients were either kept under observation and treated in the hospital ward for a short time or admitted for rehydration with I/V fluids. Three patient (2 children and 1 adult) deaths due to Acute Diarrhoea were also reported at the hospital (CFR.1%) 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 Tehsil Municipal Administration (TMA) Swat. Hygiene kits have supplied in the affected population by health cluster partners. 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 and conflict affected districts of NWFP from week 34 to 37, 29 Week 34 Week 35 Week 36 Week 37 Consultations Consultations Consultations Consultations Buner 1-3,599 1 932 5,25 8-5,857 8-6,83 Charsadda 44 355 6,818 49 21 7,864 46 4 6,474 44 332 7,52 Mardan 53 1,2 27,39 55 758 22,852 54 635 27,69 57 675 24,62 Nowshera 37 1,591 8,92 43 6,169 8,758 42 6,7 7,431 37 7,49 8,333 Peshawar 57 2,929 12,372 64 2,13 14,745 6 2,152 11,186 51 2,135 9,4 Swabi 6-937 5-278 24-3,46 24-4,869 Swat - - - - - - - - - 3-1,52 Total 27 15,75 59,685 226 1,19 59,72 234 9,887 61,63 224 1,191 62,246 During the week 37, 29, total 224 sites shared the weekly DEWS reports on due time. A total of 72,437 patient consultations have been reported in this week reflecting an increase of consultations by 1,487 (2%) as compared to the previous week. Out of the total reported consultations, 41,662 (58%) patient visits were reported for females and 3,775 (42%) for male patients. During this week 16,397 (23%) of the total consultations were reported in children less than 5 years age. Sixteen DEWS sites reported; 498 Ante Natal visits, 5 pregnancy and delivery related referrals, 678 consultations for chronic non-communicable diseases and 26 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 34 to 37, 29 IDP camp Consultations Week 34 Week 35 Week 36 Week 37 Buner Karapa - 932 - - Charsadda Palosa 355 21 4 332 Mardan Jalala 12 758 635 675 Nowshera Benazir Complex 295 36 137 274 Jalozai 1, 2, 3, 4 1296 589 6563 6775 Peshawar Kacha Garhi 1 & 2 3929 213 2152 2135 Total 1675 119 9887 1191 3. Morbidity pattern of the seven most common communicable diseases in the IDP hosting districts and conflict affected districts of NWFP, during week 37 of 29: Figure 1: Pattern of the seven most common communicable diseases reported in the 5 IDP hosting districts, and the conflict affected districts Buner and Swat, in NWFP as number of consultations during week 37, 29 Number of consultations 5 45 4 35 3 25 2 15 1 5 UR TI LR TI AD SCB UF MAL BD Mardan Nowshera Peshawar Charsadda Buner Swabi Swat 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 and conflict affected districts of NWFP. During the epidemiological week 37 of 29; Upper Respiratory Tract Infection (URTI) was reported as the most common disease (19%) 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 7 districts (Figure 1). Acute Diarrhoea (AD) was the second common disease (9%) 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, Lower Respiratory tract Infection (5%) and Un-explained fever (4%). Suspected Malaria was reported in 1,895 (3%) of the cases of the total consultations and compared to the other IDP hosting districts Mardan, reports more cases of suspected Malaria; Bloody Diarrhoea was reported in 877 (1%) patients with higher number of cases from district Mardan and Nowshera. As district Mardan is still hosting a 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 37 of 29 Figure 2: Pattern of five most common communicable diseases in the IDP camps NWFP, week 37, 29 4 35 URTI LRTI AD SCB MAL UF BD Number of consultations 3 25 2 15 1 5 Jalozai -3 Jalozai -4 Jalozai -2 Jalozai -1 KG-II KG-I Jalala Palosa B.Complex During week 37, health facilities in most of the IDP camps (except Jalozai-1) reported URTI as the leading cause and acute diarrhea as the second common cause of consultations. In Jalozai 1 health facility in the camp Acute Diarrhoea is the leading cause of consultation. The situation is being investigated and control measures are being taken. 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 37 of 29: Number of cases per 1 consultations 35 3 25 2 15 1 5 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 26 27 28 29 3 31 32 33 34 35 36 37 1 2 3 4 5 6 7 8 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 4 weeks URTI is showing an increasing trend, similarly a slight increase in LRTI has been noticed during the last week. 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. 6. Weekly morbidity pattern of Acute Diarrhea and LRTI among <5yrs population of IDP hosting districts of NWFP from week 1 to week 37 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 11 th September) 29 Number of cases per 1 consultations 3 25 2 15 1 5 9 1 11 12 13 14 15 16 17 18 19 2 21 22 23 24 25 26 27 28 29 3 31 32 33 34 35 36 37 1 2 3 4 5 6 7 8 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 37, a total of 16,397 consultations reported in the children Under Five years age, out of those, 2,82 (17%) consultations were for Acute Diarrhea and 917 (6%) 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; consultations for AD is showing a slight increase during the last 2 weeks while LRTI reflecting a more steady trend in the recent weeks with a slight increase in the last week 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 37, 29 WHO team is regularly engaged in controlling the AWD outbreak in Swat, Water sample were collected from the main unprotected sources in different part of the affected area, where health education sessions, and distribution of aqua tabs in the community is in progress with TMA, Youth front Swat, UNICEF & Malakand Development Program. WHO provided 1 units of hand washing soap & 25 sets of water disinfection leaflets & hand washing awareness poster & Banners to the Health promoter s team in Swat. The Distribution plans implemented in week 37 are: WHO EH team is coordinating with WASH cluster in mobilizing the resources for affective intervention including strengthening of the Tehsil Municipal administration for improvement of the water supply system and AWD control interventions. The WASH cluster provided.8 million water purification tablets. WHO is identifying the clusters AWD case for more targeted intervention approach. WHO EH team monitored the water treatment process in Jalala & Jalozai IDP camps where all the samples were found within.2-.5 ppm limit.
WHO EH team is following up the AWD alerts from Jalozai, intensive health education activities are in progress in phase 2, Phase 3, phase 4 with Merlin health promoters team, WHO provided 6 soap units, and health education material, refresher training on chlorination to the tube well operators, and water sampling from the sources and ice used in the camp. All of the ice samples tested were found contaminated and as a remedy the chlorine dozing have been increased to counter any contamination. WHO EH provided one complete health education kit to HDOD working in Palosa 1 IDP camp for the health education campaign. Manual chlorination is still continuing in Palosa 1 camp with residual chlorine level is in the range of WHO standards limits. WHO EH team conducted a briefing session with sanitary workers & health promoters in Palosa 1 camp on hand washing, and diarrhea control measures in the camp. In coordination with UN Habitat WHO Tested 15 water samples for bacteriological analysis, in which 11 water samples are from hand pumps in Union council Katlang, 4 water samples are from Tarakai region of Swabi. Results were shared with UN-Habitat for further action on the contaminated hand pumps. For a proposed training of provincial water authorities both managers and plant operators, WHO shared the concept paper with WATSAN Cell LGRDD for nomination of participants. Peshawar Development authority has provided nominees for training on water quality monitoring and testing, to the WHO Peshawar office. WHO is facilitating to arrange the training in collaboration with PCRWR before the renovation work of provincial water testing lab completed. During the epidemiological week 37, a total of 31 water samples were tested for biological contamination and 17 samples for residual Chlorine from the five IDP hosting districts 11 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 tested Water sample fit for drinking Water samples unfit for drinking No % No % Mardan 11 9 82% 2 18 Action Taken UN-Habitat has been requested to dysfunctional the contaminated hand pumps. Swabi 4 4 1% - - Swat 7 1 14% 6 86 Nowshera 9 6 66% 3 34 Aqua-Tabs distribution for household water disinfection and health education sessions in progress Chlorine dozing has been increased and regular health education sessions with community 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 No % Charsadda 2 2 1% Mardan 6 6 1% Action Taken Nowshera 9 4 45% Chlorine dozing increased at source and regularly by WHO team
9. Number of reporting/non-reporting Health Facilities by type and department (Week 37, 29): During the Epidemiological week 37, 29, 224 (63%) of all the assigned DEWS reporting sites reported to the system, reflecting a decrease in the weekly reporting units as compared to the previous week. 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 and Swat are being received through the health partners who have started services in the district. The DEWS network now extended to district Swat also. Table 5: DEWS reporting by type of facility, IDP hosting districts NWFP for week 37, 29 Number of DEWS Reporting Health Department Health Facility Implemented Health Percentage Facilities Facilities PPHI BHU 215 139 65 % RHC 28 16 57 % DHQ 4 2 5 % Dept. Of Health THQ 1 % IDP s 2 9 45 % Mobile, CD and CH 88 58 66 % Total 356 224 63% 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. Sixteen DEWS sites reported 498 Ante Natal visits, 5 pregnancy and delivery related referrals, 678 consultations for chronic non-communicable diseases and 26 injuries. The information on Maternal Health Care and <5 children nutrition surveillance by each district during week 37, 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 - 75 75-4 4-29 29 Charsadda 2 1 3 - - - - - - Mardan 2 382 42 - - - - - - Nowshera - - - - - - - - - Peshawar - 18 18-1 1 - - - Swabi - - - - - - - - - Total 22 476 498-5 5-29 29 Total