ly Epidemiological Bulletin Flood Response in Pakistan Volume 1, Issue 10 Monday 25 October 2010 Highlights Epidemiological week no (16-22 October 2010) Between 16-22 October 2010 (epidemiological week no. ), 50 out of 64 districts in 4 provinces provided surveillance data to the DEWS system. 509 fixed health and 105 mobile medical outreach centres provided surveillance data for this week. 257,980 consultations were reported through DEWS of which 18% were acute respiratory infections (), 9% were acute diarrhoea, 11% were skin disease, and 11% were suspected malaria. 21 alerts were received and responded to this week: 12 alerts were for Dengue Hemorrhagic Fever (DHF), 7 were for Diphtheria, and 2 for Acute Watery Diarrhoea (AWD). Four of the 9 cases of poliomyelitis confirmed this week were from the flood-affected districts Emergency conditions exist for over,000 people in Dadu District of Sindh who are stranded without food or shelter on bits of land surrounded by water. AWD alert was received on 23 October of 50 year old male with diarrhea and serious dehydration in Tent City Kakar at Dadu. 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 Acute Jaundice Syndrome Acute Respiratory Infections Acute Watery Diarrhoea/ Suspected Cholera Bloody Diarrhoea Other Diarrhoea Suspected Hemorrhagic Fever Suspected Malaria Suspected Measles Suspected Meningitis Unexplained Fever Figure-1: ly trend of leading diseases in flood affected districts of Pakistan, 29 July to 22 October 2010 (Epi week 31 -, 2010) Percentage 25 20 15 10 5 0 Wk 31 Wk 32 Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk BD Table-1: Priority diseases reported during the week 31 -, 2010 (29 July - 22 October 2010) Wk 31 Wk 32 Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Skin Disease,3(19%) 115,080(14%) 247,88(20%) 296,4(21%) 202,922(19%) 92,210(16%) 56,982(14%) 61,845(12%) 57,977(13%),325(13%),966(11%) 27,522(11%) (URI and LRI) 25,3(13%) 92,1(11%) 186,808(15%) 217,071(15%) 187,623(18%) 97,2(17%) 70,6(17%) 93,291(19%) 83,8(19%) 67,045(20%) 58,464(19%) 46,015(18%) Acute Diarrhoea 25,689(13%) 94,286(11%) 183,118(14%) 199,916(13%) 1,1(13%) 69,900(12%) 57,1(14%) 67,156(13%) 57,954(13%),925(12%) 30,6(10%) 23,3(9%) Bloody Diarrhoea 1,449(1%) 4,566(1%) 8,019(1%) 11,024(1%) 10,847(1%) 9,274(2%) 6,766(2%) 6,493(1%) 5,907(1%) 5,262(2%) 4,4(1%) 3,2(1%) Suspected Malaria 3,954(2%) 17,8(2%) 27,503(2%) 45,5(3%) 45,717(4%),483(7%) 32,795(8%) 43,121(9%),531(8%) 25,719(8%) 24,825(8%) 27,956(11%) Total consultation 194,551 845,3 1,270,525 1,2,503 1,056,106 563,6 7,643 502,282 444,948 3,690 313,9 257,980 01
Figure-2: ly average number of fixed and mobile reporting units by province ( -, 2010) Khyber Pakhtunkhwa Sindh 50 50 43 43 50 87 30 18 24 21 17 14 14 46 52 55 48 47 47 115 129 316 8 229 644 1 245 1 120 448 468 504 464 96 0 81 310 64 227 Balochistan Punjab 11 10 11 11 4 4 6 23 23 22 6 27 4 31 5 5 185 185 228 278 6 496 160 1 271 215 46 45 28 22 164 176 187 192 197 Table-2: DTCs functioning with WHO and health partners support Province Targeted Districts Functioning Handed Over In Progress KPK 16 21 7 0 Punjab 8 12 2 1 Balochistan Sindh (Sukkur) Sindh (Hyderabad) Gilgit Baltistan Remarks 7 handed over to MS Hospital for pediatric pneumonia patients 2 handed over to MS Hospital, 1 in progress 7 10 0 3 3 were started on 25th October 7 10 0 0-5 3 0 2 1 will be started on 26th October 2 2 0 0 - Total 45 58 9 6 - Table-3: Leading causes of seeking health care in the flood affected districts as of 22 Oct 2010 Total Skin 1,271,5 (17%) Acute Respiratory Infection 1,225,4 (16%) Acute Diarrhoea 987,728 (13%) Bloody Diarrhoea 77,279 (1%) Suspected Malaria 1,494 (5%) Unexplained Fever 1,686 (5%) Total Consultations 7,622,4 Figure-4: Leading causes of seeking health care in the flood affected districts by province, 29 July to 22 October 2010 of cases 800,000 700,000 600,000 500,000 0,000 300,000 200,000 100,000-743,905 610,107 458,609 6,809 58,3 9,062 844 4,855 3,6 254,078 63,6 18,0 56,786 46,570 12,4 2 3 19,52 9,519-6,821 9,229 3,780 02 129,045 18 6,8 9 3 14 9,9 0 7 Punjab Sindh Khyber Pakhtunkhwa Balochistan UF BD
Table-4: Follow-up alerts reported in week, 2010. s Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes 2010 9 Oct 10 DHF KPK Mansehra Khaki, UC Julla,65, M,M, F 2010 10 Oct 10 AWD Punjab Muzaffargarh Australian Medical Team (KAPCO Wapda Office) 5 M 2010 10 Oct 10 DHF KPK Charsadda Harichand Bangla (IPD Malakand) 18 F 2010 10 Oct 10 Measles KPK Nowshera Jalozai Phase V 5 M 2010 11 Oct 10 DHF KPK Swat Mangarkot Charbagh 18 M 2010 12 Oct 10 AWD KPK Nowshera Jalozai Phase III Pabbi 3,5,10 2010 12 Oct 10 DHF KPK Swat Sersenai Village Kabal 55 F M,F, M 2 out of 3 Blood samples were positive for DF, bed nets were provided, health education given, Active surveillance was done Stool sample was positive for V. Cholera Ogawa. Active surveillance was done. Blood sample was negative for DF. Active surveillance was done. Patient was isolated. Blood sample was positive for measles, child was guest in camp. Active surveillance was done. No other cases were found in the camp Blood sample was negative for DF. Active surveillance was done. Patient was isolated. WHO, Merlin & DoH combined response is planned. EDO Health was informed. Stool sample collected and found positive for V. Cholera Ogawa, active surveillance was done. Health education session conducted, soaps and aqua tabs were distributed. Blood sample was negative for DF. Patient was isolated, ITNs were given and health education was provided. Medical camp was established and active surveillance was done. 2010 12 Oct 10 BD Punjab Muzaffargarh Australian Medical Team (Basti Ghurki) 18 M Stool sample collected and found negative, active surveillance was done. 2010 13 10 10 AWD Punjab Muzaffargarh Australian Medical Team (Kot Addu) 25 F Alert was reported and investigated by Australian medical team. 2010 13 10 10 Malaria Punjab Muzaffargarh Australian Medical Team (KAPCO) ** ** 2010 14 10 10 DHF KPK Swat Shahdam Kaley 13 M 2010 14 10 10 AWD KPK Mardan Rashakai 5 M Table-5: Alerts and Outbreaks (, 2010) 87 blood samples were tested by Australian Medical Team and 23 were found positive for Falciparum, 31 for Vivax, cases were treated, community was prioritized for bed nets distribution. Blood sample was negative for DF, active surveillance was done. Patient is isolated, ITNs were given and health education was provided. Stool sample was positive for V. Cholera Ogawa. Active surveillance was done. s Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes 2010 17 10 10 DHFx3 Punjab 2010 17 10 10 DHFx2 Punjab Sheikh Zaid Hospital Swaitra Basti, Sadiqabad, Allama Iqbal Town, Stadium Road Sheikh Zaid Hospital Kot Faiz, Ghotki, Mouza Ahsanpur 25,20, 30 M,M, F 12, 22 M, M Blood samples were sent to IPH Lahore and were found positive for DF, active surveillance was done. Blood samples were sent to IPH Lahore and were found negative for DF, active surveillance was done. 2010 17 10 10 DHF KPK Swat Banr Charbagh M Blood sample was found positive for DF, active surveillance was done. 2010 19 10 10 AWD Sindh Ghotki DTC Ghotki Malook Kolachi 2010 20 10 10 AWD Balochistan 10, 3,10m Washuk DHQ Washuk ** ** F,F,F Stool samples collected and active surveillance is under progress. About 100 cases of acute diarrhea and 2 deaths confirmed. Investigation revealed that source of water was contaminated Karez (irrigation canal). ORS, intravenous fluids and medicines provided to patients. Household water purification by aqua tabs established. No further cases reported 2010 20 10 10 DHF Punjab Sheikh Zaid Hospital Bela 30 M Blood sample was found positive for DF at Sheikh Zaid Hospital. 2010 20 10 10 DHF KPK Swat SGTH (UC Kuzabakhel) F Blood sample was found negative for DF, active surveillance was done. 2010 21 10 10 DHF Punjab Sheikh Zaid Hospital Adda Fatehpur Punjabian 2010 21 10 10 DHF Sindh Ghotki UC Qadir Pur ** ** 2010 21 10 10 DHF Sindh Khairpur Jeelani Mohalla ** ** 2010 22 10 10 Diph KPK Peshawar KTH (Bajour) 4 M 2010 22 10 10 Diph KPK Peshawar Lady Reading Hospital (Charsadda) 7 M 2010 22 10 10 Diph KPK Peshawar KTH (Karak) 3,3,7 2010 22 10 10 Diph KPK Peshawar KTH (Lakki Marwat), LRH, Peshawar 10,6,2.5 M,M, M 2010 22 10 10 Diph KPK Peshawar KTH (South Waziristan) 3 M 2010 22 10 10 Diph KPK Peshawar Lady Reading Hospital (Upper Dir) 7 M 20 M Investigations are under process at Sheikh Zaid Hospital. F,M, M Blood samples collected and sent to NIH, active surveillance is under process Blood samples collected and sent to NIH, active surveillance is under process Death of patient with probable diphtheria, residential details are not known. Patient with probable diphtheria discharged from Lady Reading Hospital. Lost to followup 3 cases probable diphtheria, 1 death, investigation and response continuing in Karak 2 deaths probable diphtheria, residential details unknown Probable diphtheria case, discharged from KTH. Residential details unknown Probable diphtheria case, discharged from LRH. Residential details unknown 2010 22 10 10 DHF Punjab Lahore Wapda Hospital 50 F Blood sample was found negative for DF, active surveillance was done. Table-6: List of confirmed Polio Cases from flood affected districts, week -2010 S. NO. Province Districts SEX AGE (m) Date onset of Paralysis WPV Type 1 KPK Nowshera Female 54 25 09 2010 NSL1 2 Sindh Kashmore Male 28 09 2010 NSL1 3 Sindh Ghotki Male 8 29 09 2010 NSL1 4 Sindh Sanghar Female 96 06 10 2010 NSL1 03
Province KPK This week 14 out of 24 flood affected districts reported to DEWS from KPK province 47 fixed health centers and 14 mobile medical outreach centers reported to DEWS 51,175 patient consultations were reported during the reporting period of 16 22 October, week, 2010 8 alerts were received and investigated this week; 6 were for Diphtheria while 2 were for Dengue Hemorrhagic Fever. Regarding Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF), from early September up until 15th October 2010, DEWS teams have identified 311 suspected cases of DF in the districts Haripur, Mansehra and Abbotabad. Of the suspected cases, 87 were confirmed for DF, 100 were negative for DF and 124 are pending. During this time, there were nine confirmed deaths of suspected DHF. There were five confirmed cases of CCHF including one death. % of total consultations Acute Diarrhoea 2,0 5% 7,772 15% Figure-5: Trend of priority communicable diseases, province KPK (31-July - 22 October 2010) Figure-6: Proportional morbidity of priority diseases, KPK province 5% 2% 15% 4% Skin 1,999 4%,885 74% Total Consultations 51,175 Province Punjab 11 out of 11 flood affected districts reported data to DEWS from Punjab province 197 fixed health centers and 22 mobile medical outreach centers reported to DEWS 103,588 patient consultations were reported during this reporting period 8 alerts were received and investigated this week; all were for Dengue Fever, 7 alerts were reported from districts while 1 alert was received from Lahore city. In Punjab, a higher proportion of suspected malaria was reported again this week (11% to 13%), although a peak of malaria in October reflects seasonal trend of diseases, DEWS officers are collaborating with Malaria Control Program to investigate areas of increased malaria, providing rapid diagnostic test and appropriate medicines. % of total consultations Acute Diarrhoea 9,447 9% 74% Figure-7: Trend of priority communicable diseases, province Punjab (3 August - 22 October 2010) Figure-8: Proportional morbidity of priority diseases, Punjab province UF 3% 9% 13% 20,3 20% Skin 11,673 11% Suspected malaria 13,447 13% 44% 20%,1 % Total consultations 103,588 11% 04
Province Sindh 17 out of 17 flood affected districts reported to DEWS from Province Sindh 227 fixed health centers and 64 mobile medical outreach centers reported to DEWS 77,547 patient consultations were reported during the reporting period of 16-22 October, week, 2010 In Sindh, proportional morbidity of major health events remained the same when compared to last week. 3 alerts were received and responded this week; 2 for Dengue Fever and 1 alert was for Acute Watery Diarrhoea A Dengue surveillance and response cell has been established in Hyderabad to address increasing numbers of cases of Dengue Fever. Province Balochistan % of total consultations Acute Diarrhoea 8,479 11% 13,070 17% Skin 11,554 15% Suspected malaria 9,888 13% 25,944 % Total consultations 77,547 8 out of 12 flood-affected districts reported to DEWS from province Balochistan fixed health centers and 5 mobile medical outreach centers reported to DEWS 25,670 patient consultations were reported during the reporting period of 16-22 October, week, 2010 1 alert of Acute Watery Diarrhoea was received and responded this week Certain hot spots are still experiencing higher than usual levels of malaria cases. Malaria outbreaks in districts Naseerabad, Sibi, Zhob and Jhal Magsi are being addressed in collaboration with the Malaria Control Program. Figure-9: Trend of priority communicable diseases, province Sindh (6 August - 15 October 2010) Figure-10: Proportional morbidity of priority diseases, Sindh % BD 3% 15% 11% 13% 17% Figure-11: Trend of priority communicable diseases, province Balochistan (6 August - 15 October 2010) Figure-12: Proportional morbidity of priority diseases, Balochistan % of total consultations UF 4% BD 2% 12% Acute Diarrhoea 3,079 12% 15% 4,8 19% Suspected Malaria 3,794 15% % Unexplained Fever 1,150 4% Total consultations 25,670 05 9% 19%
Summary of Health Event in Flood affected districts Since July 29, 2010, approximately 7,622,4 patient consultations have been reported to DEWS from the flood affected provinces in Pakistan. DEWS is currently in place in 64 (82%) of the 78 flood affected districts and reporting is received from 50 (78%) of these 64 districts. The major causes for seeking healthcare by the affected communities continue to be diarrheal diseases, acute respiratory infections, skin diseases and suspected malaria. In KPK, increased from 12% to 14% also continues to decline, however, it remains proportionally higher compared to the corresponding reporting period from 2009. (Please see Fig.13) Figure-13: trends, KPK, 2009 and 2010 Percentage 20 16 12 8 4 0 ly pattern of acute diarrhea, IDP crises and hosting districts, Khyber Pakhtunkhwa (2009 2010) 1 4 7 10 13 16 19 22 25 28 31 43 46 49 52 Epi week 2009 2010 Focus on: Dengue Fever and Dengue Hemorrhagic Fever So far about 4,3 cases of suspected Dengue Fever (DF) have been reported in Pakistan with about 2,062 confirmed cases and 15 deaths. As Dengue Fever cases are on the rise in many places across the country, Pakistan joins % of the global community who are at risk for Dengue, the most widespread mosquito borne infection in human beings. The only way to prevent Dengue Fever is to prevent mosquito bites. Dengue is not spread by droplets or blood. Dengue mosquitoes bite during the daytime. To protect yourself wear full sleeve clothes and long trousers, avoid wearing black color, use repellents, use mosquito coils and electric vapor mats, use bednets for children and elderly who may rest in bed during the day. To control Dengue in the community, we must reduce the places where mosquitoes live and breed: drain out the water from all unused tanks, barrels, drums, and buckets and cover all stored water containers. Remove garbage piles where water collects in discarded containers. As 95% of Dengue Fever can be treated at home, when someone falls ill with a fever and headache, pain behind the eyes, or body aches and no other symptoms, the best advice is to rest at home in bed, take plenty of fluids like soup, water, milk and juice, and take paracetamol (Panadol, Calpol, etc) for pain. All dengue patients must be carefully observed for complications for at least 2 days after recovery from fever because life threatening complications often occur during this phase. Patients and households should be informed that severe abdominal pain, passage of black stools, bleeding into the skin or from the nose or gums, sweating, and cold skin are danger signs. If any of these signs is noticed, the patient should be taken to the hospital. Please use only paracetamol for pain and fever as other medicines may increase the bleeding tendency. At the hospital, the patient is monitored with frequent blood pressure readings, tests of hematocrit and platelets to determine when to give intravenous fluid and how much to give. Blood or platelets may need to be given if the patient is actively bleeding. The four WHO criteria for diagnosis of Dengue Hemorrhagic Fever, fever with headache or body aches; evidence of bleeding or positive tourniquet test; platelet count less than 100,000; and evidence of leaky capillaries such as >20% rise in hematocrit, have been found to be 62% sensitive and 92% specific for identification of dengue illness requiring intervention. Srikiatkhachorn A, et al. Dengue Hemorrhagic Fever: The Sensitivity and Specificity of the WHO Definition for Identification of Severe Cases of Dengue in Thailand, 1994 2005. Clinical Infectious 2010;50:11 1143 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
Alerts of Acute watery diarrhoea (31 July to 16 October 2010) 07