Flood Response in Pakistan

Weekly Epidemiological Bulletin Flood Response in Pakistan Volume 1, Issue 8 onday 10 October 2010 Highlights Epidemiological week no 40 (2-8 October 2010) Between 2-8 October 2010 (epidemiological week no. 40), 48 of the 78 flood-affected districts provided surveillance data to the DEWS system. Of these 48 districts, 90% reported -7 days of the week. 55 fixed health and 153 mobile medical outreach centers provided surveillance data for this week. 32,071 consultations were reported through DEWS of which 20% were acute respiratory infections (ARI), 12% were acute diarrhoea, 13% were skin disease, and 8% were suspected malaria. 42 alerts were received and responded to this week: 2 alerts were for acute watery diarrhoea (, Suspected Cholera), 9 were for Viral Hemorrhagic Fever, 4 were for Acute Flaccid Paralysis (AFP, Suspected Poliomyelitis), 2 were for easles and 1 was for Bloody Diarrhoea. Ongoing malaria surveillance in collaboration with the alaria Control Program identified districts with higher than usual malaria transmission rates during peak Falciparum season. Districts Layyah, Rajanpur, DG Khan and uzaffargarh in ; Jacobabad, Larkana, Thatta and Khairpur in Sindh; Naseerabad, Sibi, Zhob and Jhal agsi in Balochistan. Seven of the 10 cases of poliomyelitis confirmed this week were from the flood-affected districts 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 alaria Suspected easles Suspected eningitis Unexplained Fever Others Figure-1: Weekly trend of leading diseases in flood affected districts of Pakistan, 29-July to 8 October 2010 (Epi week 31-40, 2010) Table-1: Priority diseases reported during the week 31-40, 2010 (29 July - 8 October 2010) Week 31 Week 32 Week 33 Week 34 Week 35 Week 3 Week 37 Week 38 Week 39 Week 40 Acute Diarrhea 25,89 (13%) 94,288 (11%) 182,548 (14%) 199,07 (14%) 138,44(13%) 8,909 (12%) 57,072 (14%) 4,925 (13%) 54,404 (13%) 37,24 (12%) Bloody Diarrhea 1,449 (1%) 4,5 (1%) 7,907 (1%) 11,024 (1%) 10,839 (1%) 9,228 (2%),705 (2%),411 (1%) 5,89 (1%) 5,253 (2%) ARI (URTI & LRTI) 25,335 (13%) 92,134 (11%) 185,54 (15%) 217,071 (15%) 187,22(18%) 9,07 (17%) 9,99 (17%) 89,949 (18%) 81,583 (19%) 5,21 (20%) Suspected alaria 3,954 (2%) 17,348 (2%) 27,453 (2%) 45,542 (3%) 45,52 (4%) 40,441 (7%) 32,92 (8%) 42,759 (9%) 3,514 (8%) 25,25 (8%) Skin 3,383 (19%) 115,080 (14%) 24,959 (20%) 29,441 (21%) 202,30(19%) 92,039 (1%) 5,844 (14%) 0,704 (12%) 57,020 (13%) 41,4 (13%) Total consultation 194,552 845,353 1,25,912 1,424,20 1,053,827 559,00 414,437 48,37 433,890 32,071 01

Epidemiological Bulletin: Flood Response in Pakistan Figure-2: Average number of reporting units (fixed and mobile health facilities) by province Table 2: Average number of reporting districts per week Province Week 33 Week 34 Week 35 Week 3 Week 37 Week 38 Week 39 Balochistan 8 8 8 8 8 8 8 9 9 9 10 11 Sindh 18 18 18 18 18 18 18 Total 40 40 41 41 41 40 41 Week 40 5 15 11 17 48 Figure-3: Frequency of reported districts (Week 40, 2010) 4 districts have DEWS in place and 48 districts reported to DEWS this week; 5 in Balochistan, 15 in, 11 in and 17 in Sindh. Not all districts are reporting regularly. The average number of districts and health facilities reporting per week are shown in the table 2 and figure 2 above. Almost 90% of reporting districts reported 7 times during the last reporting period, 7% reported between 3 5 times, 3% reported 1 2 times. Figure-4: of fixed and mobile reporting units by province (Week 40, 2010) 02

Table-3: Follow-up alerts reported in week 39, 2010. Epidemiological Bulletin: Flood Response in Pakistan Weeks Date of alert Alert Province District Location (detailed) Age (yr) Sex Action taken / Notes 2010 39 25 Sep 10 UXF Lower Dir DHQ Timergara ** ** 2010 39 2 Sep 10 D.I. Khan Wanda Balochan 22 F 2010 39 27 Sep 10 Sind atiari alakhra Ground Camp (Bhit Shah), Shah jo Bagh Relief Camp (Bhit Shah) ** ** 2010 39 27 Sep 10 DHF Abbottabad Ayub Teaching Hospital ** ** 2010 39 28 Sep 10 Buner DHQ Daggar (Kandao Patiy Village) 8,8, Table-4: Alerts and Outbreaks (Week 40, 2010) Weeks Date of alert Alert Province District Location (detailed) Age (yr) Sex Team examined 1700 people; no DF, DHF or CCHF identified in area related to this report. Stool sample collected and was found negative. Active surveillance was done. Stool sample was negative. Public health response in place with TA, PPHI, LHWs. Tragic death of medical doctor confirmed due to CCHF. 14 contacts tested negative for both CCHF and Dengue. DF and DHF detailed below. 2 Stool samples were positive for V. Cholera Ogawa. Public health response in place. 2010 39 28 Sep 10 D.I. Khan DHQ D.I.Khan (Lakhra Village) 1.5 Stool sample was negative. Public health response in place. 2010 39 28 Sep 10 Lower Dir RHC unda (Kambat Samar Bagh) 30 F 2010 39 28 Sep 10 DHF x 3 Shangla SGTH (Kotlai, Kokrai, Chakesar) 5,75,35 2010 39 28 Sep 10 DHF x 2 L.Dir, Haripur 2010 39 28 Sep 10 BD x 4 uzaffargarh KTH (Lower Dir), (Polytechnic Colony Haripur) DHQ uzaffargarh (Wasendey Wali), (Basti Korewali), (Basti Karimabad Tibba), (Zakrya Colony),F, 24, 20 F, 9, 2, 50, 8 2010 39 30 Sep 10 easles Bhakkar BHU Dhandla 4 2010 39 1 Oct 10 Tank DHQ Tank (Kot Azam) 1 F,,, Stool sample was positive for V. Cholera Ogawa. Public health response in place. Suspected cases were found, blood samples were taken. 2 out of 3 were positive for Dengue. Lower Dir case positive for DF, Haripur case negative for DF. Active surveillance continuing. Stool samples were negative for pathogens. Active surveillance was done in four villages and no further cases were found. Blood sample was found negative. No further cases were found on active surveillance. Stool sample negative. Active surveillance was done and no further cases were found. Action taken / Notes DHF x 5 Haripur Ayub Teaching Hospital, Abbotabad: cases from New Afzal ohalla, Saeed und ohalla, Afghan Camp, Pind Hashim Khan, Harimehra all Haripur District 55, 35, 0, 27, 20 F, F,,, F Blood samples in order: positive, negative, negative, positive, positive. Active surveillance ongoing. AFP Layyah Basti Khokaran Vali 4.5 Stool samples collected, tests under process, active surveillance ongoing. uzaffargarh DHQ uzaffargarh (Sharif Shajra P.O) 50 Stool sample under process. Active surveillance ongoing. BD Bhakkar Lari Adda 55 Stool sample negative; active surveillance uncovered no further cases. 3 Oct 10 ultan THQ Shujabad 12 F Stool sample under process. Active surveillance ongoing. 4 Oct 10 easles ultan Rasheed Hospital Private 4,,F Blood sample was collected and tests are under process 4 Oct 10 Sind Jacobabad DHQ Jacobabad (UC Dashti) 35 F Stool sample was collected and tests are under process 4 Oct 10 x 5 ardan Oct 10 x 4 DHF Sind uzaffargarh DHQ ardan (Toot Kaley, Guli Bagh, Kochian, Sikandari, Janday Takhtbhai) DTC SF Kot Addu, Village Gourmani, Rojewala; Village Kita Lonwala; Pul 88, Kot Addu; Village Sheikh Umah 4m, 1m, 0y, m, 45y 19, 20, 9m, 7,F, F,F,F F, F,, Cases admitted to DTC, stool samples collected; tests are under process. Hygiene sessions were conducted, EDO H was informed. 4 Oct 10 easles Swabi Bacha Khan edical Complex 2.5 F Blood sample was collected and tests are under process 4 Oct 10 AFP x 3 Bhakkar DHQ Bhakkar 17m, m, 12m F,F, Stool samples collected, tests under process, active surveillance ongoing Australian edical Camp (Nigad Abad, Stool samples were collected and tests are under process. Teams in the 4 Oct 10 x 2 uzaffargarh 32, 2, Chah Langar Wala) field. Stool sample was collected and tests are under process. Active surveillance RHC unda (Ganderey ayar, Gambir 5 Oct 10 x 2 Lower Dir 40, 4, carried out, health education was given and IEC material was provided. DTC ayar) health staff, hygiene promotors were trained on case management. 5 Oct 10 D.I. Khan adina Colony 5 F Stool sample was collected and tests are under process Three serious cases admitted to DTC, recovered with intravenous rehydration. 5 Oct 10 Sind Badin CH Badin ** ** Blood sample positive for DF. Patient in hospital, health education messages were given. Active surveillance ongoing. Oct 10 DHF Swat SGTH (Gharib Abad Kabal) 1 Oct 10 D.I. Khan Chah Faqir Wala 25 F Stool sample was collected and tests are under process,, 3 cases tested at private labs and found positive. WHO and DG PH establishing DF task force with collaboration of alaria control program. Oct 10 DHF Sind Hyderabad Bin Tayyab Private Hospital 12,7,22 Oct 10 uzaffargarh DTC SF Kot Addu Oct 10 uzaffargarh DTC SF Kot Addu, Village Sinawan Patient treated at DTC. Alert received on Oct. EDO H/ DEWS team in field Oct 10 uzaffargarh DTC SF Kot Addu, Village Rakhpattan 37 F to investigate and respond. Oct 10 uzaffargarh DTC SF Kot Addu 25, 8, 10, 4, 8m, 1y, F,,,,, 4 positive Ogawa patients treated at DTC. Alert on Oct. EDO H/ DEWS 3 positive Ogawa patients treated at DTC. Alert on Oct. EDO H/ DEWS 3 positive Ogawa patients treated at DTC. Alert on Oct. EDO H/ DEWS 9, 7 2.5 8m,, team in field to investigate and respond. team in field to investigate and respond. team in field to investigate and respond. Patients treated at DTC. Alert received on Oct. EDO H/ DEWS team in field to investigate and respond. Swat THQ atta ** ** Stool sample collected and active surveillance is under progress for the two UCs. Hyderabad Foresight Relief Camp ** ** Death confirmed as chronic patient of TB further aggravated due to diarrhoea. Swat SGTH (ian Bela) ** ** Blood sample collected and active surveillance is under progress. DHF Haripur uhalla Syed Abad ** ** Blood sample collected and active surveillance is under progress. 03

Province 15 out of 17 flood affected districts reported to DEWS from province 47 fixed health centers and 17 mobile medical outreach centers reported to DEWS 59,482 patient consultations were reported during the reporting period of 2 8 October, week 40, 2010 20 alerts were received and investigated this week; 11 were for, 8 were for suspected DHF, and 1 was for suspected easles. Regarding Dengue Fever (DF) and Degue Hemorrhagic Fever (DHF), from early September up until 9th October 2010, DEWS teams have identified 137 suspected cases of DF, including 55 cases of suspected DHF, in the districts Haripur, ansehra and Abbotabad. Of the suspected cases, 97 were male and 40 were female, none were under five years old and five cases were between 5 and 15 years old. During this time, there were nine cinfirmed deaths of cases with fever and hemorrhagic signs but only one was confirmed positive for DF. Epidemiological Bulletin: Flood Response in Pakistan Figure-5: Trend of priority communicable diseases, province (31-July - 8 October 2010) Figure-: Proportional morbidity of priority diseases, province % of total consultations Acute Diarrhoea 4,520 8% ARI 10,074 17% Skin 2,738 5% others 39,853 7% Total Consultations 59,482 Province 11 out of 12 flood affected districts reported data to DEWS from province 187 fixed health centers and 3 mobile medical outreach centers reported to DEWS 111,5 patient consultations were reported during this reporting period 18 alerts were received and investigated this week; 12 were for, 1 was for BD, 1 was for suspected easles, and 4 were for AFP. Ten cases were confirmed positive for Vibrio cholera Ogawa in uzaffarabad District and treated successfully at the DTC while teams are in the field to assess and improve the water and sanitation situation. Four districts with highest levels of malaria in are Layyah, Rajanpur, DG Khan and uzaffargarh. Figure-7: Trend of priority communicable diseases, province (3 August - 8 October 2010) Figure-8: Proportional morbidity of priority diseases, province % of total consultations Acute Diarrhoea 13,29 12% ARI 21,439 19% Skin 15,87 14% Suspected malaria 9,785 9% Others 37,9 34% Total consultations 111,5 04

Province Sindh 17 out of 22 flood affected districts reported to DEWS from Province Sindh 390 fixed health centers and 9 mobile medical outreach centers reported to DEWS 13,129 patient consultations were reported during the reporting period of 2-8 October, week 40, 2010 4 alerts were received and investigated this week; 3 were for and one was for VHF. 15 cases of suspected DF were identifiedby DEWS teams in Hyderabad district; 14 were male and 1 was female; 12 were tested DF positive; none were ubder age five years. Jacobabad, Larkana, Thatta and Khairpur districts are experiencing peak Falciparum malaria season. Epidemiological Bulletin: Flood Response in Pakistan Figure-9: Trend of priority communicable diseases, province Sindh ( August - 8 October 2010) Figure-10: Proportional morbidity of priority diseases, Sindh % of total consultations Acute Diarrhoea 1,850 12% ARI 30,79 23% Skin 23,050 17% Suspected malaria 11,918 9% Others 3,448 27% Total consultations 13,129 Province Balochistan 5 out of 19 flood-affected districts reported to DEWS from province Balochistan 31 fixed health centers and 4 mobile medical outreach centers reported to DEWS 18,795 patient consultations were reported during the reporting period of 2-8 October, week 39, 2010 No alerts were received from Balochistan but malaria-endemic districts were reporting un usual seasonal peaks of falciparum malaria in Naseerabad and Sibi while Jhal agsi had high levels of vivax malaria. Zhob is experiencing a unusually high slide positive rate of 52% with mostly falciparum confirmed cases. Figure-11: Trend of priority communicable diseases, province Balochistan ( August - 8 October 2010) Figure-12: Proportional morbidity of priority diseases, Balochistan % of total consultations Acute Diarrhoea 2,985 1% ARI 3,024 1% Suspected alaria 3,171 17% Unexplained Fever 1,093 % Total consultations 18,795 05

Epidemiological Bulletin: Flood Response in Pakistan Table-5: List of confirmed Polio Cases from flood affected districts since 19 September 2010 S. NO. Province Districts SEX AGE (m) Date onset of Paralysis WPV Type 1 Swabi F 9 19/09/2010 NSL1 2 Sindh Ghotki F 42 20/09/2010 NSL1 3 Lakki arwat 12 20/09/2010 NSL1 4 Sindh Khairpur F 18 21/09/2010 NSL1 5 Kohat F 18 21/09/2010 NSL1 ianwali 3 21/09/2010 NSL1 7 Sindh Sukkur F 3 2/09/2010 NSL1 Summary of Health Event in Flood affected districts Since July 29, 2010, approximately 7,035,83 patient consultations have been reported to DEWS from the flood affected provinces in Pakistan. DEWS is currently in place in 4 (82%) of the 78 flood affected districts and reporting is received from 48 (75%) of these 4 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, ARI decreased from 19% to 12% also AD continues to decline, however, it remains proportionally higher compared to the corresponding reporting period from 2009. (Please see Fig.13) In, a higher proportion of suspected malaria was reported this week (9% to 10%), although a peak of malaria in October reflects seasonal trend of diseases, DEWS officers are collaborating with alaria Control Program to investigate areas of increased malaria. Figure-13: AD trends,, 2009 and 2010 Percentage 20 1 12 8 4 0 Weekly pattern of acute diarrhea, IDP crisis and hosting districts, Khayber Pakhtunkhwa (2009 2010) 2009 2010 1 4 7 10 13 1 19 22 25 28 31 34 37 40 43 4 49 52 Epi week Figure-14: alerts and confirmed cholera cases since July 29, 2010 In Sindh, proportional morbidity of major health events remained the same when compared to last week. In Balochistan, reporting remains irregular due to security issues. Suspected malaria continues to make up the largest proportion of consultations. WHO expert team has gone to Balochistan and will conduct outbreak investigation for malaria in collaboration with alaria Control Program. Focus on: alaria Every year Pakistan records about 4.5 million suspected cases of malaria and has evidence of about 1. million confirmed cases. September and October are the months for high transmission of Falciparum alaria, but out of 47 flood affected districts which are endemic for malaria, only nine are experiencing unusually high numbers of confirmed falciparum malaria cases. These districts are Layyah and Rajanpur in ; Jacobabad, Larkana, Thatta, and Khairpur in Sindh; and Naseerabad, Sibi, and Zhob in Balochistan. At the same time, DG Khan, uzaffargarh and Jhal agsi are still showing considerable number of vivax malaria cases. DEWS Teams are collaborating with alaria Control Dept and other partners to identify the malaria hot spots and bring a rapid response with medicines and appropriate vector control strategy. Preparation for malaria season started with distribution of anti malarial medicines in each of the emergency health kits deployed in flood affected districts. Provincial alaria Control Programs undertook indoor residual spraying as a vector control strategy in flood affected districts. WHO sent Rapid Diagnostic Tests (RDT) to the provinces to confirm cases of suspected malaria who were distant from microscopy centers. Supplies of primaquine tablets were distributed to areas with high vivax transmission while additional tabs of ACT SP were distributed to provinces with high numbers of falciparum cases. WHO, UNICEF, and UNHCR have distributed bed nets to the hotspots to increase coverage and protection of the population. 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. 0

Alerts of Acute watery diarrhoea (31 July to 7 October 2010) 07