The WMMR is a publication that has been developed for emergencies and previously used in other areas such as the Darfur Crisis.

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Epidemiological Week N00 38 (16 - 22 Sept 2006) 27 Sept 06/ Vol. 44/ DEWS 2006-38

Muzaffarabad:

Picture by Chris Black

Reporting Units ...2

Total number of consultations ...2

DEWS Data, Epidemiological Week N0 38 2006...3

DEWS Data, Monthly Summary (Epidemiological Weeks N0 35-38) ...4

Acute Watery Diarrhoea ...5

Bloody Diarrhoea ...6

Acute Jaundice Syndrome...6

Malaria ...7

Measles ...7

Acute Respiratory Infection ...8

Other Reportable Diseases and Conditions ...8

Outbreak Alert and Response ...9

Number of reported cases and deaths per District, AJK ...10

Number of reported cases and deaths per District, NWFP ...11

The Weekly Morbidity and Mortality Report (WMMR) is published by the Ministry of Health of Pakistan (MOH) and the World Health Organization (WHO). The WMMR is built on surveillance data that health service providers and NGOs transmit on a weekly basis from health facilities and hospitals in those areas affected by the earthquake that struck Pakistan on 8 October 2005.

The WMMR objectives are to monitor the trend of health conditions over a period of time and provide vital information to all health partners. The WMMR is only a snapshot of the health conditions in those facilities where events are registered and data collected and does not necessarily reflect the situation from other health facilities.

The WMMR is a publication that has been developed for emergencies and previously used in other areas such as the Darfur Crisis.

ƒ In the past month (Epidemiological weeks 35-38 inclusive), 163,689 health events under surveillance were reported including 70 deaths

ƒ This week, there were 303 reporting units contributing to the report

ƒ In week 38, 99,135 consultations were reported, with 27 deaths

ƒ There was one death from acute watery diarrhoea reported from Muzaffarabad district

ƒ For only the second time since reporting began, there was only one case of measles reported

ƒ Malaria cases decreased by 14% over the number in week 37

The WMMR is published by the World Health Organization (WHO),

Health Emergency Operation Centre, House #6, Street #20, F-7/2, Islamabad, Pakistan For More Information, please contact:

Dorcas Taylor, Epidemiologist, WHO/EHA/Pakistan; taylord@eqpak.emro.who.int or

Dr. Birjees Mazher Kazi, Chief, Public Health Laboratories Division, NIH MOH; kazis@isb.paknet.com.pk or

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Reporting Units

The number of sites able to report in week 38 increased by 16 this week, from 287 to 303. One site has been added in Mansehra from the Kala Dhaka area: BHU Palosa. The total number of reporting sites is now 325. See Table 1 for summary statistics.

Table1. Reported heath facilities by district, Earthquake Affected Areas, Pakistan, 26 Aug - 22 Sept 2006.

Reporting Health Facilities 26 Aug – 1

Sept 2 – 8 Sept 9 – 15 Sept 16 – 22 Sept Area Population

Week 35 Week 36 Week 37 Week 38

Muzaffarabad 894,364 105 110 96 105

Bagh 452,532 32 33 33 34

Poonch 633,712 55 55 51 56

Mansehra / Balakot 1,154,804 67 66 67 68

Battagram / Shangla 592,256 38 39 40 40

Total 3,727,668 297 (92%) 303 (94%) 287 (88%) 303 (93%)

Total number of consultations

In this week 38, there was an increase in the number of reporting sites, and the number of consultations also increased to 99,135. The highest number of consultations by district was in Muzaffarabad, with 33,853, and the lowest was in Battagram, at 8,316. The average number of consultations per facility now stands at 333, increased from 319 in week 37 and 331 in week 36.

The maximum number of consultations in a facility was 7,279, in Muzaffarabad, and the minimum was 12, in Mansehra.

Reporting Units and Consultations

0 50 100 150 200 250 300

W42 W43 W44 W45 W46 W47 W48 W49 W50 W51 W52 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 Week

No. Unit

0 50000 100000 150000 200000 No. Consult.

Reporting Unit Consultation

Figure 1. Weekly trend of reporting units and total number of consultations, Earthquake Affected Areas, Pakistan, 15 October 2005 – 22 Sept 2006.

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DEWS Data, Epidemiological Week N0 38 2006

Between 16 to 22 Sept 2006, 99,135 consultations were reported through DEWS. Overall, 19%

(18,853) were due to Acute Respiratory Infections (ARI), 10% (9,483) due to Acute Watery Diarrhoea (AWD), 6% (6,027) due to Fever of Unknown Origin (FUO), and 5% (4,890) due to Injuries (INJ). ARI accounted for 24% and 17% of consultations in the less than 5 years old and 5 or more years old respectively. All other reportable conditions each represented less than 1% of the total consultations in week 38.

ARI 17%

FUO 6%

INJ 5%

OTH*

62%

AWD ARI 8%

24%

FUO 8%

INJ OTH* 4%

42%

AWD 15%

< 5yrs (n=24,469) ≥ 5yrs (n=74,666)

ARI 19%

FUO 6%

INJ 5%

OTH*

57%

AWD 10%

All Ages (n=99,135)

Figure 2. Proportion of primary causes for all reported cases, Earthquake Affected Areas, Pakistan, 16 - 22 Sept 2006.

*OTH includes all other reportable conditions, plus all other consultations for conditions not under surveillance

DEWS Data, Epidemiological Week N0 38, 2006: Consultations by age

AWD experienced an increase in the monsoon season, then a marked decrease since the end of the monsoon. The decrease has been greater in the under five age group, which saw a drop of 9 percentage point from the maximum of 24% of all consultations, to a current level of 15%. In patients five years and over, the maximum rate of AWD was 13.5%, and it has now decreased by approximately 6 percentage points to 7.7%. See figure 3.

0 5 10 15 20 25 30

27 28 29 30 31 32 33 34 35 36 37 38 Week

AWD as a percent of all consultations within age group

<5

>=5

Figure 3: Trend in AWD as a percent of all consultations within age groups, Earthquake Affected Areas, Pakistan 2 July, – 22 Sept 2006.

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DEWS Data, Monthly Summary (Epidemiological Weeks N0 35-38)

In the past four weeks, between 26 August to 22 September (Epidemiological weeks 35-38 inclusive), 163,689 consultations for health conditions under surveillance were reported, out of a total 354,228 consultations. 21% (73,256) of consultations were due to acute respiratory infection (ARI), 12% (42,273) acute watery diarrhoea (AWD), 7% (23,148) unexplained fever (FUO) and 5% (18,692) Injuries (INJ).

Table 2. Comparison of the weekly distribution of reported cases, deaths and monthly Case Fatality Rate (CFR), Earthquake Affected Areas, Pakistan, 26 Aug - 22 Sep 2006.

Week WEEK 35 WEEK 36 WEEK 37 WEEK 38 TOTAL

Event C D C D C D C D C D CFR%

AWD 12531 1 10752 1 9507 1 9483 1 42273 4 0.009

BD 798 0 603 0 654 1 662 0 2717 1 0.000

AFP 4 0 0 0 1 0 0 0 5 0 0.000

MAL 929 1 636 0 876 0 755 0 3196 1 0.000

ARI 17993 1 18385 5 18025 1 18853 2 73256 9 0.012

MES 7 0 7 0 10 0 1 0 25 0 0.000

MEN 6 1 3 0 7 0 6 0 22 1 0.000

JAU 99 0 69 0 86 0 101 1 355 1 0.000

TET 0 0 0 0 0 0 0 0 0 0 0.000

AHF 0 0 0 0 0 0 0 0 0 0 0.000

FUO 5755 0 5808 0 5558 0 6027 0 23148 0 0.000

INJ 4644 0 4615 2 4543 0 4890 0 18692 2 0.011

OTH 64199 10 62912 9 5071 9 58357 23 190539 51 0.027

TOTAL 106965 14 103790 17 44338 12 99135 27 354228 70

RU 297 303 287 303

C – Cases, D – Deaths, AWD - Acute Diarrhoea, BD - Bloody Diarrhoea, AFP - Acute Flaccid Paralysis, MAL – Malaria, ARI - Acute Respiratory Infection, MES – Measles, Men - Meningitis, JAU - Acute Jaundice Syndrome, TET - Neonatal Tetanus, AHF Acute Hemorrhagic Fever, FUO –Unexplained fever, INJ – Injuries, OTH – Others, RU – Reporting Units. Please note data from late reporting in previous weeks has been updated.

During the same reporting period, 96,036 consultations were reported in the less than 5 years old group, (27% of the total consultations), of which 24% (23,331) were due to ARI, 17% (16,177) due to AWD, 7% (6,882) due to FUO and 4% (3,824) were reported as injuries (INJ).

Table 3. Total number of reported cases, deaths and monthly Case Fatality Rate (CFR), less than 5 years old, Earthquake Affected Areas, Pakistan 26 Aug - 22 Sep 2006.

Week WEEK 35 WEEK 36 WEEK 37 WEEK 38 TOTAL

Event C D C D C D C D C D CFR%

AWD 4707 0 4146 0 3605 0 3719 1 16177 1 0.006

BD 232 0 174 0 201 0 169 0 776 0 0.000

AFP 3 0 0 0 1 0 0 0 4 0 0.000

MAL 190 0 96 0 164 0 115 0 565 0 0.000

ARI 5982 1 5658 5 5785 1 5906 0 23331 7 0.030

MES 4 0 5 0 6 0 1 0 16 0 0.000

MEN 4 0 1 0 3 0 2 0 10 0 0.000

JAU 21 0 16 0 23 0 28 1 88 1 0.000

TET 0 0 0 0 0 0 0 0 0 0 0.000

AHF 0 0 0 0 0 0 0 0 0 0 0.000

FUO 1626 0 1750 0 1598 0 1908 0 6882 0 0.000

INJ 993 0 943 0 891 0 997 0 3824 0 0.000

OTH 12446 2 10736 3 9557 4 11624 9 44363 18 0.041

TOTAL 26208 3 23525 8 21834 5 24469 11 96036 27

RU 297 303 287 303

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In the current week, there was a minor decrease in the number of cases of AWD with 9,483 this week and 9,507 last week, with one related death reported (CFR 0.010%). In the current week, ARI increased in the total number of cases as compared with the previous week, (18,025 last week and 18,853 this week). The weekly proportion of ARI and AWD is shown in figure 4.

ARI and AWD percent of total consultations

0 5 10 15 20 25 30 35 40

W45 W46 W47 W48 W49 W50 W51 W52 W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11 W12 W13 W14 W15 W16 W17 W18 W19 W20 W21 W22 W23 W24 W25 W26 W27 W28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 Week

% Consultation

ARI AWD

Figure 4. Weekly trend of percent of consultations for ARI and AWD, Earthquake Affected Areas, Pakistan, 5 November - 22 September 2006.

Acute Watery Diarrhoea

In week 38, there were 9,483 cases of AWD reported, with one associated death, in a patient under five years old, in Muzaffarabad. Since the high of week 32, the rate of AWD has fallen considerably, but is starting to level out. The rate of descent varies considerably by district, with those districts that experienced the worst outbreaks (Battagram and Bagh) showing the greatest drop in rates. See Figure 5.

0.0 5.0 10.0 15.0 20.0 25.0 30.0

32 33 34 35 36 37 38 Week

AWD as a percent of all consultations

BAGH

BATTAGRAM MANSERA

MUZAFFARABAD POONCH

Figure 5: Trend in AWD by district, Earthquake Affected Areas, Pakistan, August 5 – 22 Sept, 2006

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Bloody Diarrhoea

I week 38, there were 662 cases of bloody diarrhoea reported, a small increase over week 37.

There were no associated deaths. When the trends by district of bloody diarrhoea are compared to those of watery diarrhoea, the patterns are very different. Though Poonch and Bagh have experienced steady drops in bloody diarrhoea rates, Mansehra has had a drop then an increase, then a steady drop, and Muzaffarabad and Battagram have seen increases, after a period of steady rates or decreases. See figure 6

0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8

32 33 34 35 36 37 38

Week

Bloody diarrhea as a percent of all consultations BAGH

BATTAGRAM MANSERA MUZAFFARABAD POONCH

Figure 6: Trend in bloody diarrhoea as a percent of all consultations, Earthquake Affected Areas, Pakistan, August 5 – 22 September, 2006

Acute Jaundice Syndrome

The number of cases of suspected hepatitis appeared to increase considerably in week 38 to 102 cases from 78 cases in week 37. However, sites reporting after publication resulted in a total of 86 cases reported in week 37, resulting in a lower increase of 18%. An increase has occurred in three of the five districts (Battagram, Mansehra, and Muzaffarabad), while Poonch and Bagh have experienced a decrease. See figure 7

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80

BAGH BATTAGRAM MANSERA MUZAFFARABAD POONCH

District

Suspected hepatitis cases per reporting site 37

38

Figure 7: Suspected hepatitis cases per reporting site by district, Earthquake Affected Areas, Pakistan, epidemiological weeks 37 and 38, 2006

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Malaria

In week 38, there were 755 malaria cases reported, with no associated deaths. The large increase in week 37 was a result of an error in reporting, and the actual number of cases in week 37 was 864. (see figure 8).

0 0.5 1 1.5 2 2.5 3

32 33 34 35 36 37 38

Week

Malaria cases per reporting site

<5

>=5

Figure 8: Trend in malaria cases per reporting site by age group, Earthquake Affected Areas, Pakistan, August 5 – 22 September, 2006

Measles

1 case of suspected measles was reported in week 38, a decrease over the 10 cases seen in week 37. The single case was from Mansehra. Since recording began, in week 42 of 2005, there has been only one week with no measles cases reported (week 43), and one week, apart from this, with one case (week 42). The reduction in measles cases throughout the earthquake affected area is an indication of the effectiveness of the vaccination drives that have been undertaken throughout the area. See figure 9.

0 20 40 60 80 100 120 140

42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38

Week

Suspected measles cases

Figure 9: Trend in measles cases, Earthquake Affected Areas, Pakistan, 15 October 2005 – 22 Sept 2006.

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Acute Respiratory Infection

In week 38, there were 18,855 consultations for ARI, a 5% increase over the number of cases in week 37. There were 2 associated deaths, both in patients five years or older, one in Mansehra and one in Muzaffarabad. Since the monsoon, districts are seeing a general trend upward in the percent of consultations that are for ARI, though there are still up and down fluctuations week to week. Bagh has seen the steepest climb in rate, from 12.8% of all consultations to 21.8%.

Poonch on the other hand has had relatively little fluctuation, varying by less than two percentage points between the highest and lowest rates recorded in this time period. See figure 10

0.0 5.0 10.0 15.0 20.0 25.0

32 33 34 35 36 37 38

Week

ARI as a percent of all consultations BA GHBA TTA GRA M

MA NSERA MUZAFFARABAD POONCH

Figure 10: Trend in ARI as a percent of all consultations, by district, Earthquake Affected Areas, Pakistan, August 5 – 22 September, 2006

Other Reportable Diseases and Conditions

There were 6 cases of suspected meningitis in week 38, all from Muzaffarabad. There were no cases hemorrhagic fever, acute flaccid paralysis, or tetanus reported. There were 6,027 cases of fever of unknown origin, an 8% increase over week 37. There were 4, 894 injuries, a slight increase over week 37.

Suspected meningitis has occurred in all districts, however, the highest rate seen has been in Muzafarrabad. In the early winter, Poonch had a high rate for several weeks, but since then has had very few cases.

0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40

42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38

Week

Suspected meningitis cases per reporting site POONCH

MUZAFFARABAD MANSERA BATTAGRAM BAGH

Figure 11: Trend in suspected meningitis cases per reporting site, by district, Earthquake Affected Areas, Pakistan, 15 October 2005 – 22 Sept 2006 .

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Outbreak Alert and Response1

Acute Jaundice Syndrome

Battagram

An alert was received from the TB clinic in Battagram, for 6 cases of suspected hepatitis. The cases are under investigation.

Muzaffarabad

7 cases of acute jaundice have been reported from Hattian Bala. An investigation is being undertaken to determine whether there is any clustering. A further 5 cases have been reported from district Neelum, in two different facilities. A visit to Neelum, which is relatively inaccessible, is planned in the coming weeks, as security and weather allow.

Measles

Mansehra

One case of measles was reported from Al Rasheed Trust Hospital. The case is being investigated.

Meningitis

Muzaffarabad

An alert was received for a suspected meningitis case in a child 5 months old from Darbar. The child was admitted, and is being treated with antibiotics. The surveillance team visited the community, and found no other children in the family were ill.

1Outbreak Investigation and response of Suspected Viral Hepatitis, Malaria, and Bloody Diarrhoea and Watery Diarrhoea would only take place when a cluster of cases is identified or there is an increase in the incidence of the disease.

(Note: Single death due to Diarrhoea and single case of reported severe dehydration among >5 years would be investigated)

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Number of reported cases and deaths per District, AJK

Table 6. Number of reported cases and deaths, Bagh District, Earthquake Affected Areas, Pakistan, 16 - 22 Sept 2006.

AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH

Week

C D C D C D C D C D C D C D C D C D C D C D C D C D

35 1272 0 66 0 4 0 39 0 2483 0 1 0 0 0 25 0 0 0 0 0 461 0 475 0 10917 0 36 824 0 52 0 0 0 25 0 2226 0 1 0 0 0 22 0 0 0 0 0 308 0 574 0 9152 0 37 592 0 33 0 0 0 33 0 2465 0 1 0 0 0 16 0 0 0 0 0 192 0 630 0 8047 0 38 610 0 35 0 0 0 24 0 2748 0 0 0 0 0 11 0 0 0 0 0 221 0 722 0 8230 0 Total 3298 0 186 0 4 0 121 0 9922 0 3 0 0 0 74 0 0 0 0 0 1182 0 2401 0 36346 0

Table 7. Number of reported cases and deaths, Poonch District, Earthquake Affected Areas, Pakistan, 16 - 22 Sept 2006.

AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH

Week

C D C D C D C D C D C D C D C D C D C D C D C D C D

35 2176 0 33 0 0 0 104 1 2827 0 0 0 0 0 5 0 0 0 0 0 2114 0 740 0 6506 4 36 1662 0 32 0 0 0 119 0 2603 0 0 0 0 0 1 0 0 0 0 0 2317 0 660 0 6560 3 37 1713 0 20 0 0 0 256 0 2791 0 0 0 1 0 3 0 0 0 0 0 1912 0 758 0 6341 3 38 1932 0 24 0 0 0 206 0 3044 0 0 0 0 0 0 0 0 0 0 0 2193 0 726 0 7794 4 Total 7483 0 109 0 0 0 685 1 11265 0 0 0 1 0 9 0 0 0 0 0 8536 0 2884 0 27201 14

Table 8. Number of reported cases and deaths, Muzaffarabad District, Earthquake Affected Areas, Pakistan, 16 - 22 Sept 2006.

AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH

Week

C D C D C D C D C D C D C D C D C D C D C D C D C D

35 4406 1 375 0 0 0 388 0 6630 0 1 0 5 1 19 0 0 0 0 0 1446 0 2283 0 18472 5 36 4351 1 333 0 0 0 267 0 7470 1 0 0 2 0 13 0 0 0 0 0 1076 0 2068 0 21389 2 37 4083 1 393 0 0 0 266 0 6476 0 0 0 5 0 17 0 0 0 0 0 1170 0 2047 0 16698 3 38 3612 1 387 0 0 0 215 0 7120 1 0 0 0 0 24 1 0 0 0 0 1298 0 2136 0 19055 15 Total 16452 4 1488 0 0 0 1136 0 27696 2 1 0 12 1 73 1 0 0 0 0 4990 0 8534 0 75614 25

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Number of reported cases and deaths per District, NWFP

Table 9. Number of reported cases and deaths, Battagram District, Earthquake Affected Areas, Pakistan, 16 - 22 Sept 2006.

AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH

Week

C D C D C D C D C D C D C D C D C D C D C D C D C D

35 1282 0 89 0 1 0 69 0 1588 0 4 0 0 0 27 0 0 0 0 0 426 0 209 0 4765 0 36 1183 0 63 0 0 0 70 0 1475 0 4 0 0 0 16 0 0 0 0 0 586 0 261 2 5414 0 37 922 0 93 0 0 0 95 0 1304 0 5 0 0 0 13 0 0 0 0 0 563 0 236 0 4676 0 38 962 0 107 0 0 0 92 0 1484 0 0 0 0 0 18 0 0 0 0 0 600 0 342 0 4711 2 Total 4349 0 352 0 1 0 326 0 5851 0 13 0 0 0 74 0 0 0 0 0 2175 0 1048 2 19566 2

Table 10. Number of reported cases and deaths, Mansehra District*, Earthquake Affected Areas, Pakistan, 16 - 22 Sept 2006.

AWD BD AFP MAL ARI MEA MEN JAU TET AHF UXF INJ OTH

Week

C D C D C D C D C D C D C D C D C D C D C D C D C D

35 3395 0 231 0 3 0 329 0 4465 1 1 0 1 0 23 0 0 0 0 0 1308 0 937 0 23539 1 36 2732 0 123 0 0 0 155 0 4611 4 2 0 1 0 17 0 0 0 0 0 1521 0 1052 0 20397 4 37 2197 0 115 1 1 0 226 0 4989 1 4 0 1 0 29 0 0 0 0 0 1721 0 872 0 14949 3 38 2367 0 109 0 0 0 218 0 4457 1 1 0 0 0 48 0 0 0 0 0 1715 0 964 0 18567 2 Total 10691 0 578 1 4 0 928 0 18522 7 8 0 3 0 117 0 0 0 0 0 6265 0 3825 0 77452 10

*Data from Balakot Tehsil were merged with the data from Mansehra district.

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