#1Cholera - Country Presentation Pakistan 5th Initiative against Diarrheal and Enteric diseases in Asia (IDEA) Prof. M. Ashraf Sultan Prof. Iqbal Memon#2Under Reporting Global cases (estimated) 3-5 M Deaths: 100,000-120,000 Cases reported to WHO: 178,000 - 58,900 Why Limitation of surveillance system Lack of systematic studies Fear of trade and travel sanctions#3BALOCHISTAN KHYBER PAKHTUNKHWA Pakistan Statistics GILGIT- ● BALTISTAN Population: 180 million SINDH FATA PUNJAB AZAD KASHMIR Punjab Sindh Balochistan Khyber Pakhtunkhwa Gilgit-Baltistan Azad Kashmir • ○ < 15yrs. = 45% (81 million) ○ < 5 yrs. = 16% (28.8 million) 。 <2 < 2 yrs. = 10 % (18 million) Paucity of Epidemiological Data Health Provincial subject since 2012#4Causes of under-five mortality (Pakistan) HIV/AIDS; 0,1 Other 22; 22 Malaria; 0,2. Injuries; 2,1. Measles; 5,5. Diarrhoea; 13,2_ Pneumonia; 15,4 Neonatal deaths; 42,2 Source: World Health Statistics, WHO, 2009#5PAKISTAN Birth cohort 4.5 million IMR 54/ 1000 U5MR 77/1000 Demographic survey of Pakistan · 4-6 episodes of diarrhea per child per year < 5 year 28.8 million x 4 = 115.2 million episodes of diarrhea/ year Under five deaths per year from Diarrhea: 59,400 of 450,000 (13.2%)#6PSLM 2014-15 16M do not have access to clean drinking water 27% consume tap water 86% have access to improved water source 73% have access to sanitation facilities • 13% no toilet facility Diarrhea cases across last 30 days Overall 9% Balochistan 11% Sindh 6%#7SEASONAL VARIATION OF VIBRIO CHOLERAE AND VIBRIO MIMICUS IN FRESHWATER ENVIRONMENT A.H. Shar and Y.F. Kazi and N.A Kanhar Table 3. Isolation Rate of Vibrio cholerae (2007). Isolation Rate (Months) Average/site/ City (Sampling site) January- April-June March July- September October- December year Khairpur 17% 33.33% 50% 0% 25.00% Sukkur 0% 33.33% 67% 33.33% 33.41% Rohri 33.33% 67% 83.33% 50% 58.41% Average/quarter 17% 44.55% 67% 28% 39.00%#8Empty#9Limitations and Sources No active case based surveillance in place Published articles Unpublished data from health facilities-Patchy Passive case based surveillance from large hospitals of major cities WHO EMRO Documents Reports of NGOs working in disaster situations.#10Epidemiology, Determinants and Dynamics of Cholera in Pakistan: Gaps and Prospects for Future... Article in Journal of the College of Physicians and Surgeons--Pakistan: JCPSP · November 2014 Source: PubMed Table 1: Epidemiology and determinants of cholera infection in Pakistan from published research articles from 1995 - 2010. Year of publication No. of articles published Agent Host Environment 1995-2000 2 2001-2005 8 2006-2010 7 1989-1992: Major serotype responsible was Ogawa 01 1993-94: Reappearance of non-01 (0139) 1990-98: Ogawa biotype El Tor predominant 1999: Emergence of classical Ogawa 01 serotype 2000-2001: Predominant serotype non-01 (0139). However, classical Ogawa also exist in this period. 2002-2004: El Tor biotype of Ogawa responsible for outbreaks and epidemics of cholera in this period. 2004-2005: upsurge in the isolation of Vibrio cholerae Inaba. 2008: predominant serotype 01 biotype El Tor. All ages and both gender are at risk of getting disease. Environmental factors of cholera infection were not explored in Non-01 involved mostly adults, youngest child this period in Pakistan. infected with cholera was 7 days old. Mean age for child affected with El Tor was 31+/-34 months. Mean age for non 01 infection was 40 years while for 01 it was 23 years. Both gender at risk. Poverty and low education were also important host factor determinants. Severity of infection and fever along with symptoms of diarrhea common with non 01. Involvement of both children and adults with younger age affected with Ogawa 01 and older age in non-01 infection. No primary research done in Pakistan to explore environmental aspect of cholera infection. Environmental factors such as water contamination with V. cholerae, use of toilet other than flush system associated with increased infection. Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (11): 855-860 857#11Local Studies Author Year Total No + ve Isolated Siddiqui FJ (LHR) 1990-96 888 Nizami et al (KHI) 1990-95 4346 348 Serogroup 01, Serogroup 0139, 36% V. cholerae 01 Ogawa biotype El Tor 64% V. cholerae 0139(14%) Hussain S et al (ISB) 1994-99 212 Memon IA (KHI) 2002 846 161 545 Jabeen et al (KHI) 2000-01 144 Shams R (ISB) 2005 V. cholerae El Tor Serotype Ogawa Vibrio cholerae 01 V. cholerae O139 V. Cholera El Tor biotype Ogawa (100%)#12Cholera burden and risk in the Eastern Mediterranean region: Mapping exercise Heather McKay, Justin Lessler, Sean Moore, Andrew Azman, Department of Epidemiology Johns Hopkins Bloomberg School of Public Health#13Cumulative number of cholera cases and deaths reported from the Eastern Mediterranean Region by Country, 2011 - 2015 Country 2011 2012 2013 2014 2015 Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Afghanistan 3733 44 12 0 3957 14 45481 4.0 0 0 Djibouti 0 0 0 0.0 0 0 Iran 1187 12 53 0 256 7 9 0.0 62 0 Iraq 0 0 4693 4 1 0 0 0.0 2724 2 Pakistan 11489 219 3395 31 1069 23 1218 6.0 0 0 Somalia 77636 1130 22576 200 6864 140 7577 0 5198 13 Sudan 0 0 이 0 0 0 0 0.0 0 0 Yemen 31789 134 0 0 0.0 0 0 Total 125834 1539 30729 235 12,147 184 54285 10.0 7984 15#14Eastern Mediterranean Region (EMR) SYRIA: 2008-2009 399 confirmed cases 2 deaths IRAQ: 2007-08, 2015 6,553 suspected cases 5 deaths IRAN: 2005-2014 2,638-confirmed Gases Missing death data AFGHANISTAN: 2007-2014 735.726 suspected cases 1.837 deaths SUDAN: 2006-07 9,495 suspected cases 358 deaths YEMEN: 2010-2012 34,190 suspected cases 134 deaths Cumulative Cases 2005-2015 845,153 suspected cases 3,037 confirmed cases 2,679 confirmed deaths - SOMALIA: 2012-2015 38,309 suspected cases Missing death data PAKISTAN: 2010-2014 20,880 suspected cases 343 deaths#15Afghan- Pakistan border Country: The Islamic Republic of Pakistan Population (2010): 170,043,918 Data received (years): 2010-2014 Cases: 20,880 (suspected) Deaths: 343 Cumulative 5-year Incidence (per 100,000) 2010-2014 Swat, Swabi, Malakand, Lower Dir districts (Khyber Pakhtunkhwa) Quetta district, (Baluchistan) -1000 Islamabad (Punjab) 1 Mirpur Khas 0.01 district (Sindh) <0.001 0.1 10 100 >10000 Number of AWD cases 0 Number of AWD cases 3000- 2000- 1000- 10000- 7500- 5000- 2500- 2005 MISSING 2006 MISSING 2007 MISSING Annual Number of Cases of Acute Watery Diarrhea Pakistan, 2005-2014 2008 MISSING 2009 MISSING 2010 Years Case fatality, Pakistan, 2010-2014 16,0 14,0 12,0 10,0 8,0 6,0 4,0 2,0 0,0 Case fatality lanterarmy.inelyget ockovec Cases of Acute Watery Diarrhea (AWD) Pakistan, 2005-2015 Jan Feb Mar Apr May Month June July Aug Sept Oct factor(Year) -2005 2006 <-2007 <-2008 2009 <-2010 <-2011 <-2012 <-2013 2014 <-2015 2014 2010 2011 2012 2013 2014 2015 MISSING#16Suspected cholera cases/deaths by province: Pakistan, 2010-2014 Administrative Cases/Deaths¹ % of total cases Case fatality Division Sindh 6,537/174 31.3 2.7 Khyber Pakhtunkhwa 6,017/65 28.8 1.1 Balochistan 4,832/46 23.1 1.0 Azad Kashmir 1,776/19 8.5 1.1 Punjab 1,330/33 6.4 2.5 FATA Gilgit-Baltistan Islamabad 237/2 1.1 0.8 93/1 0.4 1.1 58/1 0.3 1.7 Total cases = 20,880 and total deaths = 341 between 2010 and 2014, DEWS.#17WHO EMRO Incidence Rate for countries like Pakistan (calculated 2011) Infants 7.16/1000 1-4 year 7.01/1000 5-14 year 2.19/1000 >14 year 0.93/1000 Annual incidence 1.64/1000 Case fatality rate 3.63-41.56#18First cases of cholera are reported in Pakistan, say aid agencies Nayanah Siva LONDON The first suspected cases of cholera have been reported in flood stricken Pakistan, and cases of acute "We have seen a lot of suspected cholera cases in more than one district," said Ahmed Mukhtar, medical coordinator for Médecins diarrhoea are rife, aid agencies report. Sans Frontières in Pakistan. "It seems there is some kind of alarming trend." DrMukhtar said that several cases were suspected throughout the country but that he was still awaiting laboratory confirmation from samples that had been sent for testing. Most of the suspected cases were reported in the Swatvalley in the northwestem province of Khyber Pakhtunkhwa. "In the Swat [district] we saw 60 patients with acute diarrhoea who fulfilled the clinical case description of cholera," Dr Mukhtarsaid. "We had another 11 cases in a neighbouring area, the Malakand district, and another four suspected cases in another district, Lower Dir. "We are following all suspected cases closely and have started to treat them as if they are cholera cases." Cite this as: BMJ 2010;341:c4525 Medical supplies and water are thrown from a rescue helicopter BMJ | 21 AUGUST 2010 | VOLUME 341 367#19Asia Qadri et al Bangladesh 78 laboratory-confirmed cases; >3740 estimated cases in total International Centre for Bangladesh Diarrhoeal Disease Research B Dowse79 Chung” Indonesia Indonesia Burma Flooding Thousands of isolations reported to the Continuing analysis International Centre for Diarrhoeal Disease Research, Bangladesh (eg, approximately 5500 in Sept, 2004) One case imported by an Australian tourist One case imported by a Korean tourist "Scores of cases, several deaths" Flooding, and damage to sewerage systems Afghan refugee camp Chann³¹ Pacific Disaster Pakistan At least 25 deaths Management Information Network? Anon Pakistan At least 12 deaths Contaminated water drought Anon14 Pakistan Epidemic resulting in at least four deaths UK Health Protection Pakistan One case imported by a UK tourist Agency International Society for Taiwan Infectious Diseases One case imported from the Philippines Contaminated seafood Centers for Disease Thailand Control and Prevention One case imported by a tourist from the USA Contaminated seafood Robert Koch-Institut" Thailand One case imported by a German tourist Anon Thailand One case imported by an Australian tourist Infectious Agents Surveillance Report" Thailand Eight cases imported by Japanese tourists Europe Strauss et al" Austria Two cases imported from India Oceania New Zealand One case, travel history unknown GIDEON _=not reported. Table 2: Countries for which reports of cholera occurring during 2004 have been identified but who did not report cholera to WHO, by report The true burden and risk of cholera: implications for prevention and control Jane N Zuckerman, Lars Rombo, Alain Fisch http://infection.thelancet.com Vol 7 August 2007#20800000 Year Wise Reported Cases Acute Diarrhea VS Susp Cholera Punjab Information Technology year wise data 700000 600000 500000 400000 300000 200000 100000 0 LLLL ■Acute Diarhea ■Suspected Cholera 2013 2014 2015 2016#21238,613 2016 Lahore Data Top Five Diseases Pie Chart 18,216 26,209 33,502 7 Cholera +ve cases 518,746 ACUTE (UPPER) RESPIRATORY INFECTIONS PYREXIA OF UNKNOWN ORIGIN (PUO) SCABIES DIARRHOEA (ACUTE) ACUTE WATERY DIARRHEA/SUSPECTED CHOLERA#22. ● ● • Risk factors for cholera in the EMR Complex emergencies (at-least 76 million people in 9 out of 22 countries in the region are in complex emergencies) Increased population movement in the region (IDPs, Refugees and religious mass gathering) Hard to reach areas in some of the geographically remote places; Poor infrastructure and limited access to health care Poor sanitation and hygiene practice in some countries#23. • . Regional Cholera Strategic Priorities 1 Coordinating the cholera preparedness and response interventions at regional and country levels Improve preparedness and response capacity for potential cholera epidemic Improve surveillance system for early detection, verification and response Improve Laboratory capacity to confirm cholera epidemics Build the human capacities to support the cholera response Monitor water, sanitation and food safety activities#24· Regional Cholera Strategic Priorities 2 Improve environmental health management to prevent or contain cholera epidemics Regular risk assessments to identify high-risk or hotspot areas Improve case management and infection control practice to reduce the morbidity and case fatality rate to less than 1% Invest risk communication and social mobilization Oral Cholera vaccination campaigns (pre-emptive and reactive) Emergency stockpiles of drugs and other supplies#25● Main Challenges Recurrent humanitarian emergencies • Weak surveillance system and underreporting ● . . ● ● . Limited laboratory capacity in some countries Countries are not well prepared to respond major cholera epidemics Under resources of the public health control activities Poor water and sanitation condition in conflict affected countries Lack of cross border collaboration between the neighboring countries. Recurrent cholera outbreak in some countries with complex emergencies#26THANK YOU#27Pakistan Statistics PAKISTAN SHOWING ADMINISTRATIVE DIVISION Afghanistan BALOCHISTAN ARABIAN SEA ASINDH Karachi WS F. P. GILGIT GENCY JAMMU 1.C.T. KASHMIR (Disputed Territory) ISLAMABAD Lahore PUNJAB Okara India Population: 180 million ○ < 15yrs. = 45% (81 million) < 5 yrs. = 16% (28.8 million) ○ <2 yrs. = 10 % (18 million) Paucity of Epidemiological Data No Systemic analysis or evaluation even in affluent population.#28World Health Organization Eastern Mediterranean Region: Cholera Status by Country (from 2009 - 2015) MOROCCO TUNISIA LIBYA In the last recent 5 years (2009-2015): At risk of epidemic: has annual report => 1 year & < 3 years Endemic with low incidence: has annual report at least 3 years, and the annual cumulative incidence < 1 per 10000 Endemic with high incidence: has annual report at least 3 years, and the annual cumulative incidence > 1 per 10000 EGYPT SUDAN LEBANON SYRIA JORDAN KUWAIT SAUDI ARABIA DJIBOUTI YEMEN SOMALIA BAHRAIN QATAR AFGHANISTAN IRAN U.A.E. OMAN PAKISTAN At Risk of Cholera Epidemic Cholera Endemic with High Incidence Cholera Endemic with Low Incidence Reported Import Cholera Cholera Not Reported#29Current situation of cholera in the WHO Eastern Mediterranean Region Dr Abdinasir Abubakar Pandemic and Epidemic Disease World Health Organization Regional Office for Eastern Mediterranean November 17-19, 2015; Amman, Jordan