Report on Diarrhea Alert, Duhok, Week 39

Diarrheal Alert Report week 39 (ended 28 Sept)

Weekly Acute Diarrhea Surveillance

The national surveillance of acute diarrhea is of weekly reported base, it aimed to monitor the trend of acute diarrhea and early warning of outbreak potential of water-borne diseases in general and cholera in particular. The system includes stool samples collection from at least 40% of  acute watery diarrhea cases, samples to be tested for Vibrio cholerae.

Since week 33 (ended 17 Aug, 2014), the influx of IDPs had been decreased and majority of them were resettled within the host community, schools, unfinished buildings, and other places, the diarrhea trend changed.

During week 39 (ended 28 Sept, 2014), a total of 1,419 diarrhea cases reported by all surveillance sites (100% completeness) form seven districts, Duhok governorate. Compared to week 38 (1279 cases), the incidence increased.  Zakho district reported the highest, 428 cases, while Amedi reported the lowest, 79 cases. Except during week 35 in Zakho, and week 38 for Sumel district; which reported highest and lowest cases. The districts since week 36, reported diarrhea within the expected figures (Figure 1).

Figure 1: Weekly diarrhea reported by district, Duhok, as of wk 39 (ended 28 Sept, 2014)

The incidence rate of diarrhea in the districts of Akre, Bardarash and Duhok for the weeks 35 -39 was more or less stable, while for Shekhan, it decreased during week 38. The incidence rate for Sumel district was high for week 38, but it been decreased for weeks 35-37 and further decrease for week 39.  The incidence rate of diarrhea in Zakho district decreased by 2-3 times in weeks 36-38 compared to weeks 35, while it increase again during week 39 (Figure 2).    

Figure 2: Incidence rate of diarrhea by district, Duhok, wks (35-39) ended 28 Sept 2014

Diarrhea alert threshold

The reported diarrhea cases passed the alert threshold since week 33 (ended 17 Aug 2014) and continued to increase through weeks 34 (ended 24 Aug), and 35 (ended 31 Aug), with a sharp decrease in 36 (ended 7 Sept), week 37 (ended 14 Sept) and further decline during week 38, while it rose during week 39 (ended 28 Sept).

The proportional increases reached peak during week 35 (ended 31 Aug), while, there were proportional sharp decrease of diarrhea cases for weeks 36, 37 and 38, then the trend being up during week 39 (ended 28 Sept). The incidence being above the alert threshold compared to median endemic index of the years 2009-2013 (Figures 3), while the incidence returned to below the alert threshold during weeks 38 and 39, when compared to (CUMSUM+2SD) of the years 2009-2013 (Figure 4).

Figure 3: Alert threshold of diarrhea, Duhok, week 39 (ended 28 Sept) 2014

Figure 4: Alert threshold of diarrhea, Duhok, week 39 (ended 28 Sept) 2014

Conclusions

The passing of alert threshold is mainly referred to the increase in the Duhok population size by more than 50% as the result of the known crisis of Sinajr and other Mosul districts with high IDPs influx to Duhok governorate. The passed alert threshold is statistically accepted as the host population is depended upon as a denumerator.

The alert should be taken in account and to be vigilant is necessary as the increased population size are internally displaced people and majority of them already are with low health profile and low socio-economic status. The IDPs currently are living in poor health and environmental conditions  that make them at risk for health related problems.

Reports from main two hospitals shows that the IDPs are constitutes the main health facility attendees, specially complaining of diarrheal diseases, 2347 cases during week 28, which is decreased compared to week 36 (3487)  (Table 1).

Table 1: Admissions and consultation due to diarrhea among IDPs in two main hospitals, Duhok, 17- 21 Sept 2014

Reference to the active public health surveillance among IDPs reports, it was concluded that overcrowd, poor hygiene and sanitation need more work to elevate their consequences. There are low standards for living or residing IDPs in places where the people displaced. The IDPs are at risk for water-borne and other public health important diseases. 

Although all stool tested for VC were negative but cholera and other water-borne diseases outbreaks are to be expected. The cholera is endemic in Iraq with epidemic patterns of 2-4 years, the last outbreak in Iraq was during 2012.

Accordingly urgent actions by all partners are needed to expedite the measures to prevent outbreaks due to water-borne diseases and other with public health important diseases.

Actions

The Directorate of Health took urgent measures regarding previous reports on acute diarrhea alert; included activation of the technical excusive cholera control committee, which met on 11 Sept, and the province high cholera control committee met on 15 Sept chaired by the governor. The meeting attended by UN agencies and related sectors representatives.  

Important measures had been decided by the high cholera control committee include all preventive measures to be taken to prevent cholera or other water-borne diseases outbreaks.

Some immediate actions were decided in the field had been applied among IDPs like distributing ORS sachets to diarrhea cases, collecting stool samples for VC testing, supporting patients in health facility access and spreading health promotion messages.