Gorilla’s Guides

Cholera Sitrep_25

Overview:

39 districts in Irak are now affected by this cholera outbreak.

WHO report 3857 laboratory-confirmed cases of cholera This represents an increase of 87 laboratory confirmed cases of cholera since our last report on October 9th, 2007 (Sitrep 24).

18 deaths have now been reported an increase of 2 since since sitrep 24 we reported both of those deaths as they were confirmed by reliable sources before they showed up in WHO’s statistics. The following are the affected governorates/districts:

North Irak:

• 13 out of the 14 districts of Sulaimaniyah governorate
• All five districts of Kirkuk governorate
• 6 out of the seven districts of Arbil governorate
• one district in Dahuk.

Are affected by this cholera outbreak.

Central and Southern Irak:

• 3 districts in Salah ad Din (Tikrit)
• 3 districts in Ninawa (Mosul)
• 3 districts in Diyala.
• 2 districts in Basra
• 1 district in Wassit,
• 1 district in Baghdad
• 1 district in Anbar .

Are affected by this cholera outbreak.

Of the cholera cases reported by WHO 96% were reported from Sulaymaniyah and Kirkuk, the out break seems to be slowly spreading to the neighboring provinces of Arbil and Diyala. Arbil now has 151 laboratory confirmed cases, an increase of 4 since the last sitrep. In Diyala there are 3 laboratory confirmed cases and 41 diagnosed on clinical and epidemiological grounds.

Situation in Governorates Not Yet Affected:

• Preventive measures have been taken to reduce the risk of transmission of cholera to other high risk areas.
• Epidemic preparedness for cholera has been geared up in all provinces. Surveillance system for diarrhoeal disease has been intensified in all provinces.
• During the period 01 to 04 October 10778 diarrhea cases were reported from the 16 no-epidemic Directorates of Health. 9067 stool samples were collected from
  these diarrhea cases and 19 cases were found positive for vibrio cholera.

Readers’ attention is particularly directed to the situation in Mosul below.

Statistical Summary from affected governorates

Table-1 below shows the distribution of confirmed cholera cases by district in Irak.

Table-1: Reported laboratory confirmed cholera Cases, Irak, 23/08-30/10/2007

*219 cases included in previous reports as confirmed cholera case were found to be for carriers they have therefore been subtracted from the previous total for Kirkuk

Detailed reports by governorate/district are below the fold:

Al Anbar

• Nothing to add to sitrep 24.

Arbil Governorate

• The infected 6 districts in Erbil governorate have reported up to 5th of October 151 laboratory-confirmed case of O1 El Tor Inaba. The total number of cases of diarrhoeal disease reported from this province from 1st of September to 7th of October stands at 20,146 with no death; 5363 stool samples were collected out of which
  168 were positive; 151 for cases and 17 from contacts.
• Arbil seems to have a fairly sensitive diarrhea disease surveillance system that was able to pick up cholera cases very early a swift response seems to have succeeded in halting and limiting the spread and magnitude of the out break.
• Unlike the situation in both Kirkuk and Sulaimaniyah there is a definite downward trend in reported diarrhea cases. The number of cases in week 38 and 39 is almost the same as the pre-out break figure while the very high number of cases in week 36 is most likely due to the feeling of panic following the declaration by MoH of the occurrence of cholera in Kirkuk and Sulaimaniyah. There is a slight upward trend amongst the over 5 age group in week 40.

  Figure 1: Diarrhoeal cases by age group & international weeks, Arbil 03/09/2007 to 07/10/2007

  

• The figure 2 below shows the number of confirmed V cholera by date of onset for the period 05 September to 7th
  of October 2007. Although it is too early to detect any pattern but the general trend shows slight down trend
  in the number of the daily confirmed cases.

  Figure 2: Confirmed cholera cases and contacts, by date of onset, Arbil Governorate, Sep. & Oct. 2007

   

At-Ta’mim (Kirkuk) Governorate

• As figure 3 below shows between weeks 33 and 39 (ending 30th October) there was a fourfold increase in the number of diarrhea cases among adults.
• The figure also shows that there was a twofold increase in the number of diarrhea cases among children under the age of 5 in the same period.
• During week 40 there is definite down trend in reported diarrhea among above 5 however, the incidence below under 5 is still on the increase.

  Figure 3: Reported diarrhoea for the period 13/08 to 30/09 by age group and international weeks, At-Ta’mim (Kirkuk) Governorate

  

• This increase which is most probably a real increase in diarrhea cases can be partly explained by better reporting and better community treatment seeking behavior. However, there are indications that some patients may be seeking treatment in more than one health facility and the same patient is reported as a new case from 2 or more health facilities.
• It is not certain whether this sustained increase in reported diarrhea will continue during the upcoming weeks
• Figure 4 below shows that laboratory confirmed cholera cases have peaked at the level of 120 case per day during the period 16-27/09 and then decreased and leveled at 100 cases per day during the period 28/09 to 03/10/2007.
• The figure also shows that since the 4th of October there has been a sustained and sudden decrease in the number of confirmed cholera is.
• It is not known whether this is a real decrease in cholera cases or an apparent decrease due to the new strategy of collecting stools from only 10% of cases, rather than 100% of cases to decrease the load on the laboratory and reduce the probability of contamination.

  Figure 4: Daily confirmed cholera cases, At-Ta’mim (Kirkuk) Governorate, 20/08-09/10/2007

• This new policy seems to have been implemented without a similar change in the case definition of confirmed cholera to include all watery diarrhea cases.
• It is worth noting that despite assurances that the public water supply is safe and repeated efforts by local health authorities that the source of this outbreak is still untraced for the cases in Kirkuk city.
• It is also worth noting that unlike in Arbil in Kirkuk the water and sanitation departments appear not to have recognised their important and vital role in the fight against cholera and are just watching the situation and making a minimal or no contribution. Sending green zone government MoH deputy minister Dr. Isam Mamiq and CDC/Baghdad and Central Public Health laboratory staff on a mission to lead the cholera containment activities in Kirkuk appears to have had little if any effect in this regard.

Babil Governorate

• Nothing to add to sitrep 24.

Baghdad

• Nothing to add to sitrep 24.
• As indicated in sitrep 24 a team from CDC/Baghdad Baghdad-Resafa DoH and WHO visited the 2 hospitals in Madain districts and came to the conclusion that much need to be done in terms of surveillance and environmental sanitation.

Basra Governorate

• Nothing to add to sitrep 24.

Dahuk Governorate

• Nothing to add to sitrep 24

Diyala Governorate

• Nothing to add to sitrep 24.

Ninawa Governorate

• Mosul: Preparedness activities, including monitoring of diarrhea cases and drinking water quality, testing stools for cholera organisms are being enhanced and closely followed up during the daily meeting of the cholera operations room chaired by the governor with all concerned head of departments as members.
• 9241 diarrhea cases were reported during the period 09/09/07 up to 07/09/07; out of these diarrhea case 6686 were tested for cholera organism (72%) and only 2 cases and 2 carriers were discovered only on death most probably due to cholera was reported. See figure below:

  Figure 5: Total diarrhea, number and % of stool samples collected, 09/09/07 to 07/10/07 by international weeks Mosul district

   

Salah ad Din Governorate

• Nothing to add to sitrep 24.

Sulaymaniyah Governorate

• The total number of laboratory confirmed cases up to the 7th of October reached 968 an increase of 67 in one day.
• confirmed cases peaked in week 36 and then showed a slight down trend and leveled during weeks 37 to 39 however; an increase is seen in week 40 indicating another wave of cases.

  Figure 6: confirmed cases

  

• The figure below shows that confirmed cases peaked in week 36 and then showed a slight down trend and leveled during weeks 37 to 39 however; an increase is seen in week 40 indicating another wave of cases.

• Figure 7: Changing proportion of confirmed Cholera cases, between Sulaymaniyah city and areas outside side the city by week of onset, Sulaymaniyah governorate 26 August to 6 October.

   

• The increase seen in week 40 seems to be related to reporting of more and more cases from out side Sulaymaniyah city, during the early phase of the out break (week 35) , 90% of cases were reported from Sulaymaniyah city, by week 40 only 39% of cases were reported from within the city This could indicate either:

  1) Improved surveillance out side Sulaymaniyah city or;

  2) Spread of the disease to other districts outside Sulaymaniyah city implying that there is relatively good control inside the city and relatively poor control outside of it.

• Fig 8 below shows admitted diarrhea cases to the pediatric and teaching hospitals in Sulaymaniyah during the period 01/09 to 05/10/2007. It is clear that there was a sustained increase between 2nd and 6th of October followed by a sharp down trend for both age groups on the 7th.

  Figure 8:

  

   

Wasit Governorate

• WHO report one confirmed case reported from this governorate. However as we noted in our last report two deaths have been reported from normally reliable sources but have yet to appear in WHO’s figures.

Indexed under: Al Anbar (Governorate), Arbil (Erbil), Babil (Governorate), Baghdad, Basrah, Cholera Situation Reports, Dahuk (Dohuk) (Governorate), Disputed Areas, Diyala, Kirkuk, Kirkuk (At-Ta'mim) Governorate, Mosul, Ninawa (Governorate), Salah ad Din (Governorate), Tikrit, Wasit, Water Borne Disease, Water Crisis (Iraq), World Health Organisation, الكوليرا