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Cholera Sitrep_32

The number of Cholera cases seems to be slowly going down in the three affected provinces in Northern Irak, however, there are alarming signs that confirmed cholera cases are increasing in Al Resafa directorate of health, during this week the number of confirmed cases in the most risky areas in Baghdad jumped from 11 to 24. This is alarming as there is little reason to believe that health authorities in Baghdad have the capacity to cope with a widespread outbreak.

Overview

The most important development in the last week under report (week 44) is the steep increase in the number of cholera cases reported from Baghdad compared to the previous week. The number of laboratory confirmed cases jumped from 11 to 24 cholera cases representing an increase of 227% in the cumulative cases. 26% of new confirmed cholera cases this week were reported from Baghdad Resafa; mainly from the highest risk areas in the 3 most disadvantaged districts in Baghdad (Sadr City, Me’dain and Resafa districts).

Readers should note that the data provided from Baghdad is neither complete nor timely, therefore WHO have cautioned that they consider what is reported from Baghdad may be an underestimation of the real situation. WHO have also noted the following in regard to the situation in Baghdad:

Preparedness, surveillance and response to reported cases are not up to the expected standard in Baghdad.

As of 04 November 2007 (week 44), 44 districts, 28 in northern Iraq and 17 in the centre and South have reported laboratory confirmed cases of cholera.

Northern Irak by number of affected districts:

• 13 out of the 14 districts of Sulaymaniyah governorate.
• All 5 districts of Kirkuk governorate.
• 6 of 7 districts of Erbil governorate.
• 4 districts in Dahuk.

Central and Southern Irak by number of affected districts::

3 districts affected:

• Baghdad.
• Diyala.
• Ninawa (Mosul).
• Salah Ad Din (Tikrit).

2 districts affected:

• Basrah.

One district affected:

• Al Anbar.
• Wassit.

The results of the samples of vibrio cholerae isolates from Sulaymaniyah; Kirkuk, Erbil and CPHL (Central Public Health Laboratory) in Baghdad were received by the U.S. Naval Medical Research Unit No. 3 (NAMRU-3) laboratory, Cairo. NAMRU-3 results confirmed Sulaymaniyah- and Central Public Health Laboratory (CPHL) results, confirming that the out break was caused by vibrio cholerae O1 El Tor Inaba, which is sensitive to the commonly used antibiotics, the isolated strains were found resistant to trimethoprim-cotrimoxazole.

99% of Iraq’s cholera cases were reported from Kirkuk, Sulaymaniyah and Arbil, northern Iraq. Sporadic cases with definite history of travel and food consumption in Kirkuk were reported from Tikrit province; however, isolated cases with no epidemiological link to northern Iraq were also confirmed in Mosul, Wassit, Baghdad, Anbar and Basrah. One of the important features in this outbreak is that most of the cases seen have mild to moderate signs and symptoms. The traditional signs and symptoms of severe dehydrating diarrhoea were seen only very occasionally, out of the 4,527 laboratory-confirmed cholera cases; 22 deaths were reported, most of the deceased had other, serious underlying morbidity.

Specific control measures to contain this ongoing outbreak and limit its spread to other areas have been reinforced by the concerned governmental departments of the affected provinces, with technical support from WHO. In non-epidemic provinces, during the period 14 August - 04 November 2007, 53 cholera cases were discovered.

The number of Cholera cases seems to be slowly going down in the three affected provinces in Northern Irak, however, there are alarming signs that confirmed cholera cases are increasing in Al Resafa directorate of health, during this week the number of confirmed cases in the most risky areas in Baghdad jumped from 11 to 24 or 227% increase.

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. However, preparedness, surveillance and response to reported cases are not up to the expected standard in Baghdad.

Table 1: Laboratory confirmed cholera Cases, Irak, 14/08/2007-04/11/2007

Province/ Governorate	No of districts affected	Date outbreak started	No: of deaths reported	Increase in Reported Deaths	laboratory- confirmed case of cholera	Increase laboratory- confirmed case of cholera
Kirkuk	5	14/08/2007	5	0	2997	28
Sulaymaniyah	13	23/08/2007	14	0	1232	5
Arbil	6	06/09/07	0	0	235	0
Dahuk	4	23/09/07	0	0	6	0
Salah Ad Din (Tikrit)	3	12/09/2007	0	0	5	0
Ninawa (Mosul)	3	15/09/07	1	0	6	3
Baghdad-Resafa	3	19/09/07	1	0	24	13
Wasit	1	20/09/07	0	0	2	1
Basra	2	19/09/07	0	0	2	0
Anbar	1	03/10/07	1	0	2	1
Diyala	3	03/10/07	0	0	5	0
Total	44	Not Applicable	22	0	4527*	51*

* The previous total was 4467 giving an increase in this report of 60, leaving 9 Unaccounted for.

Pattern Of Transmission In Kirkuk Governorate:

During 29 October-04 November 2007 (week 44), 1283 new diarrhoea cases were reported, 787 (61%) in children under 5- vs. 496 (39%) in 5 years and older; 22 were confirmed cholera-positive from 410 samples tested. Figure 1 shows a 6-fold increases in the number of diarrhoea cases between week 33 and week 39, ending 07 October 2007, followed by a sharp decrease in reported diarrhoea cases in week 41, it must be noted that the last 4 days of week 41 (11-14 October 2007) coincide with the Eid Al Fitr holidays and massive population movement from the city to the rural area; therefore; some of this decrease in diarrhoea, especially among adults can safely be attributed to Eid holidays and population movement from urban to rural areas.

Fig 1: Total diarrhea and confirmed Cholera, Kirkuk by International weeks up to week 44 ending
04/11/2007

Laboratory-confirmed cholera cases have peaked at the level of 657 and 681 during weeks 38 (ending 23 September) and 39 (-30 September). This was followed by a sharp decrease in the number of cholera cases starting from week 40. We do not know 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. This new policy was adopted to decrease the load on the laboratory and reduce the probability of cross contamination. This new policy seems to have been implemented without a similar change in the case definition of confirmed cholera to include all watery diarrhoea cases. 69% of the total confirmed cholera cases reported from Iraq, are from Kirkuk province. 90% of Kirkuk province cases are from Kirkuk district.

Pattern Of Transmission In Sulaymaniyah Province

Fig. 2 Diarrhea admissions in 2 hospitals Vs. total confirmed cholera in the province up to week 44 ending 04 November 2007

During 29 October -04 November 2007 (week 44), there were only 6 confirmed cholera-positive and no deaths (14 total since begin of the outbreak); the total number of confirmed cholera cases is 1,232 (table 1).At the beginning of the outbreak 70% of cases were reported from Sulaymaniyah city, however more cases were gradually been reported from out side the city indicating either spread of the disease to other districts outside Sulaymaniyah city or improved reporting from rural areas as well as relative control.

Fig. 3. Diarrhoea cases, Sulaymaniyah city vs. Outside, by international week, 18/09-04/11/2007

Figure 4 shows admitted diarrhoea cases to paediatric and teaching hospitals in Sulaymaniyah during the period 01/09 to 04/11/2007. It is clear that there was sustained increase between 2 and 6 October, followed by a sharp downward trend in the number of admitted patients.

Pattern Of Transmission In Arbil

During 29 October-04 November 2007 (week 44), there were 10 confirmed cholera-positive cases; the total number of confirmed cholera cases in 6 affected districts is 245. There is a definitive downward trend in reported diarrhoea cases. The number of cases in week 38 (-23 September) and 39 (-30 September) is almost the same as the pre-outbreak figure. The very high number of cases in week 36 (-9 September) is most likely due to the feeling of panic following the declaration by MoH of the occurrence of cholera in Kirkuk and Sulaymaniyah. This success in Erbil is mainly due to the fact that key departments (water and sanitation) have recognized their important and vital role in the fight against cholera, unlike the situation in Kirkuk where key departments are just watching with minimal contribution.

Figure 5 shows the number of laboratory-confirmed vibrio cholerae cases, by date of onset, during 27 August - 04 November 2007. The number of confirmed cases peaked in weeks 37 and 42 and the plateaued at the level of 27-33 cases per week between these 2 weeks this was followed by a sustained drop during the last 2 weeks.

Arbil seems to have a fairly sensitive diarrhoea disease surveillance system that was able to pick up cholera cases very early and swiftly responded and seems to have succeeded in halting and limiting the spread and magnitude of the outbreak.

Indexed under: Cholera Situation Reports, Health, Water Borne Disease, World Health Organisation, الكوليرا