Gorilla’s Guides

Sitrep no. 34, week 45, 11 November 2007

1. New Laboratory-Confirmed Cholera Cases Reported During 05-11 November 2007 (Week 45):

• Kirkuk: 12 (of 234 samples tested) 5%
• Arbil:6 (of 328 samples tested) 2%
• Baghdad: 29 (number of samples tested not reported) %N/A
• Total new cases: 51 confirmed cholera cases

2. Overview

The most important development during weeks 44-45, is the steep increase in the number of cholera cases reported from Baghdad. Out of the 51 new cholera cases reported this week 29 (57%) were reported from Baghdad. The cumulative number of laboratory-confirmed cases increased 2.6-fold, from 19 to 49. 57% of new laboratory-confirmed cholera cases this week were reported mainly from the high-risk areas in the 4 most disadvantaged districts in Baghdad

• Sadr City,
• Me’dain,
• Baladiat
• and Al-Resafa.

Data provided from Baghdad is neither complete nor timely; therefore, reported cholera cases may underestimate the real situation. What is reported from Baghdad seems to be the tip of the iceberg.

While the cholera out break is moving quickly towards Baghdad; WHO and UNICEF are running short of the needed resources to improve case reporting; management and containment activities in all affected areas especially in Baghdad.

Figure 0: Confirmed cholera cases in Baghdad for the period 19/09-08/11/2007, by international weeks up to week 45 ending 11/11

MoH/WHO/UNICEF efforts in Arbil, Kirkuk and Sulaymaniyah seem to have halted the progress of the epidemic in these 3 provinces, however, lack of funding and delays in the approval of the cholera proposal submitted to CERF more than 2 months ago is affecting both WHO and UNICEF efforts to sustain its activities in affected areas and provided the urgently needed support in Baghdad.

As of 11 November 2007 (week 44), 45 districts, 28 in northern Irak and 17 in the centre and South have reported laboratory confirmed cases of cholera. This represents an increase of 1 since the last publicly available situation report.

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 laboratory-confirmed cholera cases are increasing in Al-Resafa Directorate of Health; during week 45, the number of laboratory-confirmed cases in the areas at greatest risk in Baghdad increased 2.6-fold from 19 to 49.

Dwindling resources are negatively affecting WHO ability to sustain preventive measures to reduce the risk of transmission of cholera in high-risk areas. Epidemic preparedness for cholera and surveillance for diarrhoeal disease has been intensified in all provinces; however, preparedness, surveillance and response to reported cases are not up to the required standard in Baghdad.

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:

4 districts affected:

• Baghdad.

  (Note that this represents an increase of 1.)

3 districts affected:

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

2 districts affected:

• Basrah.

One district affected:

• Al Anbar.
• Wassit.

99% of Irak’s cholera cases were reported from Kirkuk, Sulaymaniyah and Erbil, northern Irak. 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 Irak were also confirmed in Mosul, Wassit, Baghdad, Anbar and Basra.
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 among 4,569 cumulative 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-11 November 2007, 73 cholera cases were discovered.

 

Table 1: Laboratory-confirmed cholera cases—Irak, 14/08−11/11/2007

Province/ Governorate	No of districts affected	Date first case reported	Date most recent case reported	No: of deaths reported	Increase in Reported Deaths	laboratory- confirmed case of cholera	Increase laboratory- confirmed case of cholera
Kirkuk	5	14/08/2007	11/11/2007	5	0	3004	4
Sulaymaniyah	13	23/08/2007	10/11/2007	14	0	1236	4
Arbil	6	05/09/07	10/11/2007	0	0	250	4
Dahuk	4	07/09/2007	28/10/2007	0	0	6	0
Salah Ad Din (Tikrit)	3	12/09/2007	7/10/2007	0	0	5	0
Ninawa (Mosul)	3	15/09/07	29/10/2007	1	0	6	0
Baghdad	4 (an increase of 1)	19/09/07	08/11/2007	1	0	49	17
Wasit	1	20/09/07	20/09/2007	0	0	3	1
Basra	2	19/09/07	2/10/2007	0	0	2	0
Anbar	1	03/10/07	3/10/2007	1	0	2	0
Diyala	3	03/10/07	3/10/2007	0	0	6	0
Total	45	Not Applicable	Not Applicable	22	0	4569	29*

3. Pattern Of Transmission In Kirkuk Province

Fig. 1. Cases of diarrhoea vs. laboratory-confirmed cholera, by international week, Kirkuk Province, 14/08ƒ{-11/11/2007

Figure 1 below shows a 6-fold increase 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. 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 be attributed to Eid holidays and population movement from urban to rural areas.

 

• During 05−11 November 2007 (week 45), 892 new diarrhoea cases were reported, 583 (65%) in children under 5- vs. 309 (35%) in 5 years and older.
• 12 (5%) of 234 samples tested positive for cholera.
• The cumulative number of cholera cases since 14 August 2007 is 3,004, (66% of all cholera cases in Irak.)
• Biotype Inaba was found in 2,969 (99%), Ogawa in 34 (1%) samples tested (result for 1 sample pending).
• There seems to be an increase in the number of Ogawa biotype in the last 2 weeks.
• As can be seen from the figure above 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.
• WHO 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 from all cases. This new policy was adopted to decrease the load on the laboratory and reduce cross-contamination.
• The new policy seems to have been implemented without changing the case definition of laboratory-confirmed cholera to include all cases of acute watery diarrhoea.
• 90% of Kirkuk province cases are from Kirkuk district.

4. Pattern Of Transmission In Sulaymaniyah Province

• During 05 −11 November 2007 (week 45), there were 4 laboratory-confirmed cholera cases see figure 2 below.
• The cumulative number of confirmed cholera cases is 1,236 see table 1 above.

Fig. 2. Diarrhoea admissions to 2 main Sulaymaniyah City hospitals vs. laboratory confirmed cholera, Sulaymaniyah Province, by international week, 27/08/07-11/11/07

At the beginning of the outbreak (week 35), 82% of laboratory-confirmed cholera cases were reported from Sulaymaniyah City, however more cases were gradually reported from outside 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 inside the city. The latest available laboratory report by district (week 43) available to WHO  indicates that 51% laboratory-confirmed cases were reported from Sulaymaniyah City.

Figure 3 below shows that during weeks 38-45, while the overall number of diarrhoea cases reported to Directorate of Health has decreased since week 40, the majority of cases are reported from outside Sulaymaniyah City.

Fig. 3. Total diarrhoea cases and distribution within Sulaymaniyah City vs. outside, by international week, 27/08-11/11/2007

Figure 4 below shows admitted diarrhoea cases to 2 paediatric and teaching hospitals in Sulaymaniyah during 1 September−11 November 2007. There was an increase between 2−6 October, followed by a sustained downward trend in the number of admitted patients.

Fig. 4. Diarrhoea cases admitted to 2 main hospitals in Sulaymaniyah City, by date of onset, 01/09-11/11/2007

 

5. Pattern Of Transmission In Arbil Province

• During 05−11 November 2007 (week 45), there were 6 laboratory-confirmed cholera cases.
• The cumulative number of confirmed cholera cases in 6 affected districts is 250.
• There is a definite 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 cholera in Kirkuk and Sulaymaniyah.
• This success in Erbil is mainly due to the fact that key departments (water and sanitation) have recognized their vital role in the fight against cholera.

Figure 5 below shows the number of laboratory-confirmed cholera cases, by date of onset, during 27 August−11 November 2007. The number of laboratory-confirmed cases peaked in weeks 37 and 42, followed by a sustained drop.

Fig. 5. Cases of diarrhoea vs. laboratory-confirmed cholera, Arbil Governorate,by international week, 27/08-11/11/2007