1. Pandemic Influenza A H1N1 and Emerging Disease Occurrence in Afghanistan Islamic Republic of Afghanistan

2. Influenza A H1N1 in Afghanistan The first case was reported on 3 rd July 2009 from Bagram Airfield The total number of cases to date are 948 with 17 deaths

3. Type of Information TotalMaleFemale Foreign Military Personal411 0 Afghan Military Personal395 0 Foreign Civilians321 Afghan Civilians1399544 Total number of confirmed H1N1 cases from 3 rd July 2009 till today94890345 Total number of H1N1deaths fatalities among Afghans17125 Afghan civilians1495 Afghan National Army330 Description of influenza A H1N1 cases

4. Confirmed H1N1 Cases

6. Ministry of Public Health (MoPH) Pandemic Plan for Influenza A H1N1 1.Straightening Surveillance system all around the country 2.Announce health alert situation 3.Applying social distancing( Closer of schools and Universities) 4.Distribution of Antiviral medicine and Personal Protective Equipment) PPEs to all provinces 5.Establishment of control and command centre( CCC) 6. Appeal for H1N1 vaccines from donors and WHO

7. MoPH Pandemic Plan for Influenza A H1N1 (continued) 7. Preparedness of Pandemic Plan for Influenza A H1N1 8. Health Education and public awareness through media and health facilities 9. Trainings on H1N1 case management to health workers

8. Crimean Congo Hemorrhagic Fever (CCHF) In early 2000 outbreak of CCHF was reported in Afghanistan (Gulran district of Herat province) which was not lab confirmed. 25 inhabitants of a village were infected of which 15 died. When DEWS established in Afghanistan (Jan 2007), CCHF was detected in August 2007 in Herat Province which was confirmed by lab.

9. Sign and Symptoms: – Fever – Headache – Body Pain – Nausea – Vomiting – Diarrhea – Epistaxis – Blood in vomitus, stool or injection sites – Petechia, Purpura and Ecchymosis Crimean Congo Hemorrhagic Fever (continued)

10. Background In the 1974, cases of huge abdominal distension and emaciation appeared in the villages of Gulran district of Herat Province soon assumed epidemic proportions. The poorest families were affected. In many instances several members in a family were affected within weeks of each other and all had died. In 1976 an out-break of this illness was studied. According to the study patients with massive ascites and emaciation on were observed and based on clinic- pathological evidence those were typically cases of hepatic veno-occlusive disease.

11. Background (continued) The outbreak was due to consumption of bread made from wheat contaminated with seeds of Heliotropium plants (Charmac), which were shown to contain pyrolizidine alkaloids. Veno-Occlusive Disease of the liver is well recognized form of toxic liver injury produced by pyrolizidine group of alkaloids. This illness was seen in different countries due to consumption of pyrolizidine alkaloids in different form. Clinical improvement was observed after lengthy supportive hospital treatment.

12. Signs and Symptoms Epigastric pain with abdominal distention are the first complains of the patients. The patients looked ictirous with slight jaundice. Massive ascites is established in old age and childhood cases. The clinical prognosis is better in younger patients. All the patients were examined and adequate supportive treatment was advised. Some aids (high protein biscuits, rice, oil and other basic life requirements) were donated to the families.

13. CCHF Clinical Presentation

18. Initial Outbreak Report On Eid-days, initial reports were received from Nimroz Province that some people died due to eating contaminated camel’s meat. A primary survey was done. Reported symptoms were: Fever, Vomiting (with blood), Diarrhea, severe headache, paralysis and auxiliary lymph adenopathy Primary assessment, based on clinical details and discussion with village residents identified 20 persons sick; 5 individuals expired. Camel meat was reported as suspected source of the illness which was distributed for 250-300 families Because of Gastro Intestinal Symptoms and camel as likely source, Anthrax (Bacillus anthracis) was considered the likely cause.

19. Initial Public Health Response Patient tracking Medical examination and supportive treatment of patients Referral of complicated patients Samples of camel meat were collected Alert village residents – Not to consume camel meat – To burn or bury infected meat – Not to have contact with camel meat or other products – To properly dispose of human waste – To take care in assisting sick people As part of multi-sectoral approach an epidemiology team was sent to conduct full outbreak investigation

20. Results – Laboratory Analysis After lab analysis in CDC it was confirmed a plague outbreak had occurred.

21. Plague

22. Epidemiological Assessment Outbreak site The outbreak took place in three villages in Kang District, Nimroz Province, Southwest Afghanistan

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