This document summarizes surveillance data from Afghanistan's Disease Early Warning System (DEWS) between 2007-2012. It describes trends in priority diseases like acute respiratory infections (ARI), diarrhea, malaria, and measles. Key findings include that ARI cases show a cyclical pattern peaking in winter. The top ten provinces for various diseases are identified. For example, in 2012 the top provinces for pneumonia cases were Kabul, Nangarhar, Kandahar, Herat, and Balkh. The data aims to inform Ministry of Public Health decision-making.

1. Islamic Republic of Afghanistan
Ministry of Public Health
2013 Health Results Conference
January 13th and 14th 2013 – Kabul
SESSION: 2nd Day, Session 05
Surveillance/DEWS Data
Analysis and Results– 2007-2012
Presenter: Dr. Khwaja Mir Islam Saeed
MD (KMU), MSc-HPM (AKU), FELTP (NIH-ISB)
Director Surveillance/DEWS, ANPHI, MoPH

2.  Surveillance/DEWS Directorate is a vital department of ANPHI
involved in routine reporting of priority diseases and outbreak
investigations
 It is National Focal Point (NFP) for International Health
Regulations (IHR2005)
 In Afghanistan, DEWS was first established in mid-December
2006, with technical support of WHO and financial support of
USAID
 DEWS is a sentinel site based surveillance system for weekly
reporting of infectious diseases morbidity and mortality
 While daily reporting system for injuries and seasonal diseases
are done by through Codan Radio system

3. Surveillance/ DEWS
International Central Office MOPH and
Agencies NGOS
CER CWR NR NER WR SR ER SER
55 SS in 4 49 SS 5 37SS in 4 41 SS in 4
Provinces Provinces Provinces Provinces
30 SS in 4 43 SS in 4
Provinces Provinces 41 SS in 5 34SS in 4
Provinces Provinces
Daily Surveillance for seasonal diseases and injuries from 34 provinces

5.  To describe the pattern of morbidity and
mortality due to priority diseases and
explain burden of outbreaks in
Afghanistan
 To provide evidence for MoPH and
partners to take informed decisions
 To encourage and improve data use and
culture of action based on information

6.  Study Design: Analysis of Surveillance database
including routine reports, outbreak and lab reports
 Sampling: All weekly, daily and outbreaks reports (line
lists) with lab data 2007-2012
 Disease Under surveillance: 16 priority diseases
including ARI, Diarrheal Diseases, Meningitis/Severely ill
child, Acute Viral Hepatitis, Vaccine Preventable
diseases, Malaria, Typhoid Fever, Hemorrhagic Fever,
Pregnancy related deaths
 Data Management: Paper and computer based using
forms, Ms Word, Excel and Access
 Analysis and Dissemination: Descriptive analysis in
term of person, place and time

7. Years Sentinel Weekly Daily Outbreak
Sites Reports Reports Reports
2007 123 3143 298 129
2008 130 6731 298 235
2009 177 7871 298 232
2010 245 10349 298 217
2011 283 13544 248 329
2012 330 15870 248 358
Total 330 57508 1688 1500

8. Cyclical trend of ARI ( Cough & Cold and Pneumonia)
as percentage of total clients 2007-2012
35.0% C&C
Pneumonia
Linear (C&C)
30.0% Linear (C&C)
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Jan
Jan
Jan
Jan
Jan
Jan
Jul
Jul
Jul
Jul
Jul
Jul
Mar
Mar
May
Sep
Mar
May
Sep
Mar
May
Sep
May
Sep
Mar
Sep
Mar
May
Sep
May
Nov
Nov
Nov
Nov
Nov
Nov
2007 2008 2009 2010 2011 2012

9. Cyclical trend of ARI and ADD as percentage of total
clients 2007-2012
ADD ARI
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Jan
Jan
Jan
Jan
Jan
Jan
Sep
Sep
Jul
Jul
Jul
May
Sep
May
Sep
May
Sep
Jul
Jul
May
Sep
Jul
May
May
Mar
Nov
Mar
Nov
Mar
Nov
Mar
Nov
Mar
Nov
Mar
Nov
2007 2008 2009 2010 2011 2012

10. Cyclical trend of malaria and typhoid fever as
percentage of total clients 2007-2012
3.0%
Malaria
Typhoid F.
Linear (Malaria)
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jan
Jan
Jan
Jan
Jan
Jan
May
May
May
May
May
May
Mar
Jul
Sep
Mar
Jul
Sep
Mar
Jul
Sep
Mar
Jul
Sep
Mar
Jul
Sep
Mar
Jul
Sep
Nov
Nov
Nov
Nov
Nov
Nov
2007 2008 2009 2010 2011 2012

11. Top ten provinces with Pneumonia cases as
percentage of total clients, 2012
10%
9%
8%
7%
6%
5%
9%
4% 8%
7%
3%
5%
5% 5% 4% 4% 4%
2% 4% 4% 4% 4%
1%
0%

12. Top ten provinces with percentage of Diarrheal
Diseases from total clients, 2012
18%
16%
16% 16%
16%
15%
14% 15%
14%
14% 13% 13% 13%
12% 12%
12% 12%
10%
8%
6%
4%
2%
0%

13. Top ten provinces with percentage of Malaria cases
from total clients, 2012
2.50%
2.15%
2.00%
1.97% 1.95%
1.50%
1.34%
1.00% 1.04% 1.03%
0.89% 0.88%
0.81%
0.50%
0.50% 0.47% 0.46% 0.45%
0.00%

14. Top ten provinces with percentage of Acute viral
hepatitis cases from total clients, 2012
3000
2500
2498
2227
2000
1500
1000
500 516
440
368
319
261 260
192 178 131
0

15. Top ten provinces with percentage of Measles cases
from total clients, 2012
3500
3000
2500
2000
1500
1000
500
0

16. Top ten districts with percentage of ARI ( cough &
cold and Pneumonia) cases from total clients, 2012
Chapa Dara
Paghman
Kharwar
Dur Baba
Jabalussaraj
Fayzabad
Dara-I-Pech
Hisa-I- Awali Bihsud
Qarabagh
Muqur
Azra
Kohistan
0% 10% 20% 30% 40% 50% 60% 70%

17. Top ten districts with percentage of Acute Watery
Diarrheal cases from total clients, 2012
Dawlat Shah
Shahidi Hassas
Nawa-I- Barak Zayi
Dahana-I- Ghuri
LalPur
Dand Wa Patan
Bala Buluk
Arghandab
Kohistan
Jabalussaraj
Dawlatabad
Muqur
0% 10% 20% 30% 40% 50%

18. Top ten districts with number of Measles cases from
total clients, 2012
Maydan Shahr
Saydabad
Shinwar
Lashkar Gah
Kunduz
Khogyani
Jaji
Mihtarlam
Khost(Matun)
Mazari Sharif
Kabul
Jalalabad
0 500 1000 1500 2000 2500 3000

19. Top ten districts with percentage of Malaria cases
from total clients, 2012
Narang (Taragn -o-Badil)
Jaji
Qarghayi
Bar Kunar
Sarobi
Dawlat Shah
Dila
Maywand
Chawki
Nari
LalPur
Dand Wa Patan
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0%

20. Weekly trend of ARI (pneumonia) by age groups in
2012
18000
16000
14000
5 Years & over
<5 Years
12000
10000
8000
6000
4000
2000
0

21. Weekly trend of diarrheal diseases by age groups in
2012
35000
30000
25000
20000
15000
10000
5000
0
<5 Years 5 Years & over

22. Weekly trend of ARI Measles cases by age groups in
2012
<5 Years 5 Years & over
400
350
300
250
200
150
100
50
0

23. Weekly trend of Typhoid fever by age groups in 2012
<5 Years 5 Years & over
2000
1800
1600
1400
1200
1000
800
600
400
200
0
W1
W5
W3
W7
W9
W13
W27
W31
W21
W23
W25
W37
W39
W29
W33
W35
W17
W11
W15
W43
W19
W47
W41
W45

24.  Case Fatality Rate (CFR) Meningitis/SIC, 2007-2012
14.0
12.0
Case Fatality Rate(%)
10.0
8.0
6.0
4.0
2.0
0.0
Oct
Apr
Apr
Oct
Oct
Oct
Oct
Oct
Apr
Apr
Apr
Apr
Jan
Jan
Jan
Jan
Jan
Jan
Jul
Jul
Jul
Jul
Jul
Jul
2007 2008 2009 2010 2011 2012

25.  Cyclical trend of Case Fatality Rate (CFR)
Pneumonia and Diarrheal Diseases, 2007-2012
0.9 0.25
0.8
Diarrheal Diseases CFR
0.7 0.20
Pneumonia CFR
0.6
0.15
0.5
0.4
0.10
0.3
0.2 0.05
0.1
0.0 0.00
Jan
Apr
Jul
Jan
Apr
Jul
Jan
Apr
Jul
Jan
Apr
Jul
Jan
Apr
Jul
Jan
Apr
Jul
Oct
Oct
Oct
Oct
Oct
Oct
2007 2008 2009 2010 2011 2012
ADD-CFR Pn-CFR

26.  Trend of watery diarrheal with dehydrations
(suspected cholera) and CFR, 2007-2012
Cases CFR(%)
140000 0.70
120000 0.60
100000 0.50
Percentages
80000 0.40
Cases
60000 0.30
40000 0.20
20000 0.10
0 0.00
2007 2008 2009 2010 2011 2012

27. 250
AWD / Sus Cholera Susp CCHF Susp Pertusis Susp Measles
Number of Outbreaks Investigated and
200
150
100
50
0
2007 2008 2009 2010 2011 2012

28. 100%
90%
80%
70%
Percentages
60% 2012
2011
50%
2010
40%
2009
30% 2008
20% 2007
10%
0%
Surveillance Regions

30. Number and type of injuries 2009-2012 Number of Death due to injuries, 2009-2012
60000 2009 2010 2011 2012
1400
50000
1200
40000 1000
2009
800
30000 2010
2011
2012 600
20000
400
10000
200
0
0
Burn Criminal Explosion Natural Traffic
Burn Criminal Explosion Natural Traffic

31. 0
10000
20000
40000
50000
60000
70000
30000
Badakhshan
Badghis
Baghlan
Balkh
Bamian
Daikondy
Farah
Faryab
Ghazni
Ghor
Hilmand
Hirat
Jawzjan
Kabul
Kandahar
Kapisa
Khost
Kunarha
Kundoz
Laghman
Logar
Midan Wardak
Neemroz
Ningarhar
Nooristan
Orozgan
Paktia
Paktika
Panjsheer
Parwan
Samangan
Sar-e-pul
Takhar
Zabul

32.  Sustainability of Surveillance system
 White area in some provinces
 Poor coordination among stakeholders
 Turn-over of trained staff
 Less clear role and responsibilities of different
partners
 Lab limitation for infections and toxicology
 IHR (2005) implementation as a legal requirement
 Use of data
 Dispersion and duplications of surveillance systems
 Implementation of Influenza surveillance System
 Security concern

33.  Financial support of current successful/DEWS
surveillance system for future years
 Expansion of BPHS coverage to white areas
 Development and strengthening of coordination
 Clear-cut role and responsibilities for
stakeholders
 Motivation and maintaining of staff
 Strengthening Lab support of surveillance
System
 Supporting IHR-2005 implementations
 Encouragement and promotion of data use
 Establishment of Integrating Disease
Surveillance System (IDSR)

34. Figure-1: Proposed model-1: IDSR information flow Figure 2: Proposed model-II: Information flow
APHI – Surveillance APHI – Surveillance
National Level National Level
unit unit
CDs I I
monthly D D
(IDSR) R R
S S
Provincial APHI-Provincial APHI-Provincial
HIMS surveillance focal point Provincial Level surveillance focal point Provincial Level
manager
CDs I I I
monthly D D D
H (IDSR) R R R
M S S S
I M W
W I
S K N K I
D L L
L D
Y
R Y Y R
S
S
Health facility level N
Health facility level N
(Forms now in use: - IDSR-wkly, Tb, EPI, Polio & HMIS ) O
(Forms now in Use: - DEWS-wkly, Tb, EPI, Polio & HMIS ) O
T
T
I
N I
F N
O F
I O
T I
A T
I A
B I
F B
L F
I L
E I
A E
A
B
B
L
L
E
E
Community level
(Teams currently:- DEWS, Tb*, EPI, Malaria, Polio & HMIS )
Community level
(Teams currently:- DEWS, Tb, EPI, Malaria, Polio & HMIS )
*TB is not notifiable, but suspected cases detected are referred to the health facility (HF) *TB is not notifiable, but suspected cases detected are referred to the health facility

35. Thanks
director.surveillance@gmail.com
Phone: 0093(0)202301366, cell: 0093700290955