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Table of ContentsAbbreviation.............................................................................4
Preface......................................................................................6
General principle and practice for Diseases Surveillance..............71. IntroductIon...............................................................................8
2. natIonal notIfIable dIseases.....................................................12
Notifiable Diseases Case Definitions..............................................141. avIan Influenza (H5n1) (Last updated on 14 JuLy 2008)...........15
2. antHrax (Last updated on 14 JuLy 2008)..................................17
3. bacterIal MenIngItIs (Last updated on 20 June 2008)...............18
4. brucellosIs (Last updated on 20 June 2008)............................19
5. cHolera (Last updated on 28 February 2005)..........................19
6. dengue/dHf (Last updated on 14 JuLy 2008)...........................20
7. dIpHtHerIa...............................................................................21
8. Japanese encepHalItIs (Last updated on 15 January 2005)........22
9. leptospIrosIs (Last updated on 27 september 2006)................23
10. Measles (Last updated on 20 June 2008)...............................24
11. MuMps (Last updated on 20 June 2008).....................................24
12. pertussIs/ WHoopIng cougH
(Last updated on 20 June 2008)........................................................25
13. nIpHa vIrus....................................................................................26
14. plague (Last updated on 15 January 2005)...............................27
15. polIoMyelItIs (Last update on JuLy 2008)...................................28
16. rabIes (HuMan) (Last updated on 20 June 2008).......................28
17. rubella and congenItal rubella syndroMe
(Last updated on 14 JuLy 2008).........................................................29
18. scrub typHus (Last updated on 20 June 2008).........................31
19. severe acute respIratory syndroMe (sars)
(Last updated on 20 June 2008)........................................................31
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20. sHIgellosIs....................................................................................32
21. sMallpox (Last updated on 27 september 2005).......................33
22. tetanus (Last updated1 June 2004)............................................33
23. typHoId fever (Last updated on 20 June 2008).........................34
24. vIral HepatItIs (Last updated on 20 June 2008).......................35
25. otHers: any unusual dIseases sHould be notIfIed......................36
Reporting system..............................................................................371. reportIng unIts for surveIllance................................................38
2. role of varIous personnel at functIonarIes................................38
Analysis and interpretation of data................................................411. analyzIng surveIllance data......................................................42
2. obJectIves of surveIllance data analysIs..................................42
3. WHat to analyse – at WHIcH level?............................................43
4. WHen sHould analysIs be done?................................................43
5. HoW to perforM analysIs?........................................................44
Outbreak Investigation.....................................................................491. WHy an outbreak Has to be InvestIgated?..............................50
2. reportIng and respondIng to an outbreak................................62
3. outbreak InvestIgatIon steps...................................................64
Samples collection, storage & transportation................................73Feedback................................................................................81
1. uses of feedbacks....................................................................82
2. types of feedbacks...................................................................82
Monitoring and Supervision............................................................84References........................................................................................89
Annexes............................................................................................91
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20. sHIgellosIs....................................................................................32
21. sMallpox (Last updated on 27 september 2005).......................33
22. tetanus (Last updated1 June 2004)............................................33
23. typHoId fever (Last updated on 20 June 2008).........................34
24. vIral HepatItIs (Last updated on 20 June 2008).......................35
25. otHers: any unusual dIseases sHould be notIfIed......................36
Reporting system..............................................................................371. reportIng unIts for surveIllance................................................38
2. role of varIous personnel at functIonarIes................................38
Analysis and interpretation of data................................................411. analyzIng surveIllance data......................................................42
2. obJectIves of surveIllance data analysIs..................................42
3. WHat to analyse – at WHIcH level?............................................43
4. WHen sHould analysIs be done?................................................43
5. HoW to perforM analysIs?........................................................44
Outbreak Investigation.....................................................................491. WHy an outbreak Has to be InvestIgated?..............................50
2. reportIng and respondIng to an outbreak................................62
3. outbreak InvestIgatIon steps...................................................64
Samples collection, storage & transportation................................73Feedback................................................................................81
1. uses of feedbacks....................................................................82
2. types of feedbacks...................................................................82
Monitoring and Supervision............................................................84References........................................................................................89
Annexes............................................................................................91
Developed by:
Sonam Wangchuk (MSc)Head & MicrobiologistPublic Health LaboratoryDoPH, Ministry of Health
List of contributors:Dr. K.P. Tshering (MD)Head & NeonatologistDepartment of Pediatrics JDWNRH - Thimphu
Dr. H.K. Gurung (MD)PediatricianLungtenphu Army HospitalArmy HQ – Thimphu
Dr. Dupthop Sonam (GMP)Chief Medical Officer Paro District Hospital
Tandin Dorji (MPH)Chief Program OfficerCommunicable Disease DivisionDepartment of Public Health, MoH
Tshering Dorji (BSc)Medical TechnologistPublic Health LaboratoryDoPH, Ministry of Health
Sangay Zangmo (BSc)Medical TechnologistPublic Health LaboratoryDoPH, Ministry of Health
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Abbreviation
ACO Assistant Clinical Officer AES Acute Encephalitis Syndrome AFP Acute Flaccid Paralysis ANM Auxiliary Nurse Midwifery BHU Basic Health UnitCMO Chief Medical Officer CoV Corona Virus CRS Congenital Rebella Syndrome CSF Cerebrospinal Fluid DHF Dengue Hemorrhagic FeverDHO District Health Officer DSS Dengue Shock SyndromeELISA Enzyme Linked Immuno-Sorbant AssayFA Fluorescent antibodyGDMO General Duty Medical Officer GIS Geographical Information System H5N1 Heme-agglutinin 5 Neuraminidase 1HA Health Assistant HAV Hepatitis A Virus HBc Hepatitis B core antigen HDV Hepatitis D Virus HEV Hepatitis E Virus HIMS Health Information Management SystemIEC Information, Education & Communication IFA Immuno-Fluorescent AntibodyIgG Immunoglobulin GIgM Immunoglobulin MMS Medical Specialist OPD Outpatient department OPV Oral Polio Vaccine ORI Outbreak Response Intervention PCR Polymerase Chain Reaction
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PHA Passive HemeagglutinationPHL Public Health LaboratoryRDS Respiratory Distress Syndrome RNA Ribonucleic AcidRTT Rapid Response TeamVAPP Vaccine Associated Paralytic PolioWHO World Health Organization
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Preface
Communicable diseases continue to be a major public health problem in the developing countries. Majority of these diseases cause massive outbreaks periodically in the community causing high morbidity and mortality. While the emerging diseases are on the rise, some of the communicable diseases have re-emerged causing dent to the progress of public health activities.
Similarly, the public health in Bhutan is also threatened by the existing, emerging and the re-emerging communicable diseases. Despite the implementation of multiple public health activities to prevent infection and promote the health care system, communicable diseases such as acute respiratory infection and diarrheal disease continue to be a burden in the country.
Even though Bhutan has made good progress in controlling and preventing some vaccine preventable diseases like polio, measles and rubella, the country is now under threat from the emerging tropical and zoonotic diseases. If intervention is not implemented, the country will be burdened with many new diseases. To understand the burden of existing communicable diseases and its trend, disease surveillance plays a critical role. The surveillance will provide technical information to predict outbreaks and also relevant control and prevention measures. Currently, Bhutan has no systematic diseases surveillance system in place for infectious diseases which have high epidemic potential to cause high morbidity and mortality. Therefore, the Ministry of Health has superseded the previous notifiable diseases list and came out with a new list of diseases that are the country’s priority diseases as notifiable diseases that needs to be notified mandatory to the Ministry from all health facilities in the country.
This operational manual on the “National Notifiable Diseases Surveillance guideline” covers case definition of each notfiable disease and reporting mechanism to be used by of all categories of health workers in the hospitals and BHU. This notifiable disease surveillance is intended to institute the surveillance system and implement timely interventions.
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Section IGeneral principle and practice for
Diseases Surveillance
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1. IntroductionNotifiable Disease Surveillance will be a surveillance programme in the country. It is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. It is also expected to provide essential data to monitor progress of on-going disease control programme especially the vaccine preventable diseases and help allocate health resources more efficiently.
All outbreaks cannot be predicted or prevented. However, precautionary measures can be taken within the existing health infrastructure and service delivery to reduce risks of outbreaks and to minimize the scale of the outbreak if it occurs. The course of an epidemic is dependent on how early the outbreak is identified and how effectively specific control measures are applied. The epidemiological impact of the outbreak control measures can be expected to be significant only if these measures are applied in time. The frequency of the occurrence of epidemics is an indication of the inadequacy of the surveillance system and preparedness to identify and control outbreaks in a timely manner.
The effectiveness with which national programmes are implemented and monitored, the alertness for identification of early warning signals and the capacity for initiating recommended interventions in a timely manner are important to achieve the above objectives.
1.1 Surveillance
The final link in the surveillance chain is the application of surveillance data to prevention and control. Surveillance is the backbone of public
Surveillance is defined as an ongoing systematic collection, collation, analysis, and interpretation of data and dissemination of information to those who need to know in order that action is taken.
A more complete definition of surveillance is ‘ the ongoing systemic collection, analysis and interpretation of health data essential to planning , implementation and evaluation of public health practices closely integrated with timely dissemination of these date to those who need to know.
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health programmes and provides information so that effective action can be taken in controlling and preventing diseases of public health importance.
Most notifiable diseases require immediate action – within hours/day - in order to prevent large scale epidemics and deaths unlike some other diseases for which action may be taken in weeks, month and even years. Key elements of all surveillance system involve six key elements:
Table-1 highlights the extent of surveillance activities required to perform at various levels under decentralized notifiable diseases surveillance system.
Table-1 Surveillance activities
Activities BHU District National
Detection and notification of cases +++ ++ -
Collection and consolidation of data + +++ +++
Analysis and interpretation + +++ +++
Investigation and confirmation +++ +++ ++
Feedback + +++ +++
Dissemination + ++ +++
Action ++ +++ +
- No activity + Some activity ++ More activity +++ Great deal of activity
A. Detection and notification of health eventB. Investigation and confirmation (epidemiological, clinical, laboratory)C. Collection of dataD. Analysis and interpretation of dataE. Feed back and dissemination of resultsF. Response – a link to public health programme specially actions for prevention and control
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1.2 Uses of surveillance1. Recognize cases or cluster to trigger interventions to prevent
transmission or reduced morbidity and mortality2. Assess the public health impact of health events or determine
and measure trends3. Demonstrate the need for public health interventions
programmes and resources and allocate resources during public health planning
4. Monitor effectiveness of prevention and control measures5. Identify high-risk groups or geographical areas to target
interventions and guide analytical studies6. Develop hypothesis that lead to analytic studies about risk
factors for disease causation, propagation and progression
1.3 Surveillance planning: To plan any disease control programme and to identify and control outbreak, it is important to know who get the diseases? how many get them?, where do they get them?, when do they get them?, and why do they get them? There are five steps in the surveillance procedures, which must be carried out at each level, including BHU’s. Each level must have capacity to analyzing and using surveillance data for early detection, prevention and control of outbreaks. The five steps are:• Collection of data, • Compilation of data, • Analysis and interpretation,• Follow up action and • Feedback.
1.4 Pre-requisites for effective surveillancePrerequisites for effective surveillance are • Use of standard case definitions• Ensure regularity in reporting• Action on the report
For developing and carry out an effective notifiable disease surveillance system, the health workers must be clear about 1. What information to gather?2. How often to compile and analyze the data?3. How often and to whom to report?4. What proforma or formats to use?
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5. What action to take?The data collected should be uniform, regular and timely. Standard case definitions are important to ensure uniformity in reporting so that all health centers use the same criteria for reporting cases.
1.5 Types of surveillances1. Syndromic – diagnosis made on the basis of clinical pattern
by paramedical personnel in the community base on broad categories of presentation like fever, diarrhea, etc.
2. Presumptive – Diagnosis made on typical history and clinical examination by medical officers. The validity of presumptive diagnosis of surveillance conditions will be higher than that of the syndromic one undertaken by the health worker.
3. Confirmed – Clinical diagnosis confirmed by an appropriate laboratory test. Though it is ideal to have all diseases under surveillance confirmed by lab tests but it is not feasible.
1.6 Methods of data collectionSeveral methods can be used for collecting data. While routine reporting (passive surveillance) is universalized, other methods are need and area specific. These include:a) Passive surveillance b) Active surveillance c) Sentinel surveillance d) Laboratory surveillance e) Sample surveysf) Outbreak investigationsg) Special studies
a) Passive surveillance (Routine reporting): Ministry of Health requires all cases and deaths in every health centre. This is done through routine reporting base on the frequency prescribed by Health Information Management System (HIMS). However, unless surveillance components are identified and transferred the information to concern programme data is usually not analyzed for appropriate action.
b) Active surveillance: Active surveillance is resource intensive and usually done for disease that has case decline to negligible level especially vaccine preventable diseases like Polio eradication, Leprosy
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or Measles Elimination, etc. Active surveillance is applied for outbreaks to disrupt the transmission chain and reduce mortality rate by initiating early treatment.
c) Sentinel Surveillance: A sentinel surveillance system is developed to obtain more reliable and extensive disease related information than one that is available through the routine reporting. Since the sentinel centers are carefully selected and because the number of the reporting units is much smaller, it is easier to maintain the quality and regularity of the reports.
d) Laboratory surveillance: Laboratory surveillance plays an important part in confirming diseases since regular summary data can at best be presumptive. The validity of changing trends in suspect cases and presumed cases made by Medical Officers can be confirmed only by laboratory testing.
e) Sample Survey: Surveys give reliable epidemiological information. These are particularly useful to collect baseline data prior to the lunch of a large control programme, especially if such data is lacking through other sources.
f) Outbreak investigation: Outbreak investigation is the primarily method of confirming emerging infections. Changes in trends observed and suspected outbreaks are confirmed by outbreak investigation. Outbreak investigations provide a rich source of epidemiological information. The outbreak should be investigated to ascertain its etiology and understand why they occurred as well as to identify high risk area and groups.
g) Special studies: Special studies are required to study problems that are not addressed through the method of data collection listed above.
2. National Notifiable Diseases A notifiable disease is any disease that is required by law or heath authority to allow authority to monitor the disease and provide early warning of possible outbreaks. The notifiable disease will differ from country to country base on disease epidemiology but in Bhutan’s context, notifiable diseases are selected applying following criteria.
2.1 Criteria for selection of notifiable disease1. Does the disease condition have high health impact (morbidity,
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mortality, disability?2. Does it have significant epidemic potential?3. Is it a target of a specific national, regional or international
disease control programme?4. Will the information collect lead to significant public health
action?
2.2 List of notifiable diseases for surveillanceThe lists of national notifiable diseases (Table-2) are country’s priority diseases selected based on above four criterions. However, the list will be updated periodically and list also includes some of the diseases that are of regional and international importance or concern although they are not detected in country.
Table- 2 List of notifiable diseases / agents
Sl.No Notifiable diseases / agents Sl.No Notifiable diseases /
agents
1 Avian influenza 15 Poliomyelitis
2 Anthrax 16 Rabies (in human)
3 Bacterial Meningitis 17 Rubella / CRS
4 Brucellosis 18 Tetanus
5 Cholera 19 Typhoid fever
6 Dengue and DHF 20 SARS
7 Diptheria 21 Scrub Typhus
8 Japanese encephalitis 22 Shigellosis
9 Leptospirosis 23 Smallpox
10 Measles 24 Viral hepatitis
11 Mumps 25 Others 1
12 Nipha virus
13 Pertusis
14 Plague
1 Any other unusual diseases should also be notified
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Section IINotifiable Diseases Case Definitions
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1. Avian Influenza (H5N1) (Last updated on 14 July 2008)
Clinical case definitionA person affected by influenza A (H5N1) infection can present with any form of respiratory illness. Nonetheless, they generally fulfill one or more of the following epidemiology exposure in the 7 days prior to symptom onset.
Close contact (within 1 metre) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable, or confirmed H5N1 cases.
Exposure (e.g. handling, slaughtering, defeathering, butchering, preparation for consumption) to poultry or wild birds or their remains or to environments contaminated by their faeces in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last 6 months.
Consumption of raw or undercooked poultry products in an area where H5N1 infections in animals or humans have been suspected or confirmed in the last 6 months;Close contact with a confirmed H5N1 infected animal other than poultry or wild birds (e.g. cat or pig).
Handling samples (animal or human) suspected of containing H5N1 virus in a laboratory or other setting.
Laboratory Criteria for diagnosisOne of the following positive results conducted in a national, regional or international influenza laboratory whose H5N1 test results are accepted by WHO as confirmatory:
• Isolation of an H5N1 virus;• Positive H5 PCR results from tests using two different PCR targets,
e.g. primers specific for influenza A and H5 HA;• A fourfold or greater rise in neutralization antibody titre for H5N1
based on testing of an acute serum specimen (collected 7 days or less after symptom onset) and a convalescent serum specimen. The convalescent neutralizing antibody titre must also be 1:80 or higher;
• A microneutralization antibody titre for H5N1 of 1:80 or greater in a
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single serum specimen collected at day 14 or later after symptom onset and positive result using a different serological assay, for example, horse red blood cell haemagglutination inhibition titre of 1:160 or greater or an H5-specific western blot positive result.
Case classification
Suspected caseAn individual with acute lower respiratory illness and meets epidemiological descriptions.
Probable case• An individual meeting the criteria for a suspected case, with
infiltrates or evidence of an acute pneumonia on chest radiograph plus evidence of respiratory failure (hypoxemia, severe tachypnea), OR
• An individual meeting the criteria for a suspected case, with positive laboratory confirmation of an influenza A infections but insufficient laboratory evidence for H5N1 infections, OR
• An individual dying of an unexplained acute respiratory illness who is considered to be epidemiologically linked by time, place, and exposure to a probable or confirmed H5N1 case.
Confirmed caseA clinically compatible individual fulfilling the laboratory and epidemiological criteria
Reporting criteria for Human Influenza A (H5N1) infection (Last updated on 12 March 2008)
An individual fulfilling both the Clinical Criteria AND Epidemiological Criteria should be reported to IHR for further investigation.
Clinical Criteria• A person with acute respiratory illness, characterized by fever
(temperature >38C) AND one or more of the following:• Cough, sore throat, shortness of breath, and difficulty breathing;
OR• Person with severe pneumonia; OR• Person died of unexplained acute respiratory illness.
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Epidemiological Criteria• One or more of the following exposures in the 7 days prior to
symptom onset: contact with a human case of influenza A (H5N1); OR
• Contact with poultry or wild birds or their remains or to environments contaminated by their faeces in countries/areas with documented avian influenza H5N1 infection in birds and/or humans in the recent 6 months OR
• Consumption of raw or undercooked poultry products in countries/areas with documented avian influenza H5N1 infection in poultry and/or humans in the recent 6 months, OR
• Close contact with a confirmed H5N1 infected animal other than poultry or wild birds; OR Worked in a laboratory that is processing samples from persons or animals that are suspected from avian influenza infection
2. Anthrax (Last updated on 14 July 2008)
Clinical case definitionAn acute illness characterized by several clinical forms summarized as follows:a) Localized form:
Cutaneous: skin lesion evolving over 1 to 6 days from a papular through a vesicular stage, to a depressed black eschar invariably accompanied by oedema that may be mild to extensive.
b) Systemic forms:I. Pulmonary (inhalation): brief prodrome resembling acute viral
respiratory illness, followed by rapid onset of hypoxia, dyspnoea and high temperature, with X-ray evidence of mediastinal widening.
II. Intestinal: abdominal distress characterized by nausea, vomiting, anorexia, fever, severe abdominal pain, haematemesis, bloody diarrhea and ascites.
III. Oropharyngeal: sore throat, dysphagia, fever, regional lymphadenopathy in the neck and toxaemia.
IV. Meningeal: acute onset of high fever possibly with convulsions and loss of consciousness, meningeal signs and symptoms.
Laboratory criteria for diagnosis• Isolation of Bacillus anthracis from clinical specimens (blood,
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lesions, discharges) by reference laboratory• Demonstration of Bacillus anthracis in a clinical specimen by
microscopic examination of stained smears (vesicular fluid, blood, cerebrospinal fluid, pleural fluid, stools)
• Positive serology (ELISA, Western Blot, toxin detection, chromatographic assay, fluorescent antibody test).
Case classification (humans)
Suspected: A case that is compatible with the clinical description and has an epidemiological link to confirmed or suspected animal cases or contaminated animal products
Probable: Not applicable
Confirmed: A suspected case that is laboratory-confirmed.
3. Bacterial Meningitis (Last updated on 20 June 2008)
Clinical case definitionAcute bacterial disease with sudden onset of fever, intense headache, nausea, vomiting, neck stiffness and petechial rash with pink macules.
Laboratory criteria for diagnosis• Isolation of Neisseria meningitides, streptococcus pneumoniae
and hemophilus influenzae type B from CSF (normally sterile site).
• Positive polysaccharide antigen test in cerebrospinal fluid with other laboratory parameters consistent with meningitis.
Case classification
Suspect: Not applicableProbable: a case with clinical syndrome consistent with bacterial meningitis including haemorrhagic rash or has history of close contact with a confirmed case.Confirmed: Laboratory confirmed
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4. Brucellosis (Last updated on 20 June 2008)
Clinical Case definition An illness characterized by acute or insidious onset, with continued, intermittent or irregular fever of variable duration, profuse sweating particularly at night, fatigue, anorexia, weight loss, headache, arthralgia and generalized aching. Local infection of various organs may occur.
Laboratory criteria for diagnosis • Isolation of Brucella species from blood ior other clinical specimen
OR• IgG sero-conversion or a significant increase in antibody level or
a fourfold or greater rise in titre between acute and convalescent phase serum samples.
Case classification
Suspect: a case that meets the clinical case definition and epidemiologically linked to suspected/confirmed animal cases or contaminated animal product.
Probable: Not applicable
Confirmed: Suspect case that is laboratory confirmed
5. Cholera (Last updated on 28 February 2005)
Clinical case definition:In an area where the disease is not known to be present: severe dehydration or death from acute watery diarrhea in a patient aged 5 years or more; OR
In an area where there is a cholera epidemic: acute watery diarrhea, with or without vomiting in a patient aged 5 years or more.
Laboratory criteria for diagnosis:Isolation of Vibrio cholera O1 and O139 from stools in any patients with diarrhea
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Case classification
Suspected: A case that meets the clinical case definitionProbable: Not applicable
Confirmed: A suspected case that is laboratory confirmed
6. Dengue/DHF (Last updated on 14 July 2008)
Clinical case definition1. Dengue feverAn acute febrile illness of 2-7 days duration with two or more of the following • Headache• Retro-orbital pain• Myalgia• Arthralgia, • Rash,• Haemorrhagic manifestations,• Leucopenia.
2. Dengue Haemorrhagic fever (DHF)A probable or confirmed case of dengue fever AND Thrombocytopenia (≤ 100,000 cells per mm3); AND at least one of the following haemorrhagic manifestations:• Positive tourniquet test• Petechiae/ecchymosed/purpura/haematemesis/melaena/nasal
bleeding• Other overt bleeding: mucosa, gastroinstinal tract, injection sites
or otherAND Evidence of plasma leakage due to increased vascular permeability manifested by at least one of the following:• ≥ 20% rise in average haematocrit for age and sex• ≥ 20% drop in haematocrit following volume replacement treatment
compared to baseline• Signs of plasma leakage (pleural effusion, ascites,
hypoproteninaemia)
Dengue Shock Syndrome (DSS)All above four criteria of DHF must be present plus evidence of circulatory
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failure manifested by rapid and weak pulse and narrow pulse pressure (<20 mm Hg) OR manifested by hypotension for age and cold, clammy skin and altered mental status.Laboratory criteria for diagnosisAny one or more of the following• Isolation of dengue virus from serum, plasma and leukocytes • Demonstration of fourfold or greater change in reciprocal IgG and
IgM antibody titres to one or more dengue virus antigen in paired serum sample
• Demonstration of dengue virus antigen in serum samples by EIA/IFA
• Detection of viral genomic sequence in serum or CSF samples by PCR
Case classification
Suspected: A case compatible with the clinical case definition
Probable: A case compatible with clinical description with one or more of the following • Supportive serology (reciprocal haem-agglutination-inhibition
antibody test in serum specimen)• Epidemiologically linked with the confirmed case of dengue fever
(occurrence at same location and time as other confirmed cases of dengue fever)
Confirmed: A case confirmed by any one of the above mention lab diagnosis criteria
7. DiphtheriaClinical case definitionAn upper respiratory tract illness characterized by sore throat, low-grade fever, and adherent membrane of the tonsil(s), pharynx, and/or nose without other apparent cause.
Laboratory criteria for diagnosisIsolation of Corynebacterium diptheria from a clinical specimenCase classification
Suspected: Not applicable
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Probable: A case that meets clinical description
Confirmed: Laboratory confirmed or epidemiologically linked to laboratory confirmed case
Carrier: Presence of C. diphtheriae in nasopharynx, no symptoms.
8. Japanese encephalitis (Last updated on 15 January 2005)Clinical case definitionA case of acute encephalitis syndrome (AES) is defined as a person of any age, at any time of year, with the acute onset of fever and a change in mental status (including symptoms such as confusion, disorientation, coma, or inability to talk) AND/OR new onset of seizures (excluding simple febrile seizures). Other early clinical findings can include an increase in irritability, somnolence or abnormal behaviour greater than that seen with usual febrile illness.
Laboratory criteria for diagnosis
Presumptive: Detection of an acute phase antiviral antibody response through one of the following:• Elevated and stable serum antibody titres to Japanese
encephalitis virus through ELISA, haemagglutination/inhibition or virus neutralization assays,
• Japanese encephalitis virus-specific IgM in the serum.Confirmatory: • Detection of the Japanese encephalitis virus, antigen or genome
in tissue, blood or other body fluid by immunochemistry or immunofluorescence or PCR, or
• Presence of Japanese encephalitis virus-specific IgM in the CSF, or• A 4-fold or greater rise in Japanese encephalitis virus-specific
antibody in paired sera (acute and convalescent phases) through IgM/IgG, ELISA, haemagglutination inhibition test or virus neutralization assay, in a patient with no history of recent yellow fever vaccination and where cross-reactions to other flaviviruses have been excluded.
Case classification:
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Suspected: A case that is compatible with the clinical case definition
Probable: A suspect case with presumptive laboratory resultConfirmed: A suspect case with confirmed lab result.
9. Leptospirosis (Last updated on 27 September 2006)Clinical case definitionThe usual presentation is an acute febrile illness with headache, myalgia (particularly calf muscle) and prostration associated with any of the following symptoms/signs: a. Conjunctival suffusion b. Anuria or oliguriac. Jaundice d. Cough, haemoptysis and breathlessness e. Haemorrhages (from the intestines; lung bleeding is notorious in
some areas) f. Meningeal irritation g. Cardiac arrhythmia or failure h. Skin rash. AND history of exposure to infected animal and environment contaminated with animal urine.
Note. Other common symptoms include nausea, vomiting, abdominal pain, diarrhoea, arthralgia. The clinical diagnosis is difficult where diseases with symptoms similar to those of leptospirosis occur frequently.
Laboratory criteria for diagnosis• Isolation of pathogenic Leptospira species/ detection of leptospira
by dark field microscopy• A fourfold or greater rise in Leptospira agglutination titre between
acute and convalescent phase sera obtained at least two weeks apart and preferably conducted at the same laboratory
• A single Leptospira micro-agglutination titre greater than or equal to 400 supported by a positive ELISA IgM result.
Case classification
Suspected: A case compatible with clinical case definition
Probable: Not applicable.
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Confirmed: Laboratory confirmed.
10. Measles (Last updated on 20 June 2008)Clinical case definitionAny person in whom a clinician suspects measles infection, or Any person with fever and maculopapular rash (i.e. non-vesicular) and cough, coryza (i.e. runny nose) or conjunctivitis (i.e. red eyes)
Laboratory criteria for diagnosis:• Virus isolation • Presence of measles specific IgM antibody• Detection of measles virus by PCR
Case classification:
Suspected: A case meeting the clinical case definition in whom a laboratory investigation is not conducted and does not have epidemiologic linkage to a laboratory confirmed case.
Probable: A case that meets the clinical case definition and is linked epidemiologically to a laboratory confirmed or another epidemiologically confirmed case.Confirmed: A case that meets the clinical case definition and laboratory confirm.
11. Mumps (Last updated on 20 June 2008)Clinical case definitionAn illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting 2 days or more and without other apparent cause.
Laboratory criteria for diagnosis• Isolation of mumps virus• Detection of mumps virus by nucleic acid testing• Detection of mumps-specific IgM antibody (in the absence of recent
mumps vaccination).• IgG sero-conversion or a significant increase in antibody level or a
fourfold or greater rise in titre to mumps virus EXCEPT when there has been recent mumps-containing immunization.
Case classification
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Suspect: Not applicableProbable: A case that is compatible with clinical case definition
Confirmed: Laboratory confirmed or epidemiologically established with clinical evidences
12. Pertussis/ Whooping cough (Last updated on 20 June 2008)Clinical case definitionA cough lasting at least two weeks with at least one of the following symptoms:1. Paroxysms (i.e. fits) of coughing2. Inspiratory whooping 3. Post-tussive vomiting (i.e. vomiting immediately after coughing)
without other apparent cause
Laboratory criteria for diagnosis• Isolation of Bordetella pertussis, • Detection of genomic sequences by polymerase chain reaction
(PCR)• Positive paired serologyCase classification
Suspected: not applicable
Probable: a case that meets clinical case definitions
Confirmed: Laboratory confirmed case
13. Nipha virus Clinical case definition:The incubation period is between 4 and 18 days. In many cases the infection is mild or inapparent (sub-clinical). In symptomatic cases, the onset is usually with “influenza-like” symptoms, with high fever and muscle pains (myalgia). The disease may progress to inflammation of the brain (encephalitis) with drowsiness, disorientation, convulsions and coma. Fifty percent of clinically apparent cases die.
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Laboratory criteria:Detection of Nipha virus by PCRCase classification:
Suspect: a case that is compatible with the clinical case definition
Probable: clinical case linked with epidemiological evidences.
Confirmed: clinically suspect case with laboratory confirmed evidence.
14. Plague (Last updated on 15 January 2005)Clinical case definitionPlague is characterized by fever, chills, headache, malaise, prostration, and leukocytosis that manifest in one or more of the following clinical forms:1. Bubonic plague: Regional lymphadenitis2. Septicemic plague: Septicemia without an evident bubo3. Pneumonic plague: Plague pneumonia
a. Primary pneumonic plague: resulting from inhalation of infectious droplets.
b. Secondary pneumonic plague: Plague pneumonia, resulting from hematogenous spread in bubonic or septicemic cases.
c. Pharyngeal plague: Pharyngitis and cervical lymphadenitis resulting from exposure to larger infectious droplets or ingestion of infected tissues
Laboratory criteria for diagnosis• Isolation of Yersinia pestis in cultures from buboes, blood, CSF or
sputum, • Passive haemagglutination (PHA) test, demonstrating an at least
4-fold change in antibody titre specific for F1 antigen of Y. pestis (haemagglutination inhibition test in paired sera)
Case classification
Suspected: A case compatible with the clinical description. May or may not be supported by laboratory finding of Gram-negative bipolar coccobaccili in clinical material (bubo aspirate, sputum, tissue, blood).
Probable: A suspected case with Positive direct fluorescent
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antibody (FA) test for Yersinia pestis in clinical specimen, or Passive haemagglutination test, with antibody titre of at least 1:10, specific for the F1 antigen of Y. pestis as determined by the haemagglutination inhibition test (HI), or Epidemiological link with a confirmed case.
Confirmed: A suspected or probable case that is laboratory-confirmed.
15. Poliomyelitis (last update on July 2008)Clinical case definitionA suspected case is defined as a child less than 15 years of age presenting with acute flaccid paralysis (AFP), or as any person at any age with paralytic illness if poliomyelitis is suspected.
Laboratory criteria for diagnosisWild-type poliovirus infection• Isolation of wild poliovirus confirmed by WHO reference
Laboratory• Detection of wild-type poliovirus by PCR in WHO reference
Laboratory Vaccine-associated poliomyelitis• Isolation of Sabin-like poliovirus confirmed by WHO reference
Laboratory • Detection of Sabin-like poliovirus by PCR in WHO reference
Laboratory
Case classification
Suspect: any case of AFP including Guillian-Barre syndrome in a person under 15 years of age for any reason other than severe trauma, or paralytic illness in person of any age in which polio is suspected. The classification “suspected case” is temporary. It should be classified as probable or discarded within 48 hours of notification.
Probable: a case in which AFP is found and no other cause for the paralysis can be identified immediately. The classification o probable case is also temporary, within 10 weeks of onset the case should be reclassified as “confirmed” “compatible”, “vaccine associated” or “discarded”.
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Confirmed case: a case with acute paralytic illness, with or without residual paralysis, and isolation o wild polio virus from the stool of either the case of or its contacts.
Polio compatible case: a case in which in adequate stool specimen was not collected from a probable case within two weeks of onset of paralysis, and there is either an acute paralytic illness with polio compatible residual paralysis at 60 days, or death takes place within 60days, or the case is lost to follow up.
Vaccine associated paralytic poliomyelitis case(VAPP): a case with acute paralytic illness in which vaccine like polio virus is isolated from stool samples, and the virus is believed to be the cause of the disease. There are two possible types of VAPP: onset of AFP 4-40days after receiving OPV and has neurologic sequelae compatible with polio 60 days after the paralysis began. A case is classified as a contact VAPP when a person who has residual paralysis 60 days after the onset of AFP had contact 4-40 days before the paralytic began with a person who received OPV somewhere between 4 and 85days before the contact’s paralysis began. Discarded (not poliomyelitis) case: a case with acute paralysis for which one adequate stool specimen was obtained within 2 weeks after onset of paralysis and was negative for polio virus.
16. Rabies (human) (Last updated on 20 June 2008)Clinical case definitionAn acute neurological syndrome (encephalitis) dominated by forms of hyperactivity followed by paralytic syndromes that progress towards coma and death, usually by respiratory failure, within 4 to 7 days after the first symptom if no intensive care is instituted. Laboratory criteria for diagnosis• Detection of rabies viral antigens by direct fluorescent antibody
(FA) in clinical specimens, preferably brain tissue• (collected post mortem)• Detection by FA on skin or corneal smear (collected ante mortem)• FA positive after inoculation of brain tissue, saliva or CSF in cell
culture, or after intracerebral inoculation in mice or in suckling mice• Detectable rabies-neutralizing antibody titre in the CSF of an
unvaccinated person
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• Identification of viral antigens by PCR on fixed tissue collected post mortem or in a clinical specimen (brain tissue or skin, cornea or saliva)
• Isolation of rabies virus from clinical specimens and confirmation of rabies viral antigens.
Case classification
Human rabies:Suspected: A case that is compatible with the clinical case definition.
Probable: A suspected case plus history of contact with a suspected rabid animal.
Confirmed: A suspected case that is laboratory-confirmed
Human exposure to rabies:
Possibly exposed: A person who had close contact (usually a bite or scratch) with a rabies-susceptible animal in (or originating from) a rabies-infected area.
Exposed: A person who had a close contact (usually a bite or scratch) with a laboratory-confirmed rabid animal
17. Rubella and Congenital Rubella Syndrome (Last updated on 14 July 2008)Clinical case definition for Rubella
Suspected rubella case: An acute onset with fever, maculopapular rash (non vesicular) and one of the following: cervical, sub occipital, or post-auricular adenopathy or arthralgia/arthritis, At the measles/rubella elimination phase, suspected measles and suspected rubella are combined in a single febrile rash illness surveillance category for suspected cases.
Laboratory-confirmed rubella case: • A rubella case is a suspected case with a positive blood test for
rubella-specific IgM.• Epidemiologically confirmed rubella case
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Epidemiologically-confirmed rubella case: a patient with a febrile rash illness who has not had a blood test and has an epidemiological linkage to a laboratory-confirmed case of rubella.
Laboratory criteria for diagnosis:• Virus isolation • Presence of rubella specific IgM antibodies• Detection rubella antigen by PCR
Clinical case definition for Congenital Rubella Syndrome(CRS):
Suspected CRS: an infant aged 0-11 months presents with heart disease and/or suspicious of deafness and /or one or more of the following eye signs:• White pupil(cataract)• Diminished vision • Perpendicular movement of eyes (nystagmus)• Squint, smaller eyeball (i.e. microphthalmus) • Or larger eyeball (congenital glaucoma)
An infant’s mother has a history of suspected or confirmed rubella during pregnancy even when the infant shows no signs of CRS.
Clinically confirmed CRS case: any infants in whom a qualified physician detects at least two of the conditions from list A or one from list A and one from list B (Table-3)
Table-3List A List B
Cataract(s) Purpura
Congenital glaucoma Splenomegaly
Congenital heart disease Microcephaly
Loss of hearing Mental retardation
Pigmentary retinopathy Meningo-encephalitis
Radiolucent bone disease
Jaundice (within 24hours post delivery)
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Laboratory confirmed CRS case:• Infant with clinically confirmed CRS who has positive blood test for
rubella specific IgM.• Detection of rubella virus from the pharynx or urine of suspected
CRS.
Congenital Rubella infection: an infant who does not have clinical signs of CRS but who has a positive rubella IgM test.
18. Scrub typhus (Last updated on 20 June 2008)Clinical case descriptionScrub typhus is characterized by acute onset of fever after several days, headache, profuse sweating, myalgia, eschar, lymphadenopathy and rash.
Laboratory criteria for diagnosis • Isolation of Orientia tsutsugamushi by inoculation of patient’s blood
in white mice • Detection of specific IgM at 1:100 or higher by enzyme immunoassay,
OR at 1:32 dilution or higher by immunoperoxidase, OR at 1:10 dilution or higher by indirect immunofluorescence.
Case classification
Suspected: A case that is compatible with the clinical description.
Probable: Not applicable
Confirmed: A suspected case with laboratory confirmation
NOTE: Serological tests are complicated by the antigenic differences between various strains of the causal agent.
19. Severe Acute Respiratory Syndrome (SARS) (Last updated on 20 June 2008)
The clinical case definition of Severe Acute Respiratory Syndrome (SARS) is a patient fulfilling the following criteria:
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a. Fever (≥ 38°C); AND
b. One or more symptoms of lower respiratory tract illness (cough, difficulty breathing, shortness of breath);AND
c. Radiographic evidence of lung infiltrates consistent with pneumonia or respiratory distress syndrome (RDS); OR autopsy findings consistent with the pathology of pneumonia or RDS without an identifiable cause; AND
d. No alternative diagnosis can fully explain the illness
Laboratory criteria for diagnosis • Reverse transcription polymerase chain reaction (RT-PCR), positive
for SARS-CoV using a validated method from at least two different clinical specimens (e.g. nasopharyngeal and stool) OR the same clinical specimen collected on two or more occasions during the course of the illness (e.g. sequential nasopharyngeal aspirates) OR two different assays or repeat RT-PCR using a new RNA extract from the original clinical sample on each occasion of testing.
• Sero-conversion by ELISA or IFA• Negative antibody test on acute sate serum followed by positive
antibody test on convalescent phase serum tested in parallel. OR fourfold or greater rise in antibody titre between acute and convalescent phase sera tested in parallel.
• Isolation in cell culture from any clinical specimen and identification of SARS-CoV using a validated method such as RT-PCR.
20. ShigellosisClinical case definitionA patient experience bloody stools with abdominal cramps, and rectal pain.
Laboratory criteria for diagnosisIsolation of Shigella from the stools
Case classification
Suspected: A case corresponding to the clinical definition
Probable: Not applicable
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Confirmed: A case corresponding to the clinical definition with laboratory confirmation
21. Smallpox (Last updated on 27 September 2005)Clinical case definitionAn individual of any age presenting with:a. Acute onset of fever (≥38.3°C/101°F), malaise, and severe
prostration with headache and backache occurring 2 to 4 days before rash onsetAND
b. Subsequent development of a maculopapular rash starting on the face and forearms, then spreading to the trunk and legs, and evolving within 48 hours to deep-seated, firm/hard and round well-circumscribed vesicles and later pustules, which may become umbilicated or confluentAND
c. Lesions that appear in the same stage of development (i.e. all are vesicles or all are pustules) on any given part of the body (e.g. the face or arm)AND
d. No alternative diagnosis explaining the illness.Laboratory criteria for diagnosis• Isolation of variola virus, confirmed at a Reference Laboratory• Detection of variola virus by nucleic acid testing, confirmed at a
Reference Laboratory.
Case classification
Suspect: Not applicable
Probable: Clinical evidence AND laboratory suggestive evidence OR Clinical evidence AND epidemiological evidence.
Confirmed: A confirmed case requires laboratory definitive evidence.
22. Tetanus (Last updated1 June 2004)Clinical case definitionNeonatal: Infection with Clostridium tetani in infants less than 30 days old with progressive difficulty and inability to feed because of trismus, generalized stiffness, spasms and opisthotonus.
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Non-neonatal: Infection with Clostridium tetani in non-neonates with initial localised spasms leading to general rigidity, opisthotonus and “Risus sardonicus”.Laboratory criteria for diagnosisIsolation of Clostridium tetani from a wound
Case classification:
Neonatal case classification:
Suspected: Any neonatal death between 3 and 28 days of age in which the cause of death is unknown Or any neonate reported as having suffered from neonatal tetanus between 3 and 28 days of age and not investigated.
Confirmed: any neonate with normal ability to suck and cry during the first 2 days of life and who between 3 and 28 days of age, cannot suck normally and becomes stiff or has spasm ( i.e. jerking of muscles)
Discarded: any neonatal case or death, with above symptoms but due to other known diseases or conditions and which is clearly established either by a physician or the committee as not being tetanus.
Unable to classify:When the case or death cannot be ascertained by a physician or by a expert committee, to be a case of tetanus. 23. Typhoid fever (Last updated on 20 June 2008)Clinical case definitionAn illness characterized by high fever, malaise, headache, bradycardia, constipation or diarrhoea, rose-coloured spots on the chest, and enlarged spleen and liver.
Laboratory criteria for diagnosis • Isolation of Salmonella typhi from blood, stool, or other clinical
specimen.• Four fold rise in titre of antibody against Salmonella typhi antigen
from paired sera.
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Case classification
Suspected: a patient with fever of at least of 38 degree C for 3 or more days.Probable: a clinically compatible case that is epidemiologically linked to a confirmed case in an outbreak.
Confirmed: a suspect case with laboratory confirmed positive blood culture.
Carrier: Salmonella typhi organisms persisting in stools or urine for more than one year after onset of disease.
24. Viral hepatitis (Last updated on 20 June 2008)Clinical case definitionAcute illness typically including acute jaundice, dark urine, anorexia, malaise, extreme fatigue and right upper quadrant tenderness. Biological signs include increased urine urobilinogen and >2.5 times the upper limit of serum alanine aminotransferase.NOTE 1: Most infections occur in early childhood; a variable proportion of adult infections is asymptomatic.
Laboratory criteria for diagnosis • Hepatitis A: IgM anti-HAV positive• Hepatitis E: IgM anti-HAV and IgM anti-HBc (or HBs Antigen)
negative.• Hepatitis B: positive hepatitis B surface antigen (HBsAg) or –
preferably –IgM antibody to hepatitis B core antigen (anti-HBc)• Hepatitis D: HBsAg positive or IgM anti-HBc positive plus anti-HDV
positive (as co-infection of hepatitis B)
NOTE: For patients negative for hepatitis A or B, further testing for a diagnosis of acute hepatitis C, D, or E is recommended (hepatitis E: IgM anti-HEVpositive). HBsAg may be available, but a single positive test cannot distinguish acute from chronic infection. HBsAg positivity for more than 6 months indicates chronic infection.
Case classification
Suspected: A case that is compatible with the clinical descriptionProbable: Not applicable
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Confirmed: A suspected case that is laboratory-confirmed, For hepatitis A only - a case compatible with the clinical description, in a person who has an epidemiological link with a laboratory-confirmed case of hepatitis A (household or sexual contact with an infected person during the 15-50 days before the onset of symptoms).
25. Others: any unusual diseases should be notified
Any disease which is not included in the above notifiable disease list and which is felt to be having of public health concern should be reported for investigation.
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Section IIIReporting system
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1. Reporting Units for surveillance Figure No-1 Shows the overall reporting system of national notifiable disease surveillanceand reponsible persons at different level of health facilities1.1 BHU levelThe notifiable disease surveillance will be primarily syndromic and passive in type and each BHU will report to respective district.
1.2 District hospitals/BHU-I levelThe notifiable disease surveillance at the district/BHU-I hospital will be base on presumptive and confirmation supported by laboratory depending upon the laboratory capability to confirm notifiable diseases. The surveillance will be passive in type and each hospital will report directly to PHL with copy to respective district health authority.
1.3 National/regional referral hospitals levelAt the national/regional referral hospitals, the notifiable disease surveillance will be base on presumptive and confirmation supported by laboratory confirmation. Laboratories in national/regional will be equipped with diagnostic facilities for most notifiable diseases. The surveillance will be primarily passive in type and national and regional referral hospitals will report directly to PHL.
2. Role of various personnel at functionaries The cases that have been detected need to be transmitted to next level immediately or within time bound based on the nature of diseases. The time frame for each notifibale disease is given in notifiable disease reporting form (Annexure 1). All reporting centers will provide zero report to next higher level even if no cases were detected every month which in turn will report to national notifiable disease surveillance centre (PHL). The mode of transmission can be by fax, email, telephone or direct courier. The report made by telephone should be followed by hard copy (fax or email).
2.1. BHU levelHealth Workers (HA/ANM) will fill up notifiable disease case investigation form for each case (Annexure-2) while reporting notifiable diseases except Polio. The notifiable disease should be reported immediately to CMO who will verify and report to PHL. Health Workers will also
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send monthly zero report by filling up notifiable disease reporting form (Annexure 1) if no case has been seen to CMO; who will verify and forward to PHL with copy DHO.2.2 District hospitals level GDMO’s, ACO’s and specialists if available will fill up notifiable disease case investigation form for each case (Annexure 2) while reporting notifiable diseases except Polio. The notifiable diseases should be reported immediately to CMO/MS who will verify and report to PHL. The clinicians should also send clinical samples to lab for confirmation if lab has testing facilities. CMO/MS will also send monthly zero report if no case has been seen by filling up notifiable disease reporting form (Annexure 1) to PHL with copy DHO.
2.3 National/regional referral hospitals levelAll specialists, GDMO and ACO will fill up notifiable disease case investigation form for each case (Annexure 2) while reporting notifiable diseases except Polio. The notifiable diseases should be reported immediately to MS who will verify and report to PHL. The clinicians should also send clinical samples to lab for confirmation. MS will also send monthly zero report if no case has been seen by filling up notifiable disease reporting form (Annexure-1) to PHL.
2.4 National notifiable diseases surveillance centre (PHL)PHL will compile and report notifiable diseases status to HIMS monthly
Remember to report any unusual clustering of cases or any health event causing deaths in a shot span of time. Notifiable disease reporting time is reflected against diseases in the form. Use telephone, fax, to report immediately
Verbal report to be followed by a written cased based formIf there are no cases in that month, do not forget to report; zero reporting
District HospitalsCMO/MS
DHO
BHU’sHA & ANM
Regional Referral hospitalsMS/ focal person
Notifiable Diseases Reporting Center(Public Health Laboratory)
National Referral HospitalMS/focal person
Send copy
Monthly
Feedback (as and when required /monthly)
Report cases immediately and zero reporting monthly
Feedback (as and when required /monthly)
Report cases immediately and zero reporting monthly
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→→→→ →
→ →
Health Information & Management System (HIMS)
Monthly
Notifiable Diseases Reporting Center(Public Health Laboratory)DHO
Report cases immediately and zero reporting monthly
Feedback (as and when required /monthly)
Send copy
District HospitalsCMO/MS
Regional Referral hospitalsMS/ focal person
National Referral HospitalMS/focal person
Report cases immediately and zero reporting monthly
Feedback (as and when required /monthly)
BHU’sHA & ANM
→
Figure-1 Reporting system
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Section IVAnalysis and interpretation of data
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1. Analyzing surveillance dataAnalysis of notifiable disease surveillance data is important for detecting outbreaks and unexpected increases and decreases in disease occurrence, monitoring disease trends, evaluating the effectiveness of disease control programmes and policies. Analysis should be performed at regular intervals to identify changes in diseases reporting and provide as feedback to medical providers.Analyses of surveillance data begins with characterizing the pattern of disease reports by person, place, and time at every level. Compare patterns of disease reports at different times, in different places and among different populations. Vaccination status of cases should always be examined; if there is disease transmission in the community. Lack of vaccination is likely to be factor most strongly associated with illness. Analyses should also look at missing or inaccurate data, delay and completeness of reporting.
2. Objectives of Surveillance data analysis• Analyze and interpret the data received within 24 hours so that
action can be initiated. • Compare analysis results with thresholds to identify outbreaks and
also • Compare analysis result between regions to detect poorly
performing regions.
While collection of good quality data is important for surveillance, analysis and interpretation of this data is of equal significance. Without this, all the hard work put in by the health workers become meaningless. Data analysis provides following important outcomes• Frequency count by reporting unit helps in identifying outbreaks or
potential outbreaks• During an outbreak, analysis of the data identifies the most
appropriate and timely control measures. Analysis in terms of person, time and place will be able to focus the intervention.
• Analysis of data provides information for predicting changes of disease rates over times and enables appropriate action
• Identifies problems in the health system so that gaps can be effectively plugged.
• Identify high risk population groups to target appropriate interventions can be provided
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3. What to analyse – at which level?While data analysis should be done at all level from BHU to national level, the degree of analysis would be depend on the capacity of the persons involved. The main analysis at the district level should be up to detection of outbreaks and seasonal trends. The following analyses should be regularly performed as part of routine analysis of surveillance data.
3.1 By personDescribe the persons (cases) with vaccine-preventable diseases/other diseases identified by surveillance. Attributes of the cases include age group and sex. It may be appropriate to divide age groups based on recommended ages of vaccine administration as well as the age distribution of reported cases. Ages groups should be span a narrow age range for ages in which disease incidence is highest and a broader age range in which disease incidence is lower and interpret accordingly.
3.2 By placeDescribe the persons with vaccine preventable disease/other diseases (cases) detected by surveillance system by geographic location. Location may be defined as the place where the case was first reported, place of residence of the case, or place of hospitalization. Location may be a health centre, district or region.
3.3 By timeDescribe the distribution of cases over time. Look for changes in the number of cases over time. Time interval may be in years, months, weeks, or other unit times. Date may be defined as date of onset of illness, date of diagnosis, or date of report to public health department. Analysis by date of onset gives the most accurate representation of disease occurrence. Distribution of cases over time is most clearly presented as a graph. Compare the number of cases occurring in a current time period with the number reported during the same time period in each of the last 5 years. Compare the cumulative number of cases yea-to-date with the cumulative number of cases year-to-date of previous years.
4. When should analysis be done?Data analysis can be done at various frequencies – daily, weekly, monthly, annually. Reports should be generated either manually or computerized according to the frequency Table No.3.
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Table-3 Frequency of data analysisNo. Reports Daily Weekly Monthly Yearly
1 Timeliness and completeness of reports x x x
2 Description by time, place and person x x x x
3 Trend over time x x x x
4 Checking for crossing of threshold levels x x
5 Comparison between reporting x
6 Comparison between disease and lab data x
5. How to perform analysis?A systematic approach to analysis will help the public health manager/researcher in getting a clear picture of the situation. The steps given below are the same whether the analysis is done on a weekly basis or on a monthly or annual basis.
5.1 Steps in analysis • Convene the technical committee – preferably once a month.• Review the reports disease wise and interpret it appropriately.• Check validity of the data• Prepare a summary which is to be shared with colleague at the
same or higher level. This summary report especially the monthly report should be also used as a tool for feedback
• Take action where necessary
Analysis is one of the mainstay of the surveillance programme. A combination of accurate data and reasonable analysis is a powerful tool to identify potential and real outbreaks and takes focused action so that unnecessary morbidity and mortality are prevented. While it is important to analysis the data, it is also important that the analysis reports are sent to the appropriate authorities, both at higher level as well as at a lower level. The latter is very important as it gives the staff a tool to assess their own performance. This sort of feedback is a good motivator. However, while doing the analysis, one must be aware of the
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inherent limitations. • The quality of data may not be very high. There are various reasons
starting from inconsistent use of case definitions to difficulty in confirming case. In-depth analysis on poor quality data is not of much use.
• There is time lag between detection, reporting and analysis. The ground situation must have changed by the time of analysis.
• There is an inherent under-reporting in surveillance data; one is never able to efficiently capture all the health events that have occurred in the community. However, surveillance data gives trends which is of importance
• The data is not representative and the only way to overcome this is to increase the sources of data.
5.2 The details of the report that need to be generated are as follows:
Report 1 – Completeness and Timeliness of dataThis is one of the first reports that need to be generated. It is a reflection on the performance of the reporting units. Timeliness and completeness of reporting units is a proxy indicator of the alertness of the surveillance system. An alert system will have timeliness and completeness approaching 100%. Also completeness of reporting units gives one an idea about the reliability of the data; for example, if completeness of reports is only 50%, then the incidence of disease would be under reported by 50%. So the incidence rates and CFRs need to be read in conjunction with the completeness reports.
Report 2- Weekly/Monthly summary reportThis is second set of reports that need to be generated and consists of a subset of reports in the form of tables, graphs and maps. It is based on the compiled data of all the reporting units.
• Data must be analyzed carefully and interpreted prudently
• Ability to effective analyze, interpret and present surveillance data is an important skill for the Public Health Manager
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Tables – there are various tables, starting from the primary one giving the number of cases and deaths to tables with summarized data and rates etc.
Graphs – bar graphs to identify the incidences of diseases and deaths; pie graphs to show the load of diseases.
Maps – this will help to identify the areas where health events are occurring. Preferably data should be presented in a graphical manner so that concern health officials can review the data easily. When looking at the data of a single region/reporting unit, primary measures like cases and deaths would suffice, incidence rates and case fatality ratios are necessary for comparing data between reporting units and regions.
Some of the measures that need to be analysis are• Cases – the number of New cases that have been detected in the
specified period• Deaths – the number of deaths that have occurred in the specified
period in the community or un the institution• Incidence rate – number of new cases that have occurred in a
1000 population over a fixed period of time• Incidence rate of diseases A; No. of new cases of disease A x
100/ Mid year population in the catchment area.• Case Fatality ratio – the number of deaths from a particular
disease that have occurred per 100 cases of that particular disease. This gives an idea about the virulence of the diseases e.g. a high case fatality in a particular outbreak may be an early indication of a change in strain of the agent.
• Whether a case has been identified promptly and hence the efficiency of the surveillance system, e.g. if the cases are being identified very late, then the deaths will be high also.
• Whether a case has been managed properly and hence the effectiveness of the health services in terms of case management.
• Case fatality ratio for disease A: No. of deaths from disease A x 100/ No. of new cases of disease A
Geographical Information System (GIS)Analyzing data by place gives information about where the disease is occurring. This sort of analysis may be done manually or by using computers and GIS software. It will allow to • Detect any clustering of cases – e.g. if there is any increase in
the number of diarrhea cases, the GIS will help in checking in a
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clustering in a particular village etc. the latter has more significance.• Understand some of the risk factors that may have contributed to
the spread of disease – e.g. in the above instance if the GIS map shows the clustering to be around a water source, then one can hypothesize that this may be the source of this outbreak
• Predict any potential outbreaks e.g. if the water quality in a particular area is low, then one can predict a potential outbreak water borne disease.
Report 3 – Comparison with previous weeks/months/yearsThis report will help to detect the trend of the disease over time. It needs to be done for each disease and should do on as weekly, monthly and annual basis. Weekly analysis should compare the current week’s data with the date of the previous three week’s. Here one takes the current week’s cases and deaths and compares it with the cases and deaths for the same disease in the same region for previous 3 weeks. If there is increasing trend, this should alter the district authorities to take the necessary preventive action.
Monthly and yearly analysis looks at the secular trend and tries to identify the months in the year when the disease tends to peak. This should alert the public health managers about the possibility of intervention top prevent the peak. The main purpose of this report is to understand the trend over times.
Report 4 – Crossing threshold valueThis report will help to identify outbreak early enough. The weekly/monthly data should be always compared with established thresholds. These can be obtained in the following manners:• Pre-existing national/internationally developed threshold e.g. a
single case of measles in a tribal area is considered as an outbreak and reason for action
• Based on historical data e.g. if data for a particular disease is available, then the monthly mean should be calculated for the previous three years (excluding months in which there was an outbreak).
• Increasing trends of the disease over a short duration of time (e.g. in weeks).
Report 5 – Comparison between the reporting units in the regionThis is a useful report and is a good proxy indicator for the quality of the
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data generated. One compares the incidence rates and case fatality ratios for the current months between the various reporting units. This should ideally be done from the block and above level. If there is sharp rises or falls in the incidence rates, then one should look more carefully at the veracity of the reports from that reporting unit. In a given region or district, one will not expect a major difference in incidence rates, etc unless there are some specific interventions there.
Report 7 – Comparison of reports received from the public health sources and the lab sourcesIt is important to correlate the findings of the data analysis with the availability of other data obtained from labs. This comparison may be vis-à-vis like case diagnosed in the labs and the number of cases seen by the providers, the water quality reports and the case of water borne diseases and the entomological data and the case of vector borne diseases. Once again this sort of comparison should validate the data as well as identify potential areas of problems in data collection and generally surveillance systems.
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Section VOutbreak Investigation
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1. Why An Outbreak Has To Be Investigated?
Analysis of the data may reveal potential or actual outbreak. These need to be investigated and if verified, needs to be controlled. This is the basic essence of an outbreak investigation. The purpose of an investigation is to • Verify the outbreak• Recognize the magnitude of the outbreak• Diagnose the etiological agent; identify the source and the route of
transmission as well as the people at risk• Recommend measures so that the outbreak can be controlled as
well as prevented in the future.
2. DETECTING AN OUTBREAK
There are various ways in which outbreaks can be detected.
1.1 Rumour The rumour is one of the important sources of information from the community and should not be neglected. Source of information should be verified to identify outbreaks. On the other hand, key informants in the community should be diligently cultivated so they become the eyes and ears of the health services in the community. The media is also an effective source of information on any unusual health event in the community. The CMO/DHO should investigate all rumors of epidemic prone diseases recorded in the rumor registry (Table No. 5). The report on rumors will also be action based that the report of actions taken in response to rumor will need to be informed to PHL at regular intervals.
1.2 Review of routine dataThe first step in investigating an outbreak is to detect it. One of the common ways of early detection is to review the data from the routine surveillance and check if it crosses threshold levels. If the cases are
Definition of an outbreak: An outbreak or an epidemic is defined as sudden eruption/occurrence of illness in a community or a region which is clearly in excess than what is expected. While an outbreak is usually limited to a small focal area, an epidemic covers large geographic areas and has more than one focal point.
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approaching threshold levels or has crossed it, then an outbreak should be suspected. Remember to review the lab data also. Another method is to be alert for any unusual events that may be reflected in the routine data for other communicable diseases besides notifiable diseases.
Table-4 Epidemic related rumor register-A
Unique identifier reporting District
Dat
e of
rum
or
Des
crip
tion
of
rum
or
Sour
ce o
f in
form
atio
n
Villa
ge/u
rban
Blo
ck
Action taken
Epidemiological meeting Sample ORI
Table-5 Epidemic related rumor register-B
Action point for CMO/DHO Done Not done Remarks
Epi
dem
iolo
gica
l m
eetin
g
Verification of rumor by health workers of the area within 48 hours
If information is correct then health workers conducts active case search
Line listing of case with info on age/sex/location/immunization status
Confirmation of type of disease/syndrome by MO/DHO
Sample sent As specified for the disease/syndrome
(Outbreak Response
Intervention) ORI
Specific ORI as per guidelines
Warning signs of an impending outbreak• Clustering of cases or deaths in time and/or space• Unusual increase in cases or deaths• Even a single case of measles, AFP, Cholera• Occurrence of two or more epidemiologically linked
cases of meningitis, measles• Unusual isolate• Shifting age distribution of cases• High vector density• Natural disaster
52
Warning signs of an impending outbreak• Clustering of cases or deaths in time and/or space• Unusual increase in cases or deaths• Even a single case of measles, AFP, Cholera• Occurrence of two or more epidemiologically linked cases of meningitis, measles• Unusual isolate• Shifting age distribution of cases• High vector density• Natural disaster
1.3 Trigger eventsSome trigger events indicate a potential outbreak. Details of these are given in Table-6.
Surveillance ActionPresent trigger levels for disease will be identified with specific responses identified for various levels. The levels will depend on the epidemic potential, case fatality of the disease and the prevalence of the problem in the community.
1. Trigger Level -1 Suspected/limited outbreak- Local response2. Trigger Level -2 Epidemic- Local and regional responses3. Trigger Level -3 Wide spread Epidemic - Local, Regional and
National/PHLa) In a non endemic area even 1 cases of suspected epidemic prone disease should initiate a trigger response at various levels.
b) In an endemic region change in pattern of disease or evidence of clustering of disease should be considered a trigger event.
53
Table-6 Outbreak investigation and response against each notifiable and others diseases
Disease Trigger event Action
Avian influenza
A single suspected case
• Verify information from the local health worker/officer
• Confirm the outbreak
• Active search of cases in accordance with standard case definition provided
• Standard case management
• Collect samples for confirmation
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
SARS
Smallpox
Nipha virus
54
Cholera /Acute watery diarrhea
A single case of cholera or epidemiologically linked diarrhea cases
• Verify information from the local health worker/officer
• Confirm the outbreak
• Active search of cases in accordance with standard case definition provided
• Standard case management
• Collect stool/blood samples for confirmation
• Ensure safe water supply
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Typhoid
Clustering of cases with prolong fever in given time from a same geographical area.
Shigellosis
Clustering of cases having blood diarrhea in given time from a same geographical area
Disease Trigger event Action
55
Dengue/DHF
Endemic area southern Dzongkha: Rising number of fever cases for previous 2 weeksNon-endemic area: Single case of suspected Dengue in the community.
• Verify information from the local health worker/officer
• Confirm the outbreak
• Active search of cases in accordance with standard case definition provided
• Standard case management
• Collect blood samples lab confirmation
• Intensify vector control activities
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Japanese Encephalitis
Single cases of probable JE in a community or2 cases with fever with altered consciousness /seizure
Disease Trigger event Action
56
Leptospirosis
Single suspect case in a community
• Verify information from the local health worker/officer
• Confirm the outbreak
• Active search of cases in accordance with standard case definition provided
• Standard case management
• Collect blood samples for lab confirmation
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Brucellosis
Plaque
Scrub typhus
Clustering of cases with prolong fever in given time from a same geographical area.
Disease Trigger event Action
57
Measles Single case of measles or probable measles case in a community
• Verify information from the local health worker/officer
• Confirm the case/outbreak
• Active search of cases in accordance with standard case definition provided
• Standard case management
• Collect blood samples for lab confirmation
• Intensify surveillance response
• Immunization response
• Provide Vitamin A supplementww
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Rubella
CRS
MumpsClustering of cases from a community/institutes
Disease Trigger event Action
58
Diphtheria
Single suspect case a community
• Verify information from the local health worker/officer
• Confirm the case• Active search
of cases in accordance with standard case definition provided
• Standard case management
• Collect blood samples for lab confirmation
• Intensify surveillance response
• Immunization response
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Pertusis
Tetanus
Viral hepatitis
Clustering of cases in given time from a same geographical area
Disease Trigger event Action
59
Poliomyelitis
One suspected cases of poliomyelitis in a community or Single confirmed case.
• Verify information from the local health worker/officer
• Active search of cases in accordance with standard case definition provided
• Standard case management
• Collect stool samples for lab confirmation
• Intensify surveillance response
• Immunization response
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Disease Trigger event Action
60
Rabies
Single suspect case in a community and epidemiologically linked to rabies outbreak in animal
• Verify information from the local health worker/officer
• Confirm the case• Active search
of cases in accordance with standard case definition provided
• Standard case management
• Collect CSF or brain samples for lab test
• Intensify surveillance response
• Immunization response
• Provide IEC to the affected people and population in the area
• Coordinate with Animal health centre for disease control
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Disease Trigger event Action
61
Bacterial meningitis One suspected case
• Verify information from the local health worker/officer
• Confirm the case• Active search
of cases in accordance with standard case definition provided
• Standard case management
• Collect CSF for lab tests and confirmation
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
Disease Trigger event Action
62
Any other unusual diseases or diseases not included in notifiable list
Minimum 2 cases presenting similar signs & symptoms from a same geographical area.
• Verify information from the local health worker/officer
• Investigate base on syndromes
• Try to find out etiology
• Active search of cases in accordance with syndromes
• Case management base on presumptive diagnosis
• Collect suitable samples
• Provide IEC to the affected people and population in the area
• Notify to PHL and ask for assistance if necessary
2. Reporting and responding to an outbreak
In district, the concern CMO/DHO will be the nodal officer who will be responsible to respond to an outbreak. At the district level the special Rapid Response Team (RRT) will have the primary responsibility to investigate outbreak. If an outbreak is suspected, RRT should verify the same and notify PHL by outbreak notification form (Annexure 4). The concern authority should also send the line listing of outbreak cases (Annexure 5). Once this is done and if there is a need to investigate, the
Disease Trigger event Action
63
RRT should take over and do the needful. In an established outbreak, the response should include the following:1. Emergency case management2. Referral to an appropriate level of care3. Epidemiological investigation4. Laboratory investigations to identify the etiology5. Presumptive and definitive control measures6. Upgrading response to a high level by informing the DHO if outbreak
is confirmed
Even as the outbreak is detected, and is being investigated, control measures need to be instituted by the concernd medical officer or health worker. This should be:
1. General measures – till the specific source and route of transmission is identified. For example, if one is suspecting water borne disease, then one should start a campaign requesting people to use safe drinking water.
2. Specific measures – Depending on the causative agent. The broad steps would include • Identification and nullification of the source of the outbreak e.g.
chlorinating wells• Minimizing transmission and further exposure e.g. vector control• Protection of the host e.g. immunization or chemoprophylaxis• Effective case management
2.1 Epidemic preparednessPreparatory action before an outbreak
Formation of the RRTTraining for the RRTRegular review of the dataIdentifying outbreak seasonsIdentifying outbreak placesEnsuring that these places have necessary drugs and
materials prior to the outbreak seasonIdentifying and strengthening the labsDesignating vehicle for outbreak investigation and ensuring
that it is in working conditionEnsuring that the communication channels like telephone
are working condition
64
2.2 Rapid Response Team (RRT)The RRT is a multi faceted team that looks into the various aspects of an outbreak. A suggested composition of this team is a field Epidemiologist, a Clinician and a Microbiologist. However, in our current setting in district, the RRT team composition could be DHO, CMO and lab technologists/technicians.
The main role of the RRT is to investigate and confirm outbreaks. It is to be noted that RRT is not permanent team who is waiting for an outbreak. They are individuals who are normally performing their usual roles but in the event of an outbreak come together to undertake a special function. They should work in close coordination with the local health staff in the event of an outbreak.
While RRT will help and support the local staff in the management and control of the outbreak, the primary responsibility for implementing control measures rests with the local health authority.
The names, telephone number of the RTT members should be available with the district health authority so that they can be activated as soon as possible. Members who have transferred etc should be replaced with competent people as soon as possible.
3. Outbreak Investigation StepsStep 1: Verification of the outbreakThe preliminary step of the outbreak investigation would be to verify the outbreak by following outbreak investigation procedures (Figure No. 2). Mach time may be wasted due to false alarm. Even if the outbreak is suspected from the routine surveillance data, it must be verified. The fastest way to verify is to contact the health workers nearest to the location of the outbreak and request him/her for confirmation. This may be done telephonically or through special messenger. The health worker should check
If there is an abnormal increase in the number of cases orIf there is a clustering of case orIf the cases are epidemiologically linked or If some trigger events have occurred or if many deaths
have occurred
65
If there is evidence of an outbreak, and if the etiology, the source and the route of transmission is known, then the specific control measures need to be immediately instituted. If however, any one of the above is unknown, then the outbreak must be investigated to identify the specific cause.
The RRT should be alerted and requested to investigate the outbreak. At the same time general control measures should be instituted. Any outbreak should be notified to PHL (Annexure: 3) and provide line list (Annexure: 4) irrespective of help you require or not in investigation and responding to outbreaks. PHL will guide and act if necessary base on outbreak notification form submitted.
Step 2: Sending the RRTA RRT should be immediately formed with those readily available as stated above. Resource (vehicle, drugs, reagents, forms, etc) should be made available to the RRT and they should proceed to the location. At the location the RT members along with the local health staff should initiate a Medical / Epidemiological / Laboratory investigation simultaneously.
Step 2(a) Medical investigations:The physicians/medical officer will clinically examine the available cases (in the hospital or the community) and make a clinical diagnosis. The history will include question that will identify the possible source, routes of transmission and contacts. He will also review the case management (as per the recommended protocol) and recommended suitable amendments to the therapy if required.
Step 2(b) Laboratory investigations :The microbiologist/lab person will perform the appropriate lab investigations. The microbiologist/lab person will advise on what samples are required, mode of collection and method of transportation an also sample referral. He will be responsible for the lab confirmation of the outbreak. If the outbreak warrants an entomological investigation, entomologist should be involved to carry out investigation.
It is not necessary to collect specimens from ALL cases; just 12-15 samples are enough to confirm the diagnosis
66
Figure- 2 Outbreak investigation procedures.
Step 2(c) Epidemiological investigations:The epidemiologist will carry out a detailed epidemiological investigation that will look into the epidemiological and environmental aspect of the outbreak. The basic aim of the epidemiological investigation is to identify the source of the problem and the routes of transmission.
Describe outbreak in terms of Place, Time and Person
Develop Hypothesis regarding source, transmission, etiology and people at risk
Etiology, source and transmission know?
Institute control
measures
Further investigation (Clinical, laboratory, Epidemiological)
Is this an outbreak?
Yes
No Yes
NO
Does Hypothesis fit with the facts?
YesInstitute control measures
NO
Special studies
Unusual health event
67
Step 2(d) Formulation of hypothesis :The RRT will then review all the various investigative findings and reports/results received and formulate a provisional hypothesis to explain the cause of the outbreak. This will answer the following questions: what was the causal agent? What was the source of infection? what was the transmission pattern and who are the people at risk?. If the hypothesis fits with the facts, then specific response measures can be instituted. If however the hypothesis does not fit with the facts, then further analytical investigation in terms of case control studies will need to be carried out. In the mean time, general control measures may be instituted.
Step 2(e) Specific response measures :Based on hypothesis, RRT will recommend suitable control measures to be implemented by the local heath staff to curtail the epidemic. If the team feels that the local/district staff needs any support, then they will request the PHL and Department of Public Health to provide necessary help.
Step 2(f) Special studies if necessary: Following the institution of control measures, if the epidemic is under control and tapers off, the hypothesis of causation could be considered as correct. If the epidemic continues unabated the hypothesis would have to be reviewed. In such cases analytical studies like a case control study might have to be conducted to confirm the hypothesis. The decision to investigate further or to institute control measures are dependent on whether the source and the transmission are known or unknown after investigation (see Table No. 7).
Call for help from DoPH/PHL if:
The outbreak is usual, or the CFR is high or if the etiology cannot be determined
68
Table-7 Investigation or control of outbreakE
tiolo
gySource/Transmission
Known Unknown
Kno
wn
Control +++Investigate +
Control +Investigate +++
Unk
now
n
Control +++Investigate +++
Control +Investigate +++
+ Some activity +++ More activity
Step 2(g) Interim report:The RRT should file an interim report, giving details of the investigation, diagnosis and also the control measures initiated.
Step 2(h) Follow-up visits:Once the outbreak has come under control, the RRT can leave but should make follow-up visits to ensure that the control measures are being implemented adequately. Also these follow up visits helps to identify any new information that may have been missed in the first visit.
Step 3: Monitoring the situationThe CMO/DHO should monitor the situation on a regular basis. Ideally they should review the status on a daily basis and give feedback to the RRT as well as feed forward to the PHL/Department of Public Health. The main points to monitor are:
• The trend in the cases and deaths• The containment measures that are being implemented• Drugs/vaccine stock• Logistic issues – communication, vehicles• Community involvement• Media response
This should continue till the outbreak is officially declared to be over.
69
Step 4: Declaring the outbreak to be overThe DHO/CMO should declare the outbreak to be over only when there have been no new cases for a period of 2 incubation periods since the onset of the last case. This implies that a very active case search should continue during this period to ensure that cases are not missed.
Step 5: Review of the final reportThe DHO/CMO should receive the final report from the local health staff within 10 days of the outbreak being declared to be over. The technical committee should review the report basically to understand why the outbreak occurred. Based on this review; the committee should make recommendations –immediate and medium term, so that similar outbreaks do not occur. Most important, they should try and identify deficiencies in the system that needs to be rectified.
Some of the reports recommended are:
i) Preliminary report by nodal MOThe nodal MO/health worker of the peripheral health facility who first reports the outbreak should submit a preliminary report to their district or PHL/DoPH. The report should cover briefly about how the outbreak came to his attention, verification of the outbreak, total number of affected cases/deaths, time, person, place analysis, management of the patient, likely suspected source, immediate control measures implemented, etc.
ii) Daily situation updatesDuring the period of the outbreak the nodal MO/health worker should continue to give daily situation updates of the outbreak to next level. The report should include the list of new cases, lab results received, any new findings, any containment measures taken, etc. This daily report should continue till the end of the outbreak (i.e. no suspect case during a period which is double the incubation period). However it is important that these updates are kept as simple as possible to minimize the workload.
iii) Interim report by RRTThe RRT should submit an interim report within one week of starting their investigation, response and control activities. The report should cover verification of the outbreak, total number of affected cases/deaths, time, person, place analysis, management of the patient, likely
70
suspected source, immediate control measures implemented, etc. The report will include reports by the physician, microbiologist, responsible lab person and entomologist (where applicable), lab results received during that period, environmental factors, etc. It will also have a provisional hypothesis of the causation of the outbreak and comments/recommendations, if any including whether any further help from DoPH/PHL is necessary.
iv) Final report:Within 10 days after the outbreak has ceased, a final outbreak investigation report must be submitted by the local health authorities to PHL/DoPH. This report must be comprehensive and give a complete picture of the multi-factorial causes of the outbreak, the precipitating factors, the evolution of the epidemic, description of the persons affected, time trend, areas affected and direction of spread of the epidemic. It should have complete details of lab results including results from referral lab (cross verification and strain identification), confirmation of the provisional diagnosis and other relevant information. It is important that feedback from the report is shared with lower level and other districts. Publication in a journal will ensure wider circulation of the lessons learnt.
71
Guideline for preparing a report
Preparing a ReportAll Outbreaks must be documented in a scientific and systematic manner. While preparing a report on the outbreak investigated, following points ought to be mentioned.6.1 Title of the ReportE.g. Report on ARI outbreak in Trongsa Dzongkhag.6.2 Summary/Abstract:Give a summary of 1-2 paragraphs which must contain overview of the investigation. A summary should be able to answer WHO, WHAT, WHERE, WHEN, WHY/HOW about an outbreak and should also contain about the causative agent in brief, casual hypothesis based on the evidence, key recommendations, ongoing actions, Pending/Required actions.6.3 Introduction/Background Information:An introduction and background should describe about surveillance trends and similar outbreaks. Include specific events that had let to the investigation and mention how the outbreak is reported, steps taken to confirm the outbreak and who all were involved in investigating the outbreak. Describe about the area/site or the health facilities available in the place where the outbreak occurred.6.4 Aim/Objectives of Investigation: Mention aim and objective for investigating an outbreak.6.5 Methodology of Investigation:As you write about your methods of investigation of an outbreak, you can break down your methods of investigation into three main points as follows:6.5.1 Epidemiologic investigationDefine the cases and mention about how you ascertained and outbreak. Do not forget to mention about your case study design.6.5.2 Microbiological / toxicological investigationUnder this heading you can mention about clinical and environmental sample collection. Write where the samples were sent for analysis and types of analyses performed.6.5.3 Environmental investigation Mention about your visit to the site of the outbreak and risk assessment. You can also mention about trace back of food products or other items.
72
6.6 Results:Mention your findings of the outbreak. You can do it in the following format for easier understanding and directness of the report.6.6.1 Epidemiological findingsNumber of cases and descriptive and the clinical data on casesGeographic distribution of the caseEpidemic curveRisk factor analysisAttack rates by age, sex, exposure 6.6.2 Microbiological findings:Mention about the laboratory findings; genotyping, culture results, PFGE* results etc.6.6.3 Environmental findingsWrite about results you got of risk assessments and any trace back investigation.6.7 Discussion:Under this heading you can discuss main hypothesis and justify conclusions and actions. Also explain some of the actions to protect public health. Highlight any lessons learned when investigating this case and include problems encountered (if any), errors committed, limitations of the study, useful lessons for planning future investigations.6.8 Conclusions: Provide opinion(s) on nature of the illness, source of the outbreak, mode of transmission. 6.9 Recommendations:Include a statement on control measure for immediate control and control measure for future prevention and also mention of specific obstacles, and shortcomings. The recommendations should also include message to educate fellow Public health Professionals and inform policy makers.Attachment of supportive documents:A report without supportive document is of little importance and it would mean lack of evidence to those who study the report. Hence it is very important to attach all the supporting documents necessary. Supporting document includes: - Graphs and tables - Inspection report - testing results, etc.
73
Section VISamples collection, storage &
transportation
74
Base on agent/diseases suspected, MO/RRT team should know what sample to collect, when to collect and how to transport the samples to lab for confirmation. This is very important to establish the causative agent to take appropriate interventions.
Age
nts
Whe
n to
col
lect
sa
mpl
e
Type
of
spec
imen
to b
e co
llect
ed
Test
to b
e do
ne in
D
istr
ict /
regi
onal
ho
spita
l lab
s
Test
to b
e do
ne in
PH
LSt
orag
eTr
ansp
orta
tion
Anthrax
Whe
n a
case
of
anth
rax
pres
ente
d at
th
e O
PD
.
Bio
psy
Blo
od
Sw
ab
NIL
NIL
In re
frige
rato
r at
2-8°
C fo
r 7 d
ays.
In
cas
e of
del
ay
in tr
ansp
orta
tion,
st
ore
at -2
0°C
de
ep fr
eeze
r
Tran
spor
t m
edia
Brucellosis
Whe
n a
case
of
prob
able
bru
cello
sis
pres
ents
at t
he
OP
D.
In a
n ou
tbre
ak
situ
atio
n, s
peci
men
s fro
m fi
rst 1
0 ca
ses
need
to b
e co
llect
ed
Blo
od fo
r cul
ture
an
d se
rolo
gyN
ILC
ultu
re,
iden
tifica
tion
and
sens
itivi
ty
Sto
re s
ampl
es
and
posi
tive
isol
ates
in a
re
frige
rato
r at
2-8°
C.
Tran
spor
t med
ia
Tabl
e-8
S
ampl
e co
llect
ion,
sto
rage
and
tran
spor
tatio
n to
lab
agai
nst e
ach
agen
t/dis
ease
s
Cholera and Shigella
Whe
n a
prob
able
cas
e of
cho
lera
pre
sent
s at
the
OP
D, b
efor
e ad
min
istra
tion
of
antib
iotic
s.In
an
outb
reak
si
tuat
ion,
spe
cim
ens
from
firs
t 10
case
s ne
ed to
be
colle
cted
Fres
h st
ool/
rect
al
swab
(if s
tool
is n
ot
avai
labl
e)
Han
ging
dro
p m
otili
ty
Cul
ture
, id
entifi
catio
n an
d
sens
itivi
ty
Sto
re s
ampl
es a
nd
posi
tive
isol
ates
in a
re
frige
rato
r at 2
-8°C
. E
nric
hmen
t m
edia
75
Congenital rubella
syndrome
Whe
n a
case
of
prob
able
CR
S
pres
ents
at t
he O
PD
.
Blo
od in
pla
in
vacu
tain
er-
for
sero
logy
NIL
IgM
ELI
SA
In re
frige
rato
r of
2-8°
C fo
r 7 d
ays.
In
cas
e of
del
ay in
tra
nspo
rtatio
n, s
tore
in
-20°
C d
eep
freez
er.
In
ice
box
of
2-8°
C
Dengue/ dengue hemorrhagic
fever
Whe
n a
case
of
prob
able
den
gue
pres
ents
at t
he O
P.In
an
outb
reak
si
tuat
ion,
spe
cim
ens
from
firs
t 10
case
s ne
ed to
be
colle
cted
Blo
od in
pla
in
vacu
tain
er-
for
sero
logy
CB
C, R
apid
te
st
IgM
ELI
SA
In re
frige
rato
r of
2-8°
C fo
r 7 d
ays.
In
cas
e of
del
ay in
tra
nspo
rtatio
n, s
tore
in
-20°
C d
eep
freez
er.
In
ice
box
of
2-8°
C
Diphtheria
Whe
n a
case
of
prob
able
den
gue
pres
ents
at t
he O
PD
.
2 sw
abs-
1 fo
r sm
ear,
1 fo
r cu
lture
Cul
ture
and
id
entifi
catio
n.
Cul
ture
, id
entifi
catio
n an
d se
nsiti
vity
Sam
ples
and
pos
itive
is
olat
es a
t 2-8°C
Tran
spor
t med
ia
Japanese encephalitis
Whe
n a
case
of
prob
able
JE
pre
sent
s at
the
OP.
Blo
odfo
r ser
olog
y. C
SF
in h
ospi
taliz
ed
case
s fo
r se
rolo
gy a
nd
viru
s is
olat
ion.
Nil
IgM
ELI
SA
In re
frige
rato
r of
2-8°
C fo
r 7 d
ays.
In
cas
e of
del
ay in
tra
nspo
rtatio
n, s
tore
in
-20°
C d
eep
freez
er.
In ic
e bo
x of
2-
8°C
76
Leptospirosis
Whe
n a
case
of
prob
able
lept
ospi
rosi
s pr
esen
ts a
t the
OP,
in
early
sta
ge o
f dis
ease
an
d/ o
r 2nd
wee
k of
illn
ess,
be
fore
ad
min
istra
tion
of
antib
iotic
s.In
an
outb
reak
si
tuat
ion,
col
lect
sp
ecim
ens
from
firs
t 10
case
s
1. B
lood
in
plai
n va
cuta
iner
fo
r dar
k fie
ld
mic
rosc
opy
2. B
lood
for
sero
logy
.
NIL
1. D
ark
field
m
icro
scop
y.2.
IgM
ELI
SA
At -
20°C
dee
p fre
ezer
In ic
e bo
x of
2-8°C
Measles
Whe
n a
case
of
prob
able
mea
sles
pr
esen
ts a
t the
OP
D.
Blo
od fo
r se
rolo
gy.
Nil
IgM
ELI
SA
In re
frige
rato
r of
2-8°
C fo
r 7 d
ays.
In
cas
e of
del
ay in
tra
nspo
rtatio
n, s
tore
in
-20°
C d
eep
freez
er.
In ic
e bo
x of
2-8°C
Bacterial meningitis
Whe
n a
case
of
pro
babl
e m
enin
goco
ccal
m
enin
gitis
pre
sent
s at
the
OP
D, b
efor
e ad
min
istra
tion
of
antib
iotic
s..
CS
F/ B
lood
/ br
ain
auto
psy
Cul
ture
and
id
entifi
catio
n.
Cul
ture
, id
entifi
catio
n an
d se
nsiti
vity
Sam
ples
and
pos
itive
is
olat
es a
t 2-8°C
Enr
ichm
ent m
edia
/c
ultu
re m
edia
77
Leptospirosis
Whe
n a
case
of
prob
able
lept
ospi
rosi
s pr
esen
ts a
t the
OP,
in
early
sta
ge o
f dis
ease
an
d/ o
r 2nd
wee
k of
illn
ess,
be
fore
ad
min
istra
tion
of
antib
iotic
s.In
an
outb
reak
si
tuat
ion,
col
lect
sp
ecim
ens
from
firs
t 10
case
s
1. B
lood
in
plai
n va
cuta
iner
fo
r dar
k fie
ld
mic
rosc
opy
2. B
lood
for
sero
logy
.
NIL
1. D
ark
field
m
icro
scop
y.2.
IgM
ELI
SA
At -
20°C
dee
p fre
ezer
In ic
e bo
x of
2-8°C
Measles
Whe
n a
case
of
prob
able
mea
sles
pr
esen
ts a
t the
OP
D.
Blo
od fo
r se
rolo
gy.
Nil
IgM
ELI
SA
In re
frige
rato
r of
2-8°
C fo
r 7 d
ays.
In
cas
e of
del
ay in
tra
nspo
rtatio
n, s
tore
in
-20°
C d
eep
freez
er.
In ic
e bo
x of
2-8°C
Bacterial meningitis
Whe
n a
case
of
pro
babl
e m
enin
goco
ccal
m
enin
gitis
pre
sent
s at
the
OP
D, b
efor
e ad
min
istra
tion
of
antib
iotic
s..
CS
F/ B
lood
/ br
ain
auto
psy
Cul
ture
and
id
entifi
catio
n.
Cul
ture
, id
entifi
catio
n an
d se
nsiti
vity
Sam
ples
and
pos
itive
is
olat
es a
t 2-8°C
Enr
ichm
ent m
edia
/c
ultu
re m
edia
MumpsW
hen
a ca
se o
f pr
obab
le m
umps
pr
esen
ts a
t the
OP
D.
Blo
od fo
r se
rolo
gyN
ILIg
M E
LIS
AA
t -20
°C d
eep
freez
erIn
ice
box
of 2
-8°C
Pertussis
Whe
n a
case
of
prob
able
per
tusi
s pr
esen
ts a
t the
OP
D,
befo
re a
dmin
istra
tion
of a
ntib
iotic
s.
Nas
opha
ryng
eal
swab
Cul
ture
and
id
entifi
catio
n.
Cul
ture
, id
entifi
catio
n,
sens
itivi
ty.
Sam
ples
and
pos
itive
is
olat
es a
t 2-8°C
Enr
ichm
ent m
edia
/c
ultu
re m
edia
Plague
Whe
n a
case
of
prob
able
pla
gue
pres
ents
at t
he O
P, in
th
e ea
rly s
tage
of t
he
dise
ase
Bub
oe
Spu
tum
Blo
od fo
r se
rolo
gy
NIL
IgM
ELI
SA
In re
frige
rato
r of
2-8°C
. In
case
of d
elay
in
trans
porta
tion,
sto
re
in -2
0°C
dee
p fre
ezer
.
In ic
e bo
x of
2-8°C
Poliomyelitis
Whe
n th
ere
is a
sin
gle
case
of a
cute
flac
cid
para
lysi
s, in
the
early
st
age
of th
e di
seas
e.In
an
outb
reak
si
tuat
ion,
col
lect
sp
ecim
ens
from
firs
t 10
case
s
Two
Sto
ol
spec
imen
s at
24
hour
s in
terv
al
NIL
NIL
In re
frige
rato
r of
2-8°
C
In ic
e bo
x of
2-
8°C
with
4 d
ays
to P
HL
78
Rabies, humanW
hen
a ca
se o
f pr
obab
le h
uman
rabi
es
pres
ents
at t
he O
PD
.
Cor
neal
sm
ears
/ sk
in b
iops
y of
fa
ce o
r nec
k.B
rain
pos
tmor
tem
Nil
Imm
unofl
uo-
resc
ence
N
egri
bodi
es
scre
enin
g
In a
refri
gera
tor
of 2
-8°C
. In
case
of d
elay
in
trans
porta
tion,
sto
re
in -2
0°C
dee
p fre
ezer
.
In ic
e bo
x of
2-8°C
Rubella
Whe
n a
case
of
prob
able
rube
lla
pres
ents
at t
he O
P, 1
-2
wee
ks a
fter o
nset
of
the
rash
.
Blo
od in
pla
in
vacu
tain
er f
or
sero
logy
Nil
IgM
ELI
SA
In a
refri
gera
tor
of 2
-8°C
. In
case
of d
elay
in
trans
porta
tion,
sto
re
in -2
0°C
dee
p fre
ezer
.
In ic
e bo
x of
2-8°C
Tetanus
Whe
n a
case
of
prob
able
teta
nus
pres
ents
at t
he O
P.
Scr
apin
gs o
r ex
cise
d bi
ts o
f tis
sues
NIL
C
ultu
re a
nd
iden
tifica
tion
Spe
cim
en a
nd
posi
tive
isol
ates
at
2-8°
CE
nric
hmen
t med
ia
Typhoid fever
Whe
n a
case
of
prob
able
typh
oid
pres
ents
at t
he O
P,
in th
e ea
rly s
tage
of
the
dise
ase
befo
re
adm
inis
tratio
n of
an
tbio
tics.
In a
n ou
tbre
ak
situ
atio
n, c
olle
ct
spec
imen
s fro
m fi
rst 1
0 ca
ses
Blo
od fo
r Wid
al,
stoo
l for
cul
ture
.
Wid
al te
st,
cultu
re a
nd
iden
tifica
tion
Cul
ture
, id
entifi
catio
n an
d se
nsiti
vity
Sam
ples
and
pos
itive
is
olat
es a
t 2-8°C
Enr
ichm
ent m
edia
79
Avian Influenza
Whe
n a
case
of fl
u w
ith c
ase
defin
ition
s co
mpl
ying
that
of a
vian
in
fluen
za p
rese
nts
at
the
OP
D.
Thro
at/ n
asal
/ na
soph
aryn
geal
sw
ab
Rap
id te
st fo
r in
fluen
za.
RT-
PC
R
In a
refri
gera
tor o
f 2-
8°C
for 5
day
s.
In c
ase
of d
elay
in
trans
porta
tion,
sto
re
in -3
0°C
dee
p fre
ezer
.
In ic
e bo
x of
2-8°C
w
ith 4
day
s SARS
Whe
n a
sing
le c
ase
prob
able
SA
RS
pr
esen
ts a
t the
OP
D.
Thro
at/ n
asal
/ re
ctal
sw
abN
ILN
il
In a
refri
gera
tor o
f 2-
8°C
for 7
day
s.
In c
ase
of d
elay
in
trans
porta
tion,
sto
re
in -3
0°C
dee
p fre
ezer
.
In ic
e bo
x of
2-8°C
w
ith 4
day
s
Small pox
Whe
n a
sing
le c
ase
prob
able
sm
all p
ox
pres
ents
at t
he O
PD
.
Blo
od fo
r se
rolo
gy a
nd
viru
s is
olat
ion
NIL
NIL
-70°
C d
eep
freez
er.
In i
ce b
ox o
f 2 to
8°
C w
ithin
4 d
ays
Nipah virus
Whe
n a
sing
le c
ase
prob
able
nip
ah
viru
s pr
esen
ts a
t the
O
PD
. In
an o
utbr
eak
situ
atio
n, c
olle
ct
spec
imen
s fro
m fi
rst 1
0 ca
ses
Blo
od fo
r se
rolo
gy,
biop
sies
for
hist
opat
holo
gy/
imm
uno-
hi
stoc
hem
istry
, tis
sues
for v
irus
isol
atio
n
NIL
PC
R
In a
refri
gera
tor
of 2
-8°C
. In
case
of d
elay
in
trans
porta
tion,
sto
re
in -2
0°C
dee
p fre
ezer
In i
ce b
ox o
f 2 to
8°
C w
ithin
4 d
ays
80
Viral hepatitisW
hen
a ca
se o
f pr
obab
le p
rese
nts
at
the
OP.
Blo
od in
pla
in
vacu
tain
er f
or
sero
logy
Rap
id te
stE
LIS
A an
d P
CR
In a
refri
gera
tor
of 2
-8°C
. In
case
of d
elay
in
trans
porta
tion,
sto
re
in -2
0°C
dee
p fre
ezer
In i
ce b
ox o
f 2
to 8°C
Scrub typhus
Whe
n a
case
of
prob
able
pre
sent
s at
th
e O
P.
Blo
od in
pla
in
vacu
tain
er f
or
sero
logy
EIA
In a
refri
gera
tor
of 2
-8°C
. In
case
of d
elay
in
trans
porta
tion,
sto
re
in -2
0°C
dee
p fre
ezer
In i
ce b
ox o
f 2
to 8°C
Others agents
Whe
n a
case
of
prob
able
pre
sent
s at
th
e O
P or
out
brea
ksS
uita
ble
sam
ples
Bas
e on
lab
capa
city
All
poss
ible
te
sts
Dep
end
upon
type
of
sam
ples
col
lect
ed
and
test
nee
ds to
be
done
Use
tran
spor
t m
edia
for b
acte
rial
isol
atio
n a
nd ic
e bo
x of
2 to
8°C
for
sero
logy
and
PC
R
81
Section VIIFeedback
82
1. Uses of feedbacksRegular feedback is pivotal to keep channel of communication open, motivate and educate staff. Simple appreciation of the timeliness of reporting would energize the reporting unit to continue to report cases. It should be emphasized that feedback is to reinforce health staff efforts to continue to actively participate in the surveillance system. Some of the uses of feedbacks are:
• Keeps channel of communication open – just the process of sending feedback opens up channels of communication between the various levels and is helpful in strengthening the working relationships between the levels.
• Keep the staff informed of the larger picture – feedback allows the staff at various levels to understand what is happening in their level and also at other colleagues.
• Gives them an idea of their performance – feedback helps the staff at the lower level identify their strengths and weakness.
• Motivates them – the fact that somebody is reviewing their work and sharing constructively is a great motivator for the staff.
• Educational tool – feedback is an important educational tool to teach the staff.
2. Types of feedbacks
Feedback may be given formally. The exact modality of giving formal feedback to the reporting units should be:
2.1) Reports
The surveillance report should be made available weekly from PHL to district and district to BHU’s weekly. Also outbreak investigation report must be made available as soon as possible to all health personnel in the field so that they can remain alert to similar outbreaks from their areas also. Such reports are excellent tools for feedback and learning. The report should also include time and completeness of reporting units since this will serve as a proxy indicator of the alertness of the surveillance system. An alert system will have timeliness and completeness approaching 100%. Also completeness of reporting units gives one an idea about the reliability of the data.
83
2.2) Newsletter At national level, PHL should produce regular epidemiology bulletins with tables and graphs showing trends and progress towards target and reports on the investigation and controls of outbreaks monthly. The bulletin usually contain: summary tables showing the number of reported cases and deaths to date for the selected disease, a commentary or message on a given disease or topic. The bulletin also serves as a useful educational tool to keep the doctors and other staff abreast about case definition, disease profiles, management protocol of diseases. Latest diagnostic aids available, new strategies, etc,should also be reflected.
2.3) Informal feedback.The other form of feedback can be informal feedback . This is useful especially when one has to point out the mistakes. This could be done in form of oral feedback that points out what should have been done and how not to repect the same mistake again.
84
Section VIIIMonitoring and Supervision
85
The surveillance system must be continuously supervised and monitored if a high quality of surveillance has to be ensured. Constant and supportive supervision would vastly improve the quality of the surveillance and motivate the staff to improve their performance. Ongoing monitoring and prompt corrective action is also imperative for the success of any surveillance programme.
1. Monitoring of surveillance
All surveillance activities should be constantly monitored using standard performance indicators. If the performance of surveillance does not meet the necessary standards, prompt action should be taken to improve it. Thus constant monitoring ensures that the surveillance system is effective. Indicators should be developed for each level and classify according to the periodicity of review.
Table-9 Indicators for monitoring
Indicators Frequency of monitoring Source of information
Timeliness of reporting Weekly/ monthly/ Quarterly/ Annually Routine data
Completeness of reporting Weekly/ monthly/ Quarterly/ Annually Routine data
Percentage of outbreak detected Quarterly/ Annually Routine data
No. of outbreaks prevented Annual Comparison of previous year’s report
Percentage of clinicians and other relevant health workers using case definition
Annual Supervisory report
Percentage of clinicians and other relevant health workers whose reports are in concurrence with their record register
Annual Supervisory report
86
1.1 Weekly indicatorsThese indicators should be reviewed every week when the data is collated and reports generated. They reflect the effectiveness of data collection and transmission. There are 2 main indicators: timelines of report and completeness of report.
1.2 Monthly/Quarterly indicatorsThese indicators allow for midterm review and correction of the programme performance, so that the surveillance system remains alert and vigilant. Some of the indicators that may be used are: • Completeness of report for the period XXX• No. of reporting units that have been complete during the specific
period divide by total number of reporting.• Timeliness of report for the period XXX• No. of reporting units that have been on time during the specific
period divide by total number of reporting.• Percentage of outbreaks that been detected.
1.3 Annual indicators These indicators give an idea of the overall performance of the programme and help the programme identify gaps. Many of the indicators are similar to the monthly/quarterly ones but helps by giving a long term perspective.• Completeness of report for the year • Timeliness of report for the year• Percentage of outbreak that been detected
1.4 Input indicators• Percentage of staff at each level trained• Percentage of reporting units using case definitions• Percentage of district with functional RRTs• Percentage of district with functional labs
1.5 Outbreak response indicators• Percentage of outbreak that have been detected• Percentage of outbreaks that have been detected within one
incubation period• Percentage of outbreaks that have been confirmed• Percentage of outbreaks that have been investigated• Percentage of outbreaks that have been investigated within 48
hours of detection
87
• Percentage of outbreaks that have a CFR within the accepted norms
1.6 Lab performance indicators• Proportion of lab specimens received in good condition• Proportion of lab specimens received with properly completed lab
forms• Proportion of results reported within seven days after receipt of
specimens in the lab• Performance indicators should be fed back to the local staff so
that the quality of surveillance in areas performing poorly could be improve
2. Supervision of surveillance
Supervision should help the health staff to improve their knowledge and performance and not be a fault-finding exercise. Supervisors and health professionals works together to review progress, identify problems, decide what has caused the problem and develop feasible solution
2.1 Pre-requisite for supervision
Job descriptions: For effective supervision each category of health staff should have job description (charter of duties) for surveillance. The job description should clearly describe the surveillance activity to be performed by each category of health staff. It should also mention who the health staff reports to and also under which supervisor the staff functions.
Resources: The supervisory team would require resources like fund, vehicle, etc.
Attitude: The supervisory team should not be a fault-finding mission, but a support to the field people so that they are able to implement their activities.
2.2 Steps in supervisionThe following are the steps in supervision:
2.2.1 Supervisory plan: A supervisory plan should be prepared and at least each reporting unit (BHU’s) visited quarterly. Supervisory visits of the reporting units are vital to rectify any problems like
88
shortages of reporting formats, etc and hence mobility of the supervisory is critical. This plan must be informed to the field staff so that they are prepared for visit.
2.2.2 Make checklist: A checklist is a tool to help the supervisory team.
2.2.3 Review the previous supervisory visit report: Supervisory team should review the previous visit report to update about the situation in the field. It will also make them review the follow up actions taken from previous visit. This will also help them review the performance by the unit field.
2.2.4 Supervisory visit: The supervisory team should visit the field and using tools like checklist, observational methodology, review of records and focus group discussion should assess the performance of the staff there. Gaps identified should be tackled on the spot if possible, or solved at a later stage. On-the-job training should also be provided to improve the quality of activities.
2.2.5 Feedback: During the visit; the supervisor should provide feedback to the health staff so that corrective measures can be implemented to improve the surveillance. Both positive and negative feedback should be given so that the supervisee is aware of his performance immediately.
89
Section IXReferences
90
References:
1. Operational manual for district surveillance unit, Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi.
2. WHO recommended strategies for the prevention and control of communicable diseases, WHO/CDS/CPE/SMT/2001.13
3. Communicable diseases surveillance, Centre for Health protection, Hong Kong, Version 2.
4. Vaccine and immunization CDC website.5. Diseases Surveillance, WHO website. 6. Kansas Department of health and Environment, Varicella reporting
guidelines, 20047. Notifiable conditions, Washington State Department of Health
website8. Department of Public health and preventive Medicine, Government
of Tamil Nadu website.9. How to investigate an outbreak; National Center For Chronic
Disease Prevention And Health Promotion, Centers For Disease Control And Prevention, 2006.*
10. Epidemiological investigation of outbreaks, Communicable Disease Management Protocol Manual, Communicable Disease Control Unit, Public Health, Manitoba Health. 2006*
11. Kane J Albert & Morley S. Paul, How to investigate a disease outbreak, AAEP, reprinted in IVIS website with the permission of AAEP*.
12. Park, K. Textbook of Preventive & Social Medicine, 14th edition, M/s Banaras Bhanot, 1994.
13. CDC, principle of epidemiology. Unpublished, 1978 14. Conducting an Outbreak Investigation. The North Carolina
Communicable Disease Control Manual, North Carolina Division of Public Health. Accessed at http://www.epi.state.nc/epi/gcdc/manual/outbreakinvest.pdf
http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01262. html15. Bender AP, Williams AN, Johnson RA, Jagger HG. Appropriate
public health16. Responses to clusters: the art of being responsibly responsive. Am
J Epidemiol, 1990;132:S48-52.
91
Section XAnnexes
92
Annex-1 Notifiable disease reporting form
Name of person reporting__________________Phone No :___________________Comments______________________________________________________
All Physicians, Health worker are Strictly required to report patients visiting the health facilities sufferinng from anyone of list of notifiable diseases mentioned below.
Reporting center (BHU/Hospital) :__________________________________________________
Sl# Disease Y N No.of cases Reporting Time Remarks
1 Anthrax Immediately2 Avain Influenza Immediately3 Brucellosis Immediately4 Cholera Immediately5 Rubella/Congenital Rubella syndrome 24 hours6 Diphtheria 24 hours7 Dengue & Dengue Hemorrhagic Fever Immediately8 Shigellosis Immediately9 Human Rabies Immediately10 Japanese Encephalitis 24 hours11 Leptospirosis 24 hours12 Measles 24 hours13 Bacterial meningitis Immediately14 Mumps 7 days15 Nipha Virus Immediately16 Pertusis 24 hours17 Plague Immediately18 Poliomyelitus 24 hours19 SARS Immediately20 Small pox Immediately21 Tetanus Immediately22 Typhiod fever 24 hours23 Viral Hepatitis 24 hours24 Scrub Typhus 24 hours25 Others ( Specify) Immediately
PHLPublic Health Laboratory
National Notifiable Diseases Reporting Form
If any cases are found fill Case Investigation Form( ANNEXURE) for each patient. Duly filled report must be sent to Public Health Laboratory on weekly basis
Mail or Fax the report to :Head Public Health Laboratory, POBOX 667,Thimphu Bhutan
Phone # 00975-2-323317,Fax# 00975-2-332464 Mobile#00975-17760958Email to : toswangehuk@hotmail.com OR sonamphl@health.gov.bt
93
Annex-2 Case investigation form
PHLPublic Health Laboratory
NOTIFIABLE DISEASE CASE INVESTIGATION FORMTel # 02323317, Fax # 02332464, P.O Box 667, Thimphu : Bhutan, toswangehuk@hotmail.com OR sonamphl@health.gov.bt
Patient Information:Health centre :
Name of the patient : CID # Age: Sex:
Address : Tel # Mobile #
Suspected Probable Confirmed case of :Treatment Received ? Yes NoIf yes please provide details:Patient status :
Symptoms Symptoms Symptoms Symptoms Symptoms
Clinical Information: (tick appropriate one)
Fever (____C) onset date: ____/___/___
Rash/Macula-popular rash, onset date: ___/____/____
Acute Respiratory Distress syndrome Stiff neck Jaundice
Headache Rigor Trachypnea Unconsciousness Dysphagia
Cough Arthritis Pleural effusion Coma Red colored spot
Coryza Escher Respiratory failure Opisthotonos Conjuctivitis
Sore throat Pharyngitis/ Laryngitis Pneumonia Myalgia Conjunctival Suffusion
Acute watery diarrhea Edema Hypotension Microcephaly Cataract
Abdominal disturbances/Cramp Restlessness Myocarditis Paroxysm Pigmentary retinophathy
Diarrhea Hemetamesis Cardiac arrhythmia Convulsion Nystagmus Constipation Petechiael rash or purpura Bradycardia Seizure Glaucoma
Nausea/ Vomiting Papular/vesicular lesion Myocardiopathy Hyperactivity Micropthalmus
Chills Ecchymoses Meningitis Oliguria Diminished vision
Malaise Hemorrhagic manifestation Encephalitis Proteinuria Pustules
Anorexia Splenomegaly Meningo-encephalitis Septicemia Gangrene
Weight loss Lymphadenitis/Lymphedenopathy Mental Retardation Thrombocytopenia Arthralgia
Generalized body ache Hepatomegaly Delirium Leucopenia Ascitis
Sweating Hypoxia/hypoxemia Hydrophobia/Photophobia Leucocytosis Radioluscent bone disease
Retro-orbital pain Dsypnoea Prostration Hypoproteinemia Parotitis
Others (specify)
Epidemiological Information (circle appropriate one)1. Date of onset of illness: ____/____/___ _(dd/mm/yy) 2..Travel history prior to illness: Yes No Travel to ____________________ Duration:_______(Days/week/month).
3. Exposure to animal/infected person in the past 10 days: Yes No Unknown. If yes date of exposure: ____/____/____ (dd/mm/yy).
4. Transmission setting: Hospital Home Work place Monastery International travel Others (specify) 5. Outbreak related: Yes No Unknown
Exclusively for measles/rubella/CRS/maternal/neonatal tetanus
1. Is patient pregnant: Yes No 2. Was patient in contact with pregnant since developing symptoms: Yes No 3. Is mother vaccinated: Yes No Unknown
4. Is mother Vaccinated: Yes No Unknown if yes , vaccinated against : _____________________ 5. Date of last dose of vaccine: ___/___/___ (dd/mm/yy)
6. Macupapular rash during pregnancy of mother: Yes No Unknown if Yes, give month: ______________ 7. Was rubella laboratory confirmed: Yes No
7. Exposed during pregnancy to any person wit macupapular rash illness with fever: Yes No Unknown if yes, give month: _________________________
Immunization status:
Immunized? Yes No Unknown if Yes, Vaccinated against: _____________________(mention the name of vaccine)
Last date of vaccination : ___/___/___ (dd/mm/yy) No. Of Doses:_____________
Name of the examining physician : _______________________________________________________________ Signature _________________________________ Date :___/___/___ (dd/mm/yy)
Laboratory Information:
Sample collected Date of sample collection
Date of shipment (if sam-ples need to be confirmed by reference laboratories)
Laboratory results (If Any) use additional sheets
Serology Hematology Microbiology (Microscopy, Culture, DST, etc)
94
Annex-3 Outbreak notification form
PHLPublic Health Laboratory
Outbreak Notification FormTel # 02323317, Fax # 02332464 P.O Box 667, Thimphu : Bhutan, toswangehuk@hotmail.com OR sonamphl@health.gov.bt
1. Reporting center (BHU/Hospital ): __________________________________________________________________________________
2. General Information2.1 Name of Outbreak:_______________________________________________________________________________________________
2.2 Estimated total No. affected population:_______________________________________________________________________________
2.3 Place of the Outbreak: ____________________________________________________________________________________________
2.4 Time [mention time, date & month of outbreak]: ________________________________________________________________________
3. Clinical Information: Mention common signs and symptoms presented by patient:1.__________________________________ 2. _______________________________ 3. __________________________________________
4.___________________________________5. _______________________________6. __________________________________________
7. ___________________________________8. _______________________________9.__________________________________________
4. Laboratory Information:
4.1. Laboratory confirmation: Done Under process Not done No facilities [Circle appropriate one]
If done then write down the results below :__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
4.2 Sample sent to reference laboratory for confirmation/investigation? Yes No Not required [circle appropriate one]
. Additional Information
5.1. Outbreak investigation done? Yes No [Circle appropriate one]
5.2. Intervention measures undertaken? Yes No [Circle appropriate one]
If yes mention in detail here : _______________________________________________________________________________________
__________________________________________________________________________________________________________________
5.3. Require investigator(s) for the outbreak? Yes No [Circle appropriate one]
6. Notification details
Name of Notifier: ___________________________________________Contact # ________________________________________________
Address: ___________________________________________________________________________________________________________ [Please provide complete address]
Public Health Laboratory Tel # 02-323317 Fax # 02332464
Email: toswangehuk@hotmail.com OR sonamphl@health.gov.bt
Notify to :
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96
Annex-5 Poliomyelitis case investigation form
PHLPublic Health Laboratory
Tel # 02323317, Fax # 02332464, P.O Box 667, Thimphu : Bhutan, toswangehuk@hotmail.com OR sonamphl@health.gov.bt
1. Report/Investigation information: Date case reported: ___/___/___ (dd/mm/yy) Date case investigated: ___/___/___(dd/mm/yy
2.Investigator’s information Name of investigator:_________________(if more than one investigators, use additional blank sheets)
Title: ______________________________ Name of BHU/ Hospital _________________________
3. Patient identification:Patient name: ________________________________________ Age : _______________ Sex: _______________Address:_________________________________________________Phone #________________________Mobile #_____________________
4. Hospitalization.
Yes No Date of Hospitalization: ___/___/___ (dd/mm/yy)
Name of the hospital : ______________________________________Hospital Registration No: _______________________________
5. Immunization History :Total OPV received through routine EPI: _______________________ Total OPV received through NIDS: ___________________________Date of last day of routine OPV:___/___/___ (dd/mm/yy).
6. Clinical Signs & Symptoms:Date of paralysis onset: ___/___/___(dd/mm/yy) Number of days from onset to maximum paralysis: _________
Any injections during the 30 days before paralysis onset: Yes No Unknown
Symptoms Yes No Unknown Symptoms Yes No
Acute flaccid paralysis Sensation loss
Flaccid paralysis Descending paralysis
Fever on the day of paralysis onset paralysis: Right arm
Asymmetrical paralysis paralysis: Left arm
Asymmetrical paralysis paralysis: Right leg
Ascending paralysis paralysis: Left leg
Unknown
7. Laboratory Investigation:A. Sample collection:
B. Laboratory Result:Date of test performed: ___/___/___(dd/mm/yy)
Specimen Date of collection Date of shipment to reference laboratory
Stool 1
Stool 2
Sample √ Result √ Result √ ResultStool 1 P1 P2 P3 Wild/Vaccine Pending NPEV Negative
Stool 2 P1 P2 P3 Wild/Vaccine Pending NPEV Negative
8. Patient status:Recovered dead
9. Epidemiology:
Outbreak response done: Yes No Date ___/___/___ (dd/mm/yy) if No, why? _______________________________________
If yes, date begun: _______________ Setting: Urban/ Rural Target population of <5 yrs: ________________ Number < 5 immunized: ______________
9. Final Classification: Confirmed Polio: Yes/ No If discarded, why? (tick)
Criteria: (tick) 1. Virus isolation: [ ] 1. Gullian- Barre: [ ]
2. Residual paralysis: [ ] 2. Transverse Myelitis: [ ]
3. Died: [ ] 3. Traumatic neuritis: [ ]
4. Lost to follow-up: [ ] 4. Others: __________________________
Comments:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Poliomyelitis Case Investigation Form
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Annex-6 Outbreak investigation of acute diarrhoeal infection
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Suspected Outbreak ofAcute Diarrheal Syndrome
Definition of syndrome
Acute onset of diarrhea and severe illness and absence of known predisposing factors
Possible pathogens
Water diarrheaViral gastroenteritis
CholeraEntero-toxigenic E.coli
GiardiasisCryptosporidium
DysenteryAmoebic dysentery
CamphylobacteriosisEntero-hemorrhagic E.coli
Shigellosis
Specimen required
Fecal examination
Laboratory studies
Parasite:Macroscopic (physical) & Microscopic examination
Viral:Antigen detectionGenome detection
Bacterial:Fecal leucocytesCultureSerotypingToxin identification
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Annex-7 Outbreak investigation of AHF
Suspected Outbreak ofAcute Diarrheal Syndrome
Acute onset of diarrhea and severe illness and absence of known predisposing factors
Definition of syndrome
Possible pathogens
Water diarrheaViral gastroenteritis
CholeraEntero-toxigenic E.coli
GiardiasisCryptosporidium
DysenteryAmoebic dysentery
CamphylobacteriosisEntero-hemorrhagic E.coli
Shigellosis
Fecal examination
Specimen required
Parasite:Macroscopic (physical) & Microscopic examination
Viral:Antigen detectionGenome detection
Laboratory studies
Definition of syndrome
Possible pathogens
Specimen required
Laboratory studies
Suspected Outbreak ofAcute Hemorrhagic Fever Syndrome
Acute onset of fever less than 3 week duration and any two of the following:1. Hemorrhagic or purpuric rash2. Epistaxis3. Hemoptysis4. Blood in stool5. Other hemorrhagic symptom and ab sence of known predisposing factors
Dengue hemorrhagic fever and shock syndrome/Hemorrhagic fever with renal syndrome.
LeptospirosisMeningococcal meningitis
Hantaviruses
Blood/serum/smearPost-mortem tissue specimens
Parasite:Demonstrate parasites
Viral:Culture
Antigen detectionAntibody levels
Genome detection
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Annex-8 Outbreak investigation of acute jaundice
Definition of syndrome
Possible pathogen
Specimen Required
Laboratory studies
Suspected outbreak ofAcute Jaundice Syndrome
Acute onset of jaundice Severe illnessAbsence of predisposing factors
Leptospirosis and other Spirocheatal disease
Hepatitis A -E
Blood/serum
Viral:
Culture
Antigen detection
Antibody level
Genome analysis
Leptospiral:
Culture
Antibody level
Serotyping
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Definition of syndrome
Possible pathogen
Samples required
Laboratory studies
Suspected outbreak ofAcute Respiratory Syndrome
Annex-9 Outbreak investigation of acute respiratory infection
Acute onset of cough or RDSSevere illnessAbsence of known predisposing fac-tors
Influenza Hantavirus Respiratory Syn-cytial Virus (RSV)
DiphtheriaBacterial pneumonia includ-ing pneumococcal LegionellosisHemophilus influenza Pneumonic Mycoplasma Respiratory anthraxPlaque
Throat swabNasopharyngeal swab
Blood SerumSputumThroat swabNasopharyngeal swabUrine (for legionella)
Bacterial or Viral:Culture ASTAntigen detection Antibody levelGenome analysisSerotypingToxin identification
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Annex-10 Outbreak investigation of acute neurological infection
Definition of syndrome
Possible pathogen/ diseases
Specimens required
Laboratory studies
Suspected outbreak of Acute Neurological syndrome
Acute neurological dysfunction with one or more of the following:1. Deterioration of mental functions2. acute paralysis3. convulsions4. Signs of meningeal irritation 5. involuntary movements6. other neurological symptom7. Severe illness Absence of predisposing factors
Poliomyelitis or Guillian Barre syndrome
Viral BacterialFungalParasiticMeningo-encephalitis
Rabies
SerumPost mortum specimen
(e.g. corneal impression, brain tissues, Skin biopsy
from neck)
CSFBlood CultureBlood smear
SerumThroat swab
Feces
Viral: CultureAntigen detection
Bacterial including lepto-spiralGram stain and other microscopic techniques, culture, AST, antigen de-
tection, serotyping
Viral : Culture Antigen detectionAntibody levels Genome analysis
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