fourth quarter - rcdc.gov.bt · volume 4 4 4th quarter (october-december) 2015 3. influenza...

DISEASE SURVEILLANCE BULLETIN

Volume 1 1 1st Quarter (January – March) 2015

Contents Page No

Surveillance of Diarrhea Etiologic Agents among children under 5 years

1 - 2

Surveillance of Multi Drug Resistance 2 – 3

Influenza Surveillance 4 - 7

Measles and Rubella Surveillance 7 - 8

Acute Encephalitis Syndrome Surveillance 8

Leptospirosis Surveillance 8

Scrub Typhus 8 - 9

HIV Confirmation 9

Surveillance on Urban Drinking Water 9 - 13

Summary of Disease Outbreaks Report 13

Summary of National Notifiable Diseases 14

Fourth Quarter 2015

Department of Public Health Ministry of Health www.phls.gov.bt

PUBLIC HEALTH LABORATORY


Volume 4 1 4th Quarter (October-December) 2015

1. Surveillance of Diarrhea Etiologic

Agents among children under 5 years

A total of 237 samples were collected from children

below five years who presented with diarrhea from

JDWNRH. All the samples were subjected to different

Microbiological methods to identify the diarrheal

etiologic agents (Microscopy, Culture, Multiplex

Polymerase Chain Reaction, Antimicrobial

Susceptibility Test and ELISA).

1.1 Microscopy

Microscopic examination of stool specimens was able

to detect some parasites, most commonly Taenia

species and Entamoeba species.

1.2 Culture/Isolates

Six different types of organism were isolated from 237

samples, all of which were subjected to bio-typing,

sero-typing, geno-typing and antimicrobial

susceptibility test where necessary (Table 1).

1.3 Multiplex PCR.

A total of 116 isolates of both LF and NLF Escherichia

coli were subjected to multiplex PCR to confirm and

differentiate the strains of Diarrheagenic E-coli (Figure

1). The commonly genotyped Diarrheagenic E-coli are

Enteroagregative E-coli and Enteroinvasive E-coli.

1.4 Antimicrobial susceptibility test (AST)

Antimicrobial susceptibility testing showed that of all

Shigella species, 90% (n=10) were resistant to

Nalidixic acid, 90% to Ciprofloxacin and 70% to

Sulfamethoxazole but 100% susceptible to Ceftriaxone

and Gentamycin. Other bacterial isolates (Salmonella)

were found susceptible to Amoxycillin,

Sulfamethoxazole and Ceftriaxone. Diarrheagenic

E.coli showed resistance to Amoxycillin but were

susceptible to Ceftriaxone, Ciprofloxacin and

Tetracycline (Table 2).

1.5 ELISA

Test result for enteric viruses (rotavirus, norovirus and

adenovirus) are still pending due to shortages of test

kits.

Table 1: Common organism isolated

Organism isolated Total

Aeromonas spp 1

Campylobacter spp. 3

Shigella 10

Salmonella 5

LF E-coli 92

NLF E-coli 24

Figure 1: Multiplex PCR showing different Diarrheagenic E-coli



Table 2: Antibiotic Susceptibility pattern of bacterial isolates

S = Susceptible, I = Intermediate, R = Resistant

AMX: Amoxycillin, CIP: Ciprofloxacin, SXT: Sulfamethoxazole,

CRO: Ceftriaxone, NAL: Nalidixic acid, GEN: Gentamycin, CHL:

Choloramphenicol, TCY: Tetracycline.

2. Surveillance of Multi Drug Resistance

Tuberculosis

2.1 Culture & Drug Susceptibility Testing

A total of 136 patient sputum samples were received for

culture and Drug Susceptibility Testing (DST) at

National TB Reference Laboratory (NTRL), among

which 101 were culture positive, 14 culture negative, 6

contaminated and rest are under incubation. 152 extra-

pulmonary (EPTB) samples were also processed for

MTB culture among which 11 were culture positive, 46

negative 14 contaminated and rest are under incubation.

DST was completed for 16 samples (PTB) and 2

samples (EPTB). 4 confirmed MDR-TB cases from

PTB were reported for the given period.

Apart from routine sample processing for culture and

DST, NTRL has received and processed 125 patient

samples for MDR-TB culture follow-up and 7 patient

samples for ruling out TB by culture for the purpose of

medical certificate.

Table 3: Number of TB cases among different types of TB

Pulmonary TB Extra-

pulmonary

TB New

Smear

Positive

New

smear

Negative

Re-

treatment/

Failure/

Relapse

Unknown

Patient

Sample

received for

culture & DST

110 7 12 7 152

Culture

Positive

84 3 6 2 11

DST

completed

11 0 5 0 2

MDR-TB

detected

1 0 3 0 0

Figure 2: Pie chart showing different type of Tb cases (PTB) sent

for culture & DST

NSP81%

NSN5%

Retreatment9%

Unknown5%



Figure 3: Number of samples received for culture & DST for 4th Quarter

Figure 4: Different type of TB cases (EPT) sent for culture &

DST

2.2 Descriptive analysis of MDR-TB cases

Four MDR-TB cases were confirmed by NTRL in the

fourth quarter of 2015, among which one was new

smear positive, three retreatment/failure/relapse

cases. No MDR is detected among EPTB cases. The

MDR-TB cases were reported among the productive

age group (22 to 32 years) and the youngest one is 22

years old. 3 MDR among female and 1 MDR in male

was reported

Table 4: Number of MDR-TB case reported from hospitals

Name of the Hospital Numbers

JDWNRH 3

Samdrup Jongkhar 1

Total 4

Figure 5: Different type of MDR-TB confirmed

66

2

22

14

3

11

1 3 2 1 1 14 2 2

0

10

20

30

40

50

60

70

Hospitals

FNAC67%Urine

1%

Pus11%

Pleural Fluid10%

Ascitic Fluid5%

Biopsy4%

CSF1%

Gastric Aspirate

1%

NSP25%

Retreatment/Failure/

relapse75%



3. Influenza Surveillance

3.1 Influenza Like-Illness Surveillance (ILI) –

Epidemiological Component

Out of total 83539 OPD visits at seven sentinel sites a

cumulative of 2204 ILI visits had been recorded for

this quarter. Average ILI incidence was 38 cases per

1000 outpatient visits (Figure 6). The highest ILI

incidence among sentinel sites was observed in Paro

Hospital (1200 cases) followed by Trongsa Hospital

(418 cases). ILI cases were commonly observed in

age group of 15-29 years (28.45%), (Table 5).

Figure 6: Average number of ILI cases reported for the 4th Quarter (week 40 to 53)

Table 5: Distribution of ILI cases by age groups

Age (Years) ILI cases

Number Proportion (%)

0-1 148 6.72

2-4 286 12.98

5-14 616 27.95

15-29 627 28.45

30-64 460 20.87

65+ 67 3.04

3.2 Influenza Like-Illness Surveillance –

Virological Component

Out of 239 ILI samples received and tested by RT-

PCR, 11.29 % (27/239) were positive for Influenza

virus, which comprise of Influenza A pandemic 2009

(A/pdm H1) – 22% (6), A/H3 strain -29.6% (8) and

Flu B- 48.14% (13). Numbers of specimens positive

for various influenza subtypes by week are illustrated

in Figure 7.

Influenza B virus was the most predominantly

circulating influenza virus strain in Bhutanese

population followed by Influenza A/H3.

Geographical distribution of influenza virus strains

among sentinel sites is given in Figure 8.

A high positivity rate was detected among 30-64

years age group (25%) and was mostly influenza B

(Figure 9).



Figure 7: Influenza virus subtype by week. (Figure adopted from: FluNet ( www.who.int/flunet ), GISRS)

Figure 8: Influenza virus subtype distribution by site



Figure 9: Influenza virus subtype and positivity rate by age group

3.3 Severe Acute Respiratory Illness

Surveillance (SARI) - Epidemiological

Component

Sentinel sites that include hospitals of JDWNR,

Paro, Punakha, Samtse, CRRH, Trongsa, Tsirang,

MRRH, Trashigang, Phuntsholing and

Samdrupjongkhar hospitals recorded a total of 3349

admitted patients (only relevant wards included in

Regional and National Referral Hospital) during

this quarter of year. Of these, 195 were SARI cases.

Average SARI incidence was 6 SARI cases per 100

hospitalized patients (Figure 10). The highest

SARI incidence was observed in Paro (48 cases)

followed by Samdrupjongkhar Hospital (36 cases).

No death cases were reported from any of the sites.

SARI cases were commonly observed in children of

age group 2-4years of age (Table 6).

Table 6: SARI case distribution by age groups

Age Cases (Numbers) Proportion (%)

0-1 76 38.97

2-4 39 20

5-14 17 8.72

15-29 14 7.18

30-64 32 16.41

65+ 17 8.72

3.4 Severe Acute Respiratory Infection

Surveillance- Virological component

Total of 98 throat swab specimens were received

from SARI cases of 11 sentinels sites. Phuntsholing

Hospital collected the maximum number of

samples (26 samples) followed by Samtse Hospital

(18 samples). The samples were tested for influenza

and other respiratory viruses like Respiratory

syncytial virus (RSV) and human meta-pneumo

virus (hMPV). Out of 97 samples, 4.12% samples

tested positive for Influenza Virus, (A/pdm H1- 2

& Flu B-2), 5.15% positive for (hMPV) and 7.21%

positive for RSV.

(Figure 11).



Figure 10: No. of SARI cases reported weekly

Figure 11: Trend of influenza virus and other non-influenza virus

Table 7: Respiratory viruses detected according age groups

Age A/PdmH

1 (n*=2)

Flu B

(n*=2)

RSV

(n*=7)

hMPV

(n*=4) Total

0-1 2 0 6 3 11

2_4 0 1 1 0 2

5_14 0 1 0 1 2

15-29 0 0 0 0 0

30-64 0 0 0 0 0

65+ 0 0 0 0 0

n* = number of cases

4. Measles & Rubella Surveillance

National measles and rubella reference laboratory

has tested 57 serum samples in the last quarter and

no samples tested positive for anti-Rubella IgM. Of

the 57 serum specimens 9 tested positive for anti-

measles IgM and one of the samples obtained

during contact tracing from a positive case in

Phuntsholing tested to be equivocal on testing and

retesting from the same sample. However, awaiting

a repeat sample from the patient. Throat swab has

been collected simultaneously and referred to WHO

Regional Reference laboratory, NIH, Thailand for

0

20

40

60

80

100

120

0

0.5

1

1.5

2

2.5

3

3.5

40 41 42 43 44 45 46 47 48 49 50 51 52 53

Pe

rce

nta

ge P

osi

tive

No

. Po

siti

ve S

pe

cim

en

s

Week

PdmH1 Flu B hMPV RSV Positivity Rate(%)



confirmation. All the 9 samples testing positive has

been confirmed and tested positive.

Genotyping has been performed for the very first

time on the positive samples and have uploaded to

the measles nucleotide surveillance (MeaNS)

database. Currently we have two each of D8 and B3

genotypes obtained from sequencing the 450

nucleotide N gene of the measles virus.

Table 8: Measles and Rubella Testing Report

[email protected]

5. Acute Encephalitis Syndrome

(AES) Surveillance

ELISA for anti-JE antibody tests has been carried

out on a total of 31 CSF and serum samples,

received from JDWNRH and Gelephu. No sample

tested positive for anti-JE antibody. Most samples

received have been referrals from the pediatric

OPD and IPDs of JDWNRH. However no samples

have been received from other districts other than

just one CSF and 3 serum samples from Gelephu

CRRH.

Table 9: Number of samples tested for JE

Hospitals Samples

CS

F

Result Seru

m

Result

Pos Equi Neg Pos Equi Neg

JDWNRH 10 0 0 0 18 0 0 0

Gelephu 1 0 0 0 3 0 0 0

Total 11 0 0 0 21 0 0 0

Pos: Positive Equi: Equivocal Neg: Negative

6. Leptospirosis Surveillance

IDSL tested 31 samples in the 4th quarter of which

none tested positive. (Table 10).

Table 10: Number of samples tested for leptospirosis

Referring site Total

samples

Positive

1 JDWNRH 24 0

2 Samtse 5 0

3 S’Jongkhar 2 0

Total 31 0

Note: Laboratory uses Rapid chromatographic tests, ELISA

and MAT (Microscopic agglutination test) to detect and

confirm cases of leptospirosis.

7. Scrub typhus

Samples are tested using principles of ELISA and

rapid chromatographic assays. Figure 12 shows the

serum samples testing positive for Orientia

tsutsugamushi IgM (ELISA), IgG, IgM and IgA

mailto:[email protected]



(RDT). Sipsoo was showing an increased positivity

over the season. Literatures suggests the end of the

Scrub typhus season by October, probably the

reason for the declining number of samples coming

in from the districts year as well as positivity

Figure 12: Scrub typhus samples tested

8. HIV confirmation

IDSL has carried out 86 HIV confirmatory tests for

samples that has tested positive in their respective

referring centres (Figure 13) of which 21 were

confirmed positive by IDSL, using test kits other

than that used in the primary testing centres. Six of

the samples were collected from the people who

came for screening on the World AID’s day. Most

samples for HIV confirmation came in from

JDWNRH (n=23), followed by Chukha (n=14) and

Pemagatshel (n=10). This is probably due to the

sizable number of people living in those districts,

increased economic activities comprising social

networking, information flow, awareness and

understanding the need to get tested. The HIV

testing algorithm necessitates 2 out of 3 tests

positive/ reactive to interpret the final test a

positive. IDSL uses three testing principles namely

(i) ELISA (Genscreen), (ii) Gelatin particle

agglutination (Serodia) and (iii) rapid

chromatographic assay (Determine) for screening

the referred serum samples.

Figure 13: Total number of samples received and tested for

HIV confirmation

9. Drinking Water Quality

Monitoring 4th Quarterly Report 2015

9.1 Microbiological Report

A total of 670 samples were collected and tested for

fecal coliform from all the districts laboratories for

the 4th quarter of the year 2015(October-

December). The test results show that 284 samples

were safe water and the remaining 386 samples

were found unsafe. Among the 386 unsafe

samples, 258 samples are categorized as low health

risk, 123 as Intermediate to High health risk and 5

as grossly polluted sample.



Figure 14: Microbiological report of 20 districts water for 4th quarter.

Note: 0=Safe water; >1=Unsafe water

Figure 15: Categorization of bacteriological report VS health risk.

Note; 0 CFU=Safe water (SW); 1-10 CFU =Low Health Risk (LHR); 11-50 CFU=Intermediate to High Health Risk (IHHR);

>50 CFU=Grossly Polluted

0

10

20

30

40

50

60

70

80

90

Nu

mb

er

of

feca

l co

lifo

rm

Dzongkhag

Bacteriological report from 20 districts

GPW

IHHR

LHR

SW



9.2 Thimphu Thromde Physico-Chemical Test Report

The reports for physiochemical parameters viz. Residual Chlorine, pH, Turbidity, Total Dissolved Solids

& Conductivity, from Thimphu Thromdey at various sampling points are shown in Figure 16, 17, 18,

and 19.

Figure 16: Residual Chlorine.

Note: MTP-Motithang Treatment Plant;JTP- Jungshina Treatment Plant; BPT: Break Pressure Tank

Residual Chlorine was maintained in almost all the treatment plants and reservoir tanks. In reservoir tank

above JDWNRH residual chlorine was maintained only in November and it was not maintained in NPPF

colony reservoir tank and swimming pool tank during October month. Residual chlorine was found

beyond acceptable limit in Motithang treatment plant in the month of October.

0

1

2

3

4

5

6

7

Re

sid

ual

Ch

lori

ne

Acc

ep

tab

le v

alu

e (

0.2

-0.5

mg/

L)

Sampling station

October

November

December



Figure 17: pH

There was no much variation in pH for the 4th quarter, however there was slight change in pH during

October at Motithang treatment plant treated water, this may be due to higher residual chlorine in the

treated water.

Figure 18: Turbidity

The turbidity of the drinking water were within the acceptable limit for this quarter from all the sampling

stations.

0 2 4 6 8 10

JTP(Source)

JTP(Treated)

MTPlant (Source)

MTP (Treated)

BPT R1 Tank

Three Tank Lower Motithang

Tank above NPPF colony

Reservoir Tank near BCCI office

Tank above JDWNRH

Tank near Swimming pool

Changjiji Tank

Changjiji Pump House

pHAcceptable value(6.5-8.5)

Sam

plin

g St

atio

n

December

November

October

0

0.5

1

1.5

2

2.5

Turb

idit

y A

cce

pta

ble

val

ue

(<5

NTU

)

Sampling stations

October November December



Figure 19: Total Dissolve Solids (TDS and Conductivity (CND)

10. Summary of Disease Outbreaks Report

Figure 20: Disease Outbreak Notification Report from October to December 2015

0

50

100

150

200

250

300

350

400

450

TDS CND TDS CND TDS CND TDS CND TDS CND TDS CND

JTP (Source) JTP (Treated) MTP (Source) MTP (Treated) ChangjijiColony Tank

ChangjijiColony Pump

House

October

November

December



11. Summary of National Notifiable Diseases Surveillance

Table 13: National Notifiable Diseases Surveillance Summary during the 4th Quarter 2015

Notifiable Disease BUM CHU DAG GAS HAA LHU MON PAR PEM PUN SJK SAM SAR THI TRG TRY TRO TSI WNG ZHE Total

(1)Anthrax 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

(2)Acute Bloody Diarrhea 32 42 3 3 0 53 35 81 46 19 101199 102 32 44 80 16 15 24 32 18 101876

(3)Acute Watery Diarrhea 137 460 99 57 1 184 166 461 212 259 1014355 592 478 362 488 131 151 213 383 194 1019383

(4)Acute Encephalitis Syndrome

0 0 0 0 0 0 0 0 0 0 1 1 2 0 0 0 0 0 0 0 4

(5)Acute Flaccid Paralysis 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 4

(6)Acute Haemorrhagic Fever Syndrome

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(7)Acute Jaundice Syndrome

0 26 0 0 2 0 0 25 10 5 0 2 0 14 29 7 0 1 7 0 128

(8)Acute Respiratory Infection

927 3866 491 163 479 726 1312 3223 2068 698 3393 4121 3667 3926 2307 770 1053 1391 1576 871 37028

(9)Bacterial Meningitis 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 3

(10)Dengue Fever 0 1 0 0 0 0 0 0 3 0 0 0 0 0 3 0 0 0 0 0 7

(11)Mumps 73 9 12 0 6 69 191 49 18 44 61 91 42 25 93 98 26 29 28 69 1033

(12)Diphtheria 0 0 1 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 9 13

(13)Fever with Rash 0 9 34 0 46 1 0 19 0 10 42 6 57 1 28 1 4 135 5 14 412

(14)Food Poisoning 2 0 0 0 0 0 4 2 1 5 1 36 2 0 4 13 2 1 0 16 89

(15)Malaria 0 0 0 0 0 0 0 0 0 0 0 0 19 0 0 0 0 0 1 0 20

(16)Pertussis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(17)Rabies (Human) 0 0 0 0 0 0 0 0 0 0 11 0 0 0 0 0 0 0 0 0 11

(18)Congenital Rubella Syndrome

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(19)Multi-drug Resistance TB

0 0 0 0 0 0 0 0 0 0 0 1 0 10 0 0 0 0 0 1 12

(20)Tetanus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(21)Typhoid / Paratyphoid Fever

0 46 0 0 1 2 4 4 18 2 100 10 19 0 47 4 0 0 1 10 268

(22)Unusual Disease(s), Death(s) OR Event(s)

0 36 0 3 0 0 0 0 0 1 0 0 25 0 0 0 0 0 0 0 65

(23)Severe Acute Respiratory Infection

4 25 0 0 0 0 1 9 39 22 16 82 15 15 8 22 12 12 4 61 347

(24)Rickettsioses 0 6 0 0 0 0 0 0 14 1 19 18 3 0 2 2 0 0 2 16 83

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