table of contents - royal centre for disease control · this notifiable disease surveillance is...

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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.


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


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

27

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.


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


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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


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

38

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

39

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



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→→→→ →

→ →

Health Information & Management System (HIMS)

Monthly

Notifiable Diseases Reporting Center(Public Health Laboratory)DHO



Send copy

District HospitalsCMO/MS

Regional Referral hospitalsMS/ focal person

National Referral HospitalMS/focal person



BHU’sHA & ANM

→

Figure-1 Reporting system

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Section IVAnalysis and interpretation of data

42

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

45

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

47

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

48

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

50

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.

51

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

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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





• Collect stool/blood samples for confirmation

• Ensure safe water supply



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


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.





• Collect blood samples lab confirmation

• Intensify vector control activities



Japanese Encephalitis

Single cases of probable JE in a community or2 cases with fever with altered consciousness /seizure


56

Leptospirosis

Single suspect case in a community





• Collect blood samples for lab confirmation



Brucellosis

Plaque

Scrub typhus

Clustering of cases with prolong fever in given time from a same geographical area.


57

Measles Single case of measles or probable measles case in a community


• Confirm the case/outbreak




• Intensify surveillance response

• Immunization response

• Provide Vitamin A supplementww



Rubella

CRS

MumpsClustering of cases from a community/institutes


58

Diphtheria

Single suspect case a community


• Confirm the case• Active search

of cases in accordance with standard case definition provided







Pertusis

Tetanus

Viral hepatitis

Clustering of cases in given time from a same geographical area


59

Poliomyelitis

One suspected cases of poliomyelitis in a community or Single confirmed case.




• Collect stool samples for lab confirmation






60

Rabies

Single suspect case in a community and epidemiologically linked to rabies outbreak in animal





• Collect CSF or brain samples for lab test




• Coordinate with Animal health centre for disease control




61

Bacterial meningitis One suspected case





• Collect CSF for lab tests and confirmation




62

Any other unusual diseases or diseases not included in notifiable list

Minimum 2 cases presenting similar signs & symptoms from a same geographical area.


• 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



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


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 : [email protected] OR [email protected]

93

Annex-2 Case investigation form


NOTIFIABLE DISEASE CASE INVESTIGATION FORMTel # 02323317, Fax # 02332464, P.O Box 667, Thimphu : Bhutan, [email protected] OR [email protected]

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


Outbreak Notification FormTel # 02323317, Fax # 02332464 P.O Box 667, Thimphu : Bhutan, [email protected] OR [email protected]

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: [email protected] OR [email protected]

Notify to :

95

Ann

ex-4

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ne li

stin

g fo

rm

Publ

ic H

ealth

Lab

orat

ory

OU

TB

RE

AK

LIN

EL

IST

ING

FO

RM

Tel #

023

2331

7, F

ax #

023

3246

4, P

.O B

ox 6

67, T

him

phu

: Bhu

tan,

tosw

ange

huk@

hotm

ail.c

om O

R s

onam

phl@

heal

th.g

ov.b

t PH

LSl

.#Pa

tient

’s n

ame

Add

ress

Age

/Sex

Sym

ptom

s

1 2 3 4 5 6 7

H/O

rec

ent

trav

el to

ot

her

plac

es (

Y/N

)

Dat

e of

ons

et o

f illn

ess

(dd/

mm

/yy)

Imm

uniz

atio

n [if

app

licab

le]

(Y/N

Man

agem

ent

done

(Y/N

)

Out

com

e of

illn

ess:

Rec

over

ed(R

)St

ill il

l(SI

) D

ead(

D)

96

Annex-5 Poliomyelitis case investigation form


Tel # 02323317, Fax # 02332464, P.O Box 667, Thimphu : Bhutan, [email protected] OR [email protected]

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

98

Annex-7 Outbreak investigation of AHF

Suspected Outbreak ofAcute Diarrheal 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

Fecal examination

Specimen required

Parasite:Macroscopic (physical) & Microscopic examination

Viral:Antigen detectionGenome detection

Laboratory studies


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


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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100


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


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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