INTEGRATED DISEASE SURVEILLANCE PROGRAMME Operational manual - (IDSP)
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INTEGRATED DISEASE SURVEILLANCE PROGRAMME Operational manual - (IDSP)
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Pagel 16
WHO
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6/17/2002
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Operational manual - IDSP
Mon, 17 Jun 2002 18:18:14 +0530
Dear All
Am attaching the draft version of the operational manual for your comments.
The individual disease components will be added - we have developed 2 just
as an example.
With regards
Deva «Final version 1 ,pdf» «Disease Wise Summary 1 .pdf»
Dr. N. Devadasan MDBS, MPH
National Professional Officer - Communicable Diseases
WHO - India
534, Awing, Nirman Bhavan,
Maulana Azad Road,
New Delhi - 110011
Tel: +91 11 3015931
Fax: +91 11 3012450
d.eyadasann@whoindi.a;org
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TABLEOFCONTENTS
1. Introduction
2. CaseDefinitions
3. RoleoftheFunctionaries
4. RecordingandReporting
5. Analysis
6. InvestigationandResponse
7. Specimencollectionandtransportation
8. Monitoring a ndsu pervision
9. Feedback
10.Disease-wisesummaries
a. Acutediarrhoealdiseases
b. Cholera
c. Typhoid
d. AcuteHepatitis
e. Measles
f.
Dengue
g. JapaneseEncephalitis
h. Plague
11 .References
12.Acknowledgements
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INTRODUCTION
Surveillance
Detecting disease and its distribution in time and space offers clues to the silent
background phenomena of amplification and transmission of infectious agents,
which is essential for disease control. Surveillance is the first step in intervention and
serves to detect early outbreaks of diseases. Surveillance is essential for the early
detection of emerging (new) and re-emerging (resurgent) diseases. Emerging
infectious diseases encompasses those diseases caused by new pathogens (e.g.
HIV/AIDS, V. cholera 0139, Hanta virus and Ebola virus). Re-emerging diseases are
due to reappearance of pathogens previously under control (e.g. Yersinia pestis),
diseases increasing in incidence/prevalence (e.g. malaria, leptospirosis), recognized
diseases appearing in new territories (e.g. Dengue Hemorrhagic Fever), zoonotic
diseases affecting humans (eg anthrax), and diseases due to pathogens showing
newly acquired anti-microbiological resistance (e.g. typhoid fever). The outbreaks of
plague in 1994, cholera in 1995 and dengue hemorrhagic fever in 1996 highlighted
the urgent need for disease surveillance system so that early warning signals are
recognized and appropriate control measures are initiated in a timely manner.
Communicable diseases surveillance
Communicable diseases are still the most common causes of death, disability and
illness in the country. They are the major causes of hospital admissions in the health
facilities and account for high mortality and morbidity in children. Earlier only
disease specific surveillance was being carried out in the country. The success of the
smallpox eradication programme was basically due to a strong surveillance
component. The present AFP surveillance (acute flaccid paralysis) for polio is also
reaping good results but has been very labour intensive which would be required for
diseases under eradication/ elimination. TB, HIV/AIDS and malaria also have wellorganized vertical surveillance systems. The first multiple disease surveillance
system in the country was the NSPCD (National Surveillance Programme for
Communicable Diseases) which having started in 5 districts in 1997-98, now extends
to 100 districts in 28 states/UT's in the country. It has laid the foundation for basic
surveillance activities and reporting and responding to outbreaks in the selected
districts. Based on this multi-disease surveillance model, Orissa and Gujarat also
have strengthened surveillance in their states following the recent disasters.
Non Communicable Disease surveillance
During the last decade of the 20th century it has been increasingly recognized that
non-communicable diseases (NCDs) also constitute a major health challenge to
economic and social development by imposing a tremendous strain on national
health budgets and curative health services in the country. This epidemiological
transition characterized by a rapid increase in NCDs has almost outweighed the
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burden due to communicable diseases. Major NCDs like cardio-vascular diseases,
cancers and diabetes are linked to lifestyle changes. High prevalence of common risk
factors namely tobacco use, alcohol abuse, obesity, unhealthy diet, physical
inactivity, etc have compromised the health of people. Thus community-based
strategies to prevent and control the risk factors are gaining importance. The strategy
therefore targets common risk factors to lower the prevalence of NCDs.
One very successful surveillance programme for NCDs that already exists is the
Population based Cancer Registries. Other than this there are surveillance systems
for blindness, iodine deficiency, iron deficiency anaemia etc. Risk factor surveillance
for NCDs is still in the nascent phase.
Integrated Disease Surveillance Programme
Keeping in mind the disintegrated fashion in which current surveillance
programmes exist, the Govt, of India is proposing to implement the Integrated
Disease Surveillance Programme (IDSP). The IDSP proposes a comprehensive
strategy for improving disease surveillance and response through an integrated
approach. This approach provides for a rational use of resources for disease control
and prevention. In the integrated disease surveillance system:
> The district level is the focus for integrating surveillance functions.
> All surveillance activities are coordinated and streamlined. Rather than using scarce
resources to maintain vertical activities, resources are combined to collect information
from a single focal point at each level.
> Several activities are combined into one integral activity and take advantage of
similar surveillance functions, skills, resources and target populations.
> The IDSP integrates both public and private sector by involving the private
practitioners, private hospitals, private labs, NGOs, etc and also emphasis on
community participation.
>
Integrates communicable and NCDs since many of the principles of surveillance
traditionally applied to communicable diseases also apply to them. Common to both
of them are their purpose in describing the health problem, monitoring trends,
estimating the health burden, and evaluating programmes for prevention and
control.
> Integration of both rural and urban health systems as rapid urbanization has resulted
in the health services not keeping pace with the growing needs of the urban
populace. The gaps in receiving health information from the urban areas needs
urgently to be bridged.
> Integration with the medical colleges (both private and public) would also
qualitatively improve the disease surveillance especially through involvement of the
departments of community medicine, microbiology, medicine and paediatrics. They
would also serve as sentinel centres for disease surveillance.
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Objectives
The overall general objective of the IDSP is to provide a rational basis for decision
making and implementing public health interventions that are efficacious in
responding to priority diseases. Keeping this in mind the main objectives of the IDSP
are:
•
To establish a decentralized district-based system of surveillance for communicable
and non-communicable diseases so that timely and effective public health actions can
be initiated in response to health challenges in the urban and rural areas
•
To integrate existing surveillance activities (to the extent possible without having a
negative impact on their activities) so as to avoid duplication and facilitate sharing of
information across all disease control programmes and other stake holders so that
valid data is available for health decision making at district, state and national levels.
Operational Manual
To facilitate the implementation of the IDSP, this operational manual has been
developed. It basically informs each of those who are involved in the IDSP
What to do.
•
How to do it. However, further details of this will be given in the training manuals.
This manual is intended for all those involved in the IDSP, especially for those in the
States and District level. However, being a generic manual it is not State specific. So
each State needs to modify the roles of the individuals keeping in mind their own
systems of flow and designations. This is particularly true for the urban health
services where there is tremendous variety between each State.
In this manual certain terms are used which may need to be explained e.g.
•
Private sector includes Private practitioners (both registered and unregistered) of all
systems of medicines, Private nursing homes, hospitals, clinics, dispensaries,
corporate hospitals and NGO dispensaries and hospitals.
•
Urban health services includes Urban link workers, dispensaries and Hospitals
belonging to the Municipalities and the Municipal Corporations.
•
CHC includes Block PHC, rural hospitals, cottage hospitals at the Block level.
•
District Hospital will include any sub district hospitals in the region.
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The operation manual is provided in a modular manner, especially the disease
summaries. This will enable a state to add or delete specific diseases and then do the
needful vis-a-vis the manual.
It is hope that this manual will be of use to the workers who have to actually carry
out the various surveillance tasks.
WHO - India
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CASEDEFINITIONS
ACUTE DIARRHOEAL DISEASES
Clinical case description:
Acute watery diarrhoea (passage of 3 or more loose or watery stools in the past 24
hours) with or without dehydration.
Laboratory criteria for diagnosis:
Not necessary
Case classification
Suspect case:
Probable case:
Confirmed case:
As per clinical case description.
Not applicable
Not applicable
ACUTE BLOODY DIARRHOEA
Clinical case description:
Acute diarrhoea with visible blood in the stool.
Laboratory criteria for diagnosis:
Lab culture of stools maybe used to confirm possible outbreaks of specific diarrhoea,
such as S. dysenteriae type 1, but is not necessary.
Case classification
Suspect case:
Probable case:
Confirmed case:
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as per clinical case definition.
Not applicable
Not applicable
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CHOLER 0
Clinical case description:
In an area where the disease is not known to be present:
Severe dehydration or death from acute watery diarrhoea in a patient aged 5
years or more1
In an area where there is a cholera epidemic:
Acute watery diarrhoea, with or without vomiting, in a patient aged 5 years or
more
Laboratory criteria for diagnosis:
Isolation of Vibrio cholera O1 or 0139 from stools in any patient with diarrhoea.
Case classification
Suspect case:
A case that meets the clinical case definition.
Probable case:
Not applicable
Confirmed case:
A suspected case that is laboratory-confirmed.
1 CholeradoesappearinchildrenunderSyearsjhowever.theinclusionofallcasesofacute
waterydiarrhoeainthe2-4yearagegroupinthereportingofcholeragreatlyreducesthespecificityof
reporting. Formanagementofcasesofacutewaterydiarrhoeainanareawherethereisacholera
epidemic,cholerashouldbesuspectedinallpatients.
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Dengue Fever (DF’
Clinical case definition:
An acute febrile illness of 2-7 days duration with 2 or more of the following:
♦
headache,
♦
arthralgia,
♦
retro-orbital pain,
♦
rash
♦
myalgia.
♦
haemorrhagic manifestations
♦
leucopoenia
Laboratory criteria for diagnosis:
Any one or more of the following:
•
Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy samples
•
Demonstration of a fourfold or greater change in reciprocal IgG or IgM antibody
titres to one or more dengue virus antigens in paired serum samples
•
Demonstration of dengue virus antigen in autopsy tissue by
immunohistochemistry or immunofluorescence or in serum samples by EIA
•
Detection of viral genomic sequences in autopsy tissue, serum or CSF samples by
polymerise chain reaction (PCR)
Case classification
Suspected: A case compatible with the clinical description.
Probable:
A case compatible with the clinical description with one or more of
the following:
• supportive serology (reciprocal haemagglutination-inhibition antibody
titre >_1280, comparable IgG EIA titre or positive IgM antibody test in
late acute or convalescent-phase serum specimen).
• Epidemiologically linked with a confirmed case of dengue fever
(occurrence at same location and time as other confirmed cases of dengue
fever).
Confirmed: A case compatible with the clinical description and laboratoryconfirmed.
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a
Dengue Haemorrhagic Fever (DHF
A probable or confirmed case of dengue
1. And Haemorrhagic tendencies evidenced by one or more of the following:
•
Positive tourniquet test
•
Petechiae, ecchymoses or
purpura
•
Bleeding: mucosa, gastrointestinal tract,
injection sites or other
•
Haematemesis or melaena
2. And thrombocytopenia (100,000 platelets or less per mm3)
3. And evidence of plasma leakage due to increased vascular permeability,
manifested by one or more 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, hypoproteinaemia)
Dengue Shock Syndrome (DSS
All the above criteria, plus evidence of circulatory failure manifested by rapid and
weak pulse, and narrow pulse pressure (<_20 mm Hg) or hypo-tension for age,
cold, clammy skin and altered mental status.
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ACUTE VIRAL HEPATITIS
Clinical case description:
Acute illness typically including acute jaundice, dark urine, anorexia, malaise,
extreme fatigue, and right upper quadrant tenderness. Biological signs include
increased urine urobilonogen and >2.5 times the upper limit of serum alanine
aminotransferase2.
Laboratory criteria for diagnosis:
Hepatitis A:
Hepatitis B:
Hepatitis C:
Hepatitis D:
Hepatitis E:
IgM anti HAV positive
Positive for HbsAg or IgM anti-HBc3
Positive for anti-HCV
Positive for HbsAg or IgM anti-HBc Plus anti-HDV
Positive for anti-HEV
Case classification
Suspect case:
as per clinical case definition.
Probable case:
Not applicable
Confirmed case:
A suspect case that is laboratory confirmed. For
Hepatitis A, a case compatible with the clinical
description and with epidemiological link with a lab
confirmed case of Hepatitis A.
HIV INFECTION
Clinical case description:
There is no clinical description, the diagnosis is based on lab criteria
Laboratory criteria for diagnosis:
HIV positive serology (ELISA)
Confirmation should be a second ELISA4.
2Mostinfectionsoccurinearlychildhood.Avariableproportionofadultinfectionsisasymptomatic.
3Theanti-HBclgMtest,specificforacuteinfection.isnotavailableinmostcountries.HbsAg,oftenavailable,cannotdistinguishbetweenacutenew
infectionsandexacerbationsofchronichepatitisB,althoughcontinuedHBsAgseropositivity(>6months)isanindicatorofchronicinfection.
4ConfirmationbyasecondserologicaltestisnecessaryonlyinsettingswhereestimatedHIV
prevalenceisknowntobe<10%
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AIDS
Clinical case description:
WHO clinical case definition for AIDS in an adult or adolescents (>12 years of age)
when diagnostic resources are limited. For the purposes of AIDS surveillance an
adult or adolescent (>12 years of age) is considered to have AIDS if at least 2 of the
following major signs are present in combination with at least 1 of the minor signs
listed below, and if these signs are not known to be related to a condition unrelated
to HIV infection
Major signs (2 signs or more):
•
•
•
Weight loss >_10% of body weight
Chronic diarrhoea for >1 month
Prolonged fever for >1 month (intermittent or constant)
Minor signs (1 or more):
•
•
•
•
Persistent cough for >1 month
Generalized pruritic dermatitis
History of herpes zoster
Oropharyngeal candidacies
Laboratory criteria for diagnosis:
HIV positive serology (ELISA)
Confirmation should be a second ELISA5.
Case classification
Suspect case:
Probable case:
Confirmed case:
A case that meets the clinical case definition.
?
A suspect case that is lab confirmed.
5Confirmationbyasecondserologicaltestisnecessaryonlyinsettingswhereestimat.edHIV
prevalenceisknowntobe<10%
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5
APANESE ENCAPHILITIS (JE;
Clinical case description:
A case of fever associated with neurological symptoms like
•
•
Headache, meningeal signs, stupor, disorientation, coma
Tremors, generalised paresis, hypertonia, loss of co-ordination.
Laboratory criteria for diagnosis:
Presumptive: Detection of an acute phase anti-viral antibody response
through one of the following:
•
•
Elevated and stable serum antibody titres to JE virus through
ELISA, haemagglutination-inhibition or virus neutralisation assays
or
IgM antibody to the virus in the serum
Confirmed:
•
•
•
Detection of the JE virus, antigen or genome in tissue, blood or other
body fluid by immunochemistry or immunofluorescence or PCR, or
JE virus-specific IgM in the CSF, or
Fourfold or greater rise in JE virus-specific antibody in paired sera
(acute and convalescent phases) through IgM / IgG, ELISA,
haemagglutination inhibition test or virus neutalization test, in a
patient with no history of recent yellow fever vaccination and where
cross-reactions to other flaviviruses have been excluded
Note: JE infections are common and the majority are asymptomatic. JE
infections may occur concurrently with other infections causing central
nervous system symptoms, and serological evidence of recent JE viral
infection may not be correct in indicating JE to be the cause of the
illness.
Case classification
Suspect Case:
Probable Case:
Confirmed Case:
WHO
A case that is compatible with the clinical description
A suspect case with presumptive lab. Results
A suspect case with confirmatory lab results.
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3
MALARL
Clinical case definition:
A case of fever with or without
•
Headache, backache, chills, rigors, sweating, myalgia, nausea and vomiting
•
Splenomegaly and anaemia
•
May be accompanied by generalised convulsions, coma, shock, spontaneous
bleeding, pulmonary oedema, renal failure and death (untreated falciparum
infection)
Laboratory definition of malaria:
Demonstration of malaria parasites in blood films (mainly asexual forms)
Case classification
Suspect case: as per the clinical case definition
Probable uncomplicated malaria: A person with symptoms and/or signs of
malaria who receives anti-malarial treatment
Probable severe malaria: A patient who requires hospitalisation for
symptoms and signs of severe malaria and receives anti-malarial treatment.
Confirmed uncomplicated malaria: A patient with symptoms and/or signs of
malaria who received anti-malarial treatment with laboratory confirmation of
diagnosis.
Confirmed severe malaria: a patient who requires hospitalisation for
symptoms and/or signs of severe malaria and receives anti-malarial treatment
with laboratory confirmation of diagnosis.
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MEASLES
Clinical case description:
Any person with:
•
•
•
Fever and
Maculopapular rash, and
Cough, coryza or conjunctivitis
Laboratory criteria for diagnosis:
•
•
•
At least a fourfold increase in antibody titre or
Isolation of measles virus or
Presence of measles specific IgM antibodies.
Case classification
Suspect case:
A case that meets the clinical case definition.
Probable case:
Not applicable
Confirmed case6:
A case that meets the clinical case definition and that is
laboratory-confirmed or linked Epidemiologically to a
lab-confirmed case.
POLIOMYELITIS
Clinical case description:
Any child under fifteen years of age with acute, flaccid paralysis or any person with
paralytic illness at any age when poliomyelitis is suspected.
Laboratory criteria for diagnosis:
•
Isolation of the virus from stool samples
Case classification
Suspect case:
Probable case:
Confirmed case:
A case that meets the clinical case definition.
Not applicable
A suspect case that is lab confirmed7
6Onlyforoutbreakconfirmationandduringeliminationphase.
7acaseissaidtobecompatiblewithPolio,ifthelabresultisnegativeduetoinadequatespecimen,
butaNationalreviewcommitteefeelsthatclinicallythereisevidencetosuspectpolio.
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PLAGUE
Clinical case description:
Disease characterised by rapid onset of fever, chills, headache, severe malaise,
prostration with
•
•
•
Bubonic form: extreme painful swelling of lymph nodes
Pneumonic form: cough with blood-stained sputum, chest pain, difficult
breathing
Septicaemic form: toxic changes in the patient.
Laboratory criteria for diagnosis:
•
•
Isolation of Y. pestis in cultures from lymph nodes, blood, CSF or sputum or
Passive Haemagglutination (PHA) test, demonstrating an at least fourfold
change in antibody titre, specific for F! antigen of Y.pestis as determined by
the haemagglutination inhibition test (HI) in paired sera.
Case classification
Suspect case: A case that meets the clinical case definition.
Probable case: A suspect case with
•
•
•
Positive direct fluorescent antibody (FA) test for Y. pestis in clinical
specimen or
PH A test with antibody titre of at least 1:10, specific for the Fl antigen
of Y. pestis as determined by the HI test or
Epidemiological link with a confirmed case.
Confirmed case: a suspected or probable case that is lab-confirmed
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uUBERCULOSIS
CASE DEFINITION (according to site and bacteriology).
Pulmonary tuberculosis, sputum smear positive (PTB+)
•
Tuberculosis in a patient with at least two initial sputum smear examinations (direct
smear microscopy) positive for Acid-Fast Bacilli (AFB), or
•
Tuberculosis in a patient with one sputum examination positive for acid-fast bacilli
and radiographic abnormalities consistent with active pulmonary tuberculosis as
determined by the treating medical officer, or
•
Tuberculosis in a patient with one sputum specimen positive for acid-fast bacilli and
at least one sputum that is culture positive for acid-fast bacilli.
Pulmonary tuberculosis, sputum smear negative (PTB-)
Tuberculosis in a patient with symptoms suggestive of tuberculosis and having one
of the following:
•
Three sputum specimens negative for acid-fast bacilli
•
Radiographic abnormalities consistent with pulmonary tuberculosis and a lack of
clinical response to one week of a broad-spectrum antibiotic
•
Decision by a physician to treat with a full curative course of anti-tuberculous
chemotherapy
Extra-pulmonary tuberculosis (ETB)
•
TB of organs other than lungs: pleura, lymph nodes, abdomen, genito-urinary tract,
skin, joints, bones, meninges etc.
•
Diagnosis should be based on one culture positive specimen from an extrapulmonary site, or histological or strong clinical evidence consistent with active extrapulmonary TB, followed by a decision by a MO to treat with a full course of ATT.
Any patient diagnosed with both pulmonary and extra-pulmonary TB should be
classified as a case of pulmonary TB.
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TYPHOID
Clinical case description:
Any person with an insidious onset of sustained fever, headache, malaise, anorexia,
relative bradycardia, constipation or diarrhea, and non-productive cough. However,
many mild and atypical infections occur.
Laboratory criteria for diagnosis:
Isolation of S. typhi from blood, stool, or other clinical specimen
Case classification
Suspect case:
Probable case:
Confirmed case:
WHO
A case that meets the clinical case definition.
a clinically compatible case that is epidemiologically
linked to a confirmed case in an outbreak
a clinically compatible case that is laboratory confirmed
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HYPERTENSION
Clinical case description:
The definition of hypertension has been reviewed by various authorities, including
the World Health Organisation/International Society of Hypertension (WHO/ISH)
and The Joint National Committee on the Detection' Evaluation and Treatment of
High Blood Pressure (JNC). The definition and classification of high blood pressure is
illustrated in the table below (Table 1) and is adopted from the Fifty Report of the
JNC.
Table 1. Classification of Blood Pressure for Adults Aged 18 Years and Older
Systolic, mmH;
Categor
<130
Normal
_____
High Normal
130 -139
f Hypertension:
140 - 159
Stage 1 (mild)
Stage 2 (moderate)
160 -179
180-209
Stage 3 (severe)
>210
Stage 4 (very severe)
Diastolic, mmH;
<85
85-89
90-99
iqd-109
110-119
'
>120
I
The above table provides a new classification of adult blood pressure based on
impact on risk. The traditional terms mild and moderate hypertension failed to
convey the major impact of high blood pressure on risk of cardiovascular diseases
(CVD). High-normal blood pressure is included as a category because persons with
systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) in these ranges
are at increased risk of developing definite high blood pressure, and of experiencing
non-fatal and fatal cardiovascular events, compared with otherwise similar persons
with lower blood pressures. Individuals with high-normal blood pressure should be
monitored yearly and counselled in regard to life-style modifications that can reduce
their blood pressure pharmacological treatment is rarely if ever needed.
All stages of hypertension are associated with increased risk of non-fatal and fatal
CVD events, stroke and renal disease. The higher the blood pressure, the greater is
the risk. Stage 1 Hypertension is the commonest form of high blood pressure in the
adult population and is responsible for a large proportion of the morbidity and
mortality associated with hypertension. All stages of hypertension warrant effective
long term therapy.
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DIABETES MELLITUS
Clinical case description:
The clinical diagnosis of diabetes is often prompted by symptoms such as increased
thirst and urine volume, recurrent infections, unexplained weight loss and, in severe
cases, drowsiness and coma
Laboratory criteria for diagnosis:
A single blood glucose estimation in excess of the diagnostic values indicated in
Figure 1 (black zone) establishes the diagnosis in such cases. Figure 1 also defines
levels of blood glucose below which a diagnosis of diabetes is unlikely in non
pregnant individuals.
Figure 1: Unstandardized (casual, random) blood glucose values in the diagnosis of
diabetes in mmol h1 (mg dh1). Taken from the 1985 WHO Study Group Report (3).
Whole btood
Venous
Capillary
Plasma
Venous
Capillary
Diabetes meflitus
likely
12.2 (220)
10.0(160)
11.1 (200)
11.1 (200)
Diabetes mellilus
uncertain
5.5 (100)
{80}
5.5(100)
4.4 (60)
Diabetes me Hilus
unlikely
For population studies of glucose intolerance and diabetes, individuals have been
classified by their blood glucose concentration measured after an overnight fast
and/or 2 h after a 75 g oral glucose load. Since it may be difficult to be sure of the
fasting state, and because of the strong correlation between fasting and 2-h values,
epidemiological studies or diagnostic screening have in the past been restricted to the
2-h values only (Table 1). Whilst this remains the single best choice, if it is not
possible to perform the OGTT (e.g. for logistical or economic reasons), the fasting
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plasma glucose alone may be used for epidemiological purposes. It has now been
clearly shown, however, that some of the individuals identified by the new fasting
values differ from those identified by 2-h post glucose challenge values (10,11). The
latter include the elderly (12) and those with less obesity, such as many Asian
populations. On the other hand, middle-aged, more obese patients are more likely to
have diagnostic fasting values (10). Overall population prevalence may (13) or may
not (7,10,14) be found to differ when estimates using fasting and 2-h values are
compared.
Table 1: Values for diagnosis of diabetes mellitus and other categories of
hyperglycaemia
Glucoseconcentration,mmoir 1(mgdr
Wholeblood
Diabetes Mellitus:
Capillary
Venous
F’lasma*
Venous
Fasting or
6.1 (110)
6.1 (110)
7.0 (126)
2-h post glucose load
or both
10.0 (180)
11.1 (200)
11.1 (200)
< 6.1 (< 110) and
7.0 (< 126) and
7.8 (140)
<11.1 (<200)
7.8 (140)
5.6 (100) and
< 6.1 (< 110)
6.1 (110) and
<7.0 (<126)
6.1 (<110)
7.0 (< 126)
7.8 (< 140)
7.8 (< 140)
Impaired Glucose
Tolerance (IGT):
Fasting (if measured)
and
6.1 (< 110)
2-h post glucose load
6.7 (120)
and
<10.0 (<180)
Impaired Fasting
Glycaemia (IFG):
Fasting
5.6 (100) and
<6.1 (<110)
and (if measured)
6.1 (< 110)
2-h post glucose load
6.7 (< 120)
* Corresponding values for capillary plasma are: for Diabetes Mellitus, fasting 7.0 (□
126), 2-h 0 12.2 (□ 220); for Impaired Glucose Tolerance, fasting < 7.0 (< 126) and 2-h
8.9 (□ 160) and < 12.2 (< 220); and for Impaired Fasting Glycaemia 6.1 (□ 110)
and < 7.0 (< 126) and if measured, 2-h < 8.9 (< 160).
For epidemiological or population screening purposes, the fasting or 2-h value after
75 g oral glucose may be used alone. For clinical purposes, the diagnosis of diabetes
should always be confirmed by repeating the test on another day unless there is
WHO
20
6/17/2002
unequivocal hyperglycaemia with acute metabolic decompensation or obvious
symptoms.
Glucose concentrations should not be determined on serum unless red cells are
immediately removed, otherwise glycolysis will result in an unpredictable under
estimation of the true concentrations. It should be stressed that glucose preservatives
do not totally prevent glycolysis. If whole blood is used, the sample should be kept at
0-4 °C or centrifuged immediately, or assayed immediately.
OBESITY
Clinical case description:
A person above 15 years of age whose BMI is more than 30 is considered to be obese.
If the BMI is between 25 to 30, then the person is considered to be overweight.
Table 1:
Cut-off points for body mass index £ proposed by a World Health Organization
Committee for the classification of overweight (WHO Expert Committee. Physical
Status: the use and interpretation of anthropometry. WHO Technical Report Series
no. 854. Geneva: WHO, 1995) Cut-off points for body mass index § proposed by a
World Health Organisation Committee for the classification of overweight(WHO
Expert Committee. Physical Status: the use arid interpretation of anthropometry. WHO
Technical Report Series no. 854. Geneva: WHO, 1995)
body mass
index
WHO classification
18.5 kg/m2
underweight
popular description
thin
"healthy", "normal", or "acceptable" weight
18.5-24.9
kg/m2
25.0-29.9
kg/m2
grade 1 overweight
overweight
30.0-39.9
kg/m2
grade 2 overweight
obesity
>40.0 kg/m2
grade 3 overweight
morbid obesity
WHO
21
6/17/2002
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ACTIVITIES OF THE COMMUNITY INFORMANTS
These include people like teachers, AWWs, Panchayat members. Ward members,
SHG leaders. Health club / Youth club / Farmer's club leaders etc.
Case detection
Their main role is in the detection of potential outbreaks. In the event that they
suspect any unusual health event8 occurring in their village, they must take the
responsibility of informing the nearest PHC. In urban areas, they can inform the
nearest Municipal Dispensary or other designated institution.
Investigation
They can help the investigation team in investigating the outbreak, identifying the
households with the cases
Response
Similarly they can help the response team in containing the outbreak by mobilising
the community to take the necessary preventive measures.
ACTIVITIES OF THE MPWs/ Urban Link workers and the HEALTH
ASSISTANTS
These are the Male and Female Multi-Purpose workers and their supervisors the
Health Assistants (M & F). In the urban areas, they would be the link workers. They
form the most peripheral unit of the formal government health services. This group
may also include the trained field workers of the NGOs who are participating in
disease surveillance activities.
Case detection
They can help in case detection through various ways
•
•
•
•
Identify patients during the home visits
The diseases that they would be able to identify would be diarrhoeal diseases,
jaundice, suspected malaria, measles, suspected dengue, suspected JE and
suspected TB.
Trace the contacts of these patients especially in contagious diseases
Use key informants (see above) to identify cases occurring in the community
8Unusualhealtheventmaybedescribedas‘
oralteredconsciousness
aclusteringofcaseswithdiarrhoeaorjaundiceorfever
WHO
23
6/17/2002
•
For NCD surveillance, if the sample falls in their area, they should sensitise
the village about the surveillance and with the help of the community leaders,
mobilise the community to participate in the surveillance activity
Data collation and transmission
Once the cases are detected, they need to enter the details in the register. The data is
then compiled once a week or once a month (depending on the disease), entered into
the relevant form, which is then transmitted to the PHC / Municipal dispensary.
This may be done manually, or by telephone.
However, if the disease detected is one that has outbreak potential, e.g. cholera,
measles, dysentery, suspected dengue s/he needs to inform the appropriate MO
immediately (by telephone or special messenger).
Investigation and response
They should help the investigation / response teams in the investigation and
response mechanism. Some of the roles that they can perform are:
•
•
•
•
Identify the households where the cases have occurred
Identify the contacts
Identify some of the risk factors, e.g. contaminated water sources, mosquito
breeding sites, local events that may have potentiated the event like a
marriage leading to food poisoning etc.
Mobilising the community to actively participate in the containment
measures.
ACTIVITIES OF THE PHARMACISTS (PHC / CHC/ Hospitals)
These are the pharmacists in the PHCs and the CHC or Block PHCs. They are the
personnel usually entrusted with the responsibility of compiling the statistics from
the OP / IP registers. In states, if others are designated for this activity, then this
section applies to them. In urban areas, the pharmacists of the Urban dispensaries
would be responsible for this activity. Similarly, in Private hospitals / nursing homes
I NGO hospitals, the designated person for doing the above duties will have to
perform these activities.
Data collection and compilation
They should go through the OP registers every day and segregate the diagnosis (as
made by the MO) into the various diseases and age wise (i.e. < 5 and > 5). This
should then be aggregated on a weekly / monthly basis and entered into the
reporting form and sent to the appropriate level.
WHO
24
6/\7/2Q02
MO-PHC/CHC
People responsible
Public Sector
Urban
______ Rural
MO of PHC / CHC MO in Dispensary
Private sector
Urban
Rural
Practitioner in clinic
Case detection
They are the key qualified person to detect cases from the community level. They can
do this by
•
•
•
•
•
•
Documenting clearly the patients that attend their Outpatient or are admitted.
Identify patients while on a field visit / camp.
The diseases that they would be able to identify would be diarrhoeal diseases,
jaundice, suspected malaria, suspected typhoid, measles, suspected dengue,
suspected JE, suspected TB and suspected HIV/ AIDS.
For Non-communicable diseases, the MO in the PHC would head the team
that would collect the data in the community.
Maintain a rumour register at the institution and investigate any reports there
Monitor the press daily and investigate any reports published in the
newspapers.
Data collation and transmission
The MO will be primarily responsible for ensuring that the data is compiled and
transmitted in the frequency that it is supposed to be transmitted.
Analysis
The MO at the CHC / Urban dispensary is responsible for conducting some
preliminary analysis. This will include
•
•
•
•
•
•
WHO
Monitoring the completeness of the reporting units. This will include reports
from the PHCs / Link workers, the Private practitioners and the labs if any.
Monitoring the timeliness of the reporting units
Monitoring the secular trends of those diseases with outbreak potential. This
may be done manually or maybe computerised.
All this analysis maybe done separately for the public sector and private
sector. However the trends maybe compared to identify any misreporting.
Comparing the current year's data with that of the corresponding period for
the previous year(s).
Making spot maps to identify any clustering of cases.
25
6/17/2002
All this maybe done using the existing Health Mapper software.
Investigation and response
The MO of the PHC/CHC/Urban dispensary is responsible for investigation and
response mechanism. The detection of outbreaks can be done
•
•
•
From analysis of routine data
From the media
From the rumour register
The thresholds for definitions of outbreaks are given below.
In the event of an outbreak the MO from the CHC / Urban dispensary will have to
•
•
Make a preliminary visit to the area to confirm the outbreak.
If confirmed, then s/he will have to ensure that
o specimens are collected for lab diagnosis,
o containment measures are initiated and
o an initial report is sent to the District level if there are more than 25
cases or if there is mortality.
S/he can use the help of the MO and staff of the local PHC.
Threshold levels___________
CHOLERA
If a single suspect case is confirmed
DYSENTERY
If a single suspect case is confirmed
MEASLES
If a single suspect case is confirmed.
ACUTE DIARRHOEAL DISEASES
If the number of new cases exceeds the upper
limit of cases seen in a previous non-epidemic
period in previous years.
DENGUE/DHF/DSS
If a suspect case is confirmed.
JAPANESE ENCEPHALITIS
If a single suspect case is confirmed.
MALARIA
If the number of new cases exceeds the upper
limit of cases seen in a previous non-epidemic
period in previous years.
VIRAL HEPATITIS
If the number of new cases exceeds the upper limit
of cases seen in a previous non-epidemic period in
previous years.
The investigation and response measures are given in further detail in the
subsequent chapters
WHO
26
6/17/2002
Supervision and monitoring
The MO of the PHC / CHC / Urban dispensary are expected to supervise the MPWs.
The main objectives of the supervision are to
1) To support the MPWs in their work
2) To understand the gaps in the field and to bridge them
3) To provide on the job training
Before making a supervisory visit, the MO will prepare for it by reviewing the past
notes relevant for that centre and also the programme achievements of that centre.
The MO will then visit the field staff and interact with them and use the following
tools
• Observation
• Checklist (see Annex)
• Review of records and registers
At the end of the visit, the MO will share the finding of his/her visit with the MPW
and make a report that is filed for subsequent use.
The MO will monitor the following indicators on a regular basis. The source of data
will be varied and are given in the table below.
Indicator
Freq of monitoring
Source of
information
Timeliness of reporting
Weekly / monthly /
Quarterly / Annually
Weekly / Monthly /
Quarterly / Annually
Quarterly / Annually
Routine data
Completeness of reporting units (separately
for public and private sector)_____________
Percentage of outbreaks detected by the
reporting units
Percentage of MPWs with Case definitions
and using them________________________
Percentage of MPWs whose reports are in
concurrence with their registers_________
Percentage of private sector enrolled as
reporting units________________________
No of outbreaks prevented
Annual
Annual
Annual
Annual
Routine data
Routine data.
Media,
Supervisory
reports_______
Supervisory
reports_______
Special annual
survey_______
Comparison of
previous year's
reports._______
Training
The MO of the PHC / CHC will be responsible for ensuring that all the staff under
him/her as well as the staff of the private sector reporting units are properly trained.
S/he may conduct the training directly or may request the District team to help with
the training.
WHO
27
6/17/2002
J
Feedback
The MO will provide regular monthly feedback to the MPWs using the forum of the
Monthly meeting. S/he should also share any feedback that s/he has received from
the District/State. Other than this, as mentioned earlier, the MO should give
feedback during the supervisory visits.
In the case of the private sector, feedback on a monthly basis should be sent to the
private practitioners who are involved in the surveillance activities. This maybe in
the form of a written note.
ACTIVITIES OF THE HEALTH ASSISTANT - DISTRICT
SURVEILLANCE OFFICE
This is basically the person responsible for collating all the data at the District
Surveillance office or the Municipal / Corporation Health Office. His/her activities
would include
•
•
•
•
Receiving all the data from the reporting units (CHCs, District Hospital,
Private practitioners. Private institutions. Labs, Urban dispensaries etc.) This
may be manually or electronically
Entering the data into the master format at the District / Municipal /
Corporation office.
Checking the validity of the data reported. This will be done electronically and
the software will have the inbuilt checks.
Once the data is entered and checked, then the reports may be generated.
These include
o
o
o
o
o
o
o
•
WHO
Completeness of reporting units
Timeliness of reporting units (disaggregated for private and public
sector and for labs)
The trends over time for each disease - comparing it with the previous
weeks
The trends over time for each disease - comparing it with the
corresponding period in the previous years
Comparison of the trends for each disease - comparing the public private - lab sector.
Comparison of the trends for each disease - comparing the data of the
various CHCs.
The Spot maps using the CIS software.
These reports will be generated weekly for diseases of outbreak potential and
monthly for the other communicable diseases. For non communicable
28
6/17/2002
•
•
diseases, the report will be generated as and when the special survey is
conducted in the field.
Once the reports are generated, they will be submitted to the District
Surveillance Officer / Municipal - Corporation Health Officer.
After the analysis by the concerned officer, they will then prepare a report
summarising the analysis and submit it to the State Surveillance officer.
ACTIVITIES OF THE DISTRICT SURVEILLANCE OFFICER
This includes the DSO in the rural areas and the MHO / Corporation Health Officer
in the urban areas.
S/he is the crucial person in the IDSP surveillance system. His main responsibility is
to analyse the data that is coming in, identify areas of potential outbreak and ensure
that these are contained before they grow out of control. Other support functions
include supervision, monitoring, training and providing feedback to the lower levels.
And finally the DSO is supposed to have strong links with the state surveillance
officer and other programme managers.
The main activities of the DSO / MHO are
•
•
Calling for the disease surveillance reports on a weekly/monthly basis
These reports will include
o Completeness of reporting units
o Timeliness of reporting units (disaggregated for private and public
sector and for labs)
o The trends over time for each disease - comparing it with the previous
weeks
o The trends over time for each disease - comparing it with the
corresponding period in the previous years
o Comparison of the trends for each disease - comparing the public private - lab sector.
o Comparison of the trends for each disease - comparing the data of the
various CHCs.
o The Spot maps using the CIS software.
•
Review the above reports and
o Review the validity of the data
o Identify any reporting units that are not functioning satisfactorily
o Detect any outbreaks
•
In the event of any outbreak (potential or existing), inform the concerned
reporting unit for investigation and response.
Submit a summarised monthly report to the State Surveillance officer and
relevant programme managers.
•
WHO
29
6/17/2002
•
•
•
•
Provide feedback to the CHCs / Private providers about the performance of
the district vis-a-vis the surveillance activities. This maybe in the form of a talk
in the monthly meeting, a newsletter or even a website.
If the outbreak is confirmed, then the DSO/MHO should initiate a full-fledged
investigation with the help of the Epidemic Investigation Team.
If the CHC/PHC or Urban dispensary needs any help in the response and
containment measures, then the DSO/MHO needs to mobilise additional staff
and resources to support them.
If the outbreak is of a large magnitude, then the DSO/MHO needs to
immediately also alert the State Surveillance officer for support.
Other than this the DSO / MSO will supervise the reporting units under his/her
area. The main objectives of the supervision are to
•
•
•
To support the MOs and lab technicians in their work
To understand the gaps in the field and to bridge them
To provide on the job training
Before making a supervisory visit, the DSO / MHO will prepare for it by reviewing
the past notes relevant for that centre and also the programme achievements of that
centre.
The DSO / MHO will then visit the field staff and interact with them and use the
following tools
•
•
•
Observation
Checklist (see Annex)
Review of records and registers
At the end of the visit, the DSO/MHO will share the finding of his/her visit with the
MOs / LT and make a report that is filed for subsequent use.
The DSO / MHO will also monitor the following indicators on a regular basis. The
source of data will be varied and are given in the table below.
Indicator
Freq of monitoring
Source of
information
Timeliness of reporting
Weekly / monthly /
Quarterly / Annually
Weekly / Monthly /
Quarterly / Annually
Quarterly / Annually
Routine data
Percentage of MOs with Case definitions
and using them______________________
Percentage of MOs whose reports are in
concurrence with their registers
Annual
Supervisory
reports____
Supervisory
reports
WHO
30
Completeness of reporting units (separately
for public and private sector)_____________
Percentage of outbreaks detected by the
reporting units
Annual
Routine data
Routine data.
Media,
6/17/2002
Percentage of private sector enrolled as
reporting units_____________________
No of outbreaks detected____________
No of outbreaks prevented
Annual
Percentage of labs whose reports are in
concurrence with their registers
Annual
Annual
Annual
Special annual
survey_________
Outbreak reports
Comparison of
previous year's
reports.________
Supervisory
reports
ACTIVITIES OF THE MOs IN THE HOSPITALS
People responsible
________
Public Sector____________ ____________ Private sector
______ Rural______ ______Urban_____ ______ Rural_____________ Urban_____
MO in the Department of Medicine,
MO in the
MOs in the
Pediatrics, Infectious diseases and
Department of
Department of
Casualty of the Private / NGO Hospitals.
Medicine,
Medicine,
Pediatrics,
Pediatrics,
Infectious diseases Infectious diseases
and Casualty of the and Casualty of the
Municipal /
District Hospital.
Corporation
Hospital.
Case detection
They would be able to detect all cases, which attend their hospital as OP or IP. They
can do this by
•
•
•
•
•
WHO
Documenting clearly the patients that attend their Outpatient or are admitted.
The diseases that they would be able to identify would be clinical cases /
confirmed cases of diarrhoeal diseases, viral hepatitis, malaria, typhoid,
measles and TB, suspected cases of JE, dengue and HIV/ AIDS.
From lab results which are sent to them.
Monitor all cases of death (including brought-in-dead) to see if any case fits
the description of diseases under surveillance
For Non-communicable diseases, these MOs could assist the MOs in the
PHC/CHC during the surveys for the biochemical investigations and other
facilities as well as providing sentinel information about the results of their
labs as far as blood sugar and blood cholesterol is concerned.
31
6/17/2002
Investigation & Response
The specialists in medicine, paediatrics and microbiology (or senior lab tech) may be
co-opted as a team member of the BIT to investigate an outbreak and support the MO
PHC/CHC in management of the cases.
•
•
The medical specialist/paediatrician will clinically examine the cases to make
a clinical diagnosis of the cases and also outline the standard case
management protocol to be implemented by the MO PHC.
The microbiologist/lab technician will guide the MO PHC in what samples
are to be taken and methodology of collection, storage and transportation of
specimens. They will also rapidly process the specimens in their labs and give
the confirmatory diagnosis and antibiotic sensitivity of the implicated
organism.
Training
The specialists in the district / private hospitals would assist in the training
conducted by the DSO and act as resource persons.
Activities Of The Lab Technician
People responsible
Public Sector____________ ____________ Private sector_______
______Urban_____ ______ Rural_____________ Urban
______ Rural
Lab technicians / lab in-charge from
Lab technicians in
Lab technicians at
accredited and identified labs
the CHC or the Lab the urban
dispensary or the
in charge at the
lab in-charge at the
District Hospital /
Municipal /
Public Health Lab.
Corporate Hospital
Data collection
The nodal person in the lab is responsible for reporting confirmed cases of the
diseases under surveillance to the District Authorities. S/he would
•
•
•
•
Take note of any samples that have tested positive.
Personally recheck all the samples/reports of stool, blood, CSF, etc for
confirmatory diagnosis of cases of cholera, diarrhoea, dysentery, malaria, viral
hepatitis, etc.
Be alert to any clustering of diseases of outbreak potential.
Report immediately to the appropriate authorities if any sample is tested
positive for cholera or shigella.
WHO
32
6/17/2002
•
•
•
•
Report all other positive samples on a routine weekly / monthly basis as per
form XXX
Take the responsibility of organising further investigations at identified
regional labs for diagnosing dengue, JE and AFP.
Also closely monitor the lab results of water quality testing samples and
immediately intimate the DHO/DSO/SSO of unfit results.
Also check the condition of specimens received from the field and informs
they are not well preserved/desiccated, poor quality of slides, etc.
Investigation
The lab technician will be a part of the EIT to investigate outbreaks. S/he will
•
•
•
•
will supervise the collection of lab samples and guide the PHC staff on how
to store and transport further samples.
also ensure rapid processing of the specimens so that a confirmatory
diagnosis is immediately available.
also collect water samples from the area of outbreak if a waterborne outbreak
is suspected.
Monitor the Antimicrobial resistance patterns and share the information with
the treating physician.
Supervision
The District lab in charge would also supervise the work of the lab technicians of the
other labs i.e. PHC/CHC, urban dispensary labs, private labs etc. They will set up a
quality assurance mechanism.
Training
The lab technician will be involved in training the junior lab technicians in basic lab
procedures and also in providing on-the-job training. They will also be involved in
training peripheral staff in proper collection, storage and transportation of
specimens.
Feedback
The lab tech will provide feedback of their lab results to all concerned both to the
next higher level as well as to the lower level who have provided the samples for
immediate action at the local level.
WHO
33
6/17/2002
RECORDINGANDREPORTING
Data collection involves detection of cases for which surveillance is being carried out,
documentation or recording details of these cases, reporting on the relevant formats
and transmitting this information to the next higher level. This is one of the
fundamental activities in public health surveillance and the success of any
surveillance programme depends on the quality of data collection.
Based on the public health importance, the outbreak potential and the feasibility of
interventions, the following diseases have been short listed for surveillance
Diseases of outbreak
potential
(Weekly monitoring)
Acute diarrhoeal disorders
Cholera_________________
Typhoid________________
Hepatitis_______________
Measles_________________
Dengue_________________
Japanese Encephalitis____
Plague
Diseases of public health
importance
(Monthly monitoring)
TB
HIV___________________
AFP___________________
Malaria________________
Water quality monitoring
Air quality monitoring
Road traffic accidents
Non-communicable
diseases
(Monitoring once in 3 years)
Tobacco use______________
Alcohol use
Height
Weight__________________
Blood Pressure___________
Blood Glucose
Types of surveillance
While detecting the cases, one must keep in mind the type of surveillance that needs to be
employed. There are various types, e.g.
•
•
•
•
Active or passive,
Comprehensive or sentinel,
Regular or survey,
Disease based or entomological or lab based surveillance
Each disease has its own peculiarities and may warrant a different approach, but
keeping in mind the multi disease approach to surveillance, one must optimise the
existing resources and develop as far as possible a common surveillance programme.
Table XXX gives some suggestions on how surveillance can be undertaken for
various diseases within a multi-disease framework.
In general the communicable diseases will be detected in a passive manner, by
routine comprehensive surveillance (i.e. all the reporting units will include these
diseases in their list and report regularly). All of it will be disease based and some
will be supported by lab based / entomological surveillance also. On the other hand
non-communicable diseases will be detected in an active manner by special surveys
conducted periodically (every 3 to 5 years) in the same population.
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34
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The above suggestion does not take away from the fact that in some cases sentinel
surveillance maybe the most efficient method, e.g. neurologists for JE, laboratories
for hepatitis etc. Each State needs to decide what type of surveillance it needs to
undertake to detect the cases.
TableXXXSuggestedsurveillancemethodologies
Disease
Active or
Passive
Comprehensive
or Sentinel
Routine or
Survey
Acute Diarrhoeal diseases
P
C
R
D
Cholera
P
C
R
D+L
Typhoid
Hepatitis
£
P
C
C and S
R
R
D+L
D+L
Dengue
P
C and S
R
D+E+L
Jap Encephalitis
P
C and S
R
D+E+L
Measles
A+P
C
R
D
AFP
TB____
Malaria
A+P
P
A+P
C and S
C
C
£
£
R
D+L
D+L
D+E+L
P
A
A
P
A
S
S
R
R
R
S
L
L
L
D
L
HIV________
Air pollution
Water quality
RTA________
Risk Factors
£
S
S
S
Disease /
ento/ lab
Case detection
For surveillance to be effective the cases in the community must be correctly
diagnosed and detected as early as possible. There are various methods of case
detection:
o
o
o
o
o
WHO
A patient seeks care at a health facility
The MPW detects cases during his/her routine home visit
The Mobile team identifies cases during village visits
Active case finding as in Malaria
Surveys to identify certain risk factors e.g. risk factors for Cardio vascular
diseases.
35
6/17/2002
o
o
o
o
o
A community member reports a suspect case of an epidemic prone disease e.g.
measles.
The media report clustering of cases in a community or area e.g. outbreak of
diarrhoeal diseases in a village.
Sentinel surveillance sites e.g. for HIV
Labs may detect cases when they get positive results
Other departments like "Water Board", Pollution Control Board or the Police
may detect water pollution, air pollution and Road traffic accidents
respectively.
Usually most of the health events will be detected at the reporting units. Some of the
reporting units are given in Table 3.2. The staff of the reporting units should use the
standard case definitions (suspect, probable, confirmed and community definitions)
to identify cases (refer chapter 2) to ensure uniformity of detection. How the
functionaries at various levels would carry out case detection is outlined in table 3.3.
Ensure that all the reporting units have a copy of the case definitions
and that the concerned staff - MPWs, MOs, Nurses, Pharmacists, Lab
technicians are familiar with it and are using it regularly to diagnose
and detect cases.
TableXXXReportingunitsfordiseasesurveillance
Rural
Urban
Public health sector
Sub centres, PHCs,
Hospitals
CHCs,
Sub-District
Urban dispensaries. Urban Hospitals, ESI /
Railway / Defence Hospitals, Medical college
hospitals.
Water boards. Pollution control boards. Police
stations
Private health sector
Private Clinics (formal and
informal sector).
Private clinics, Nursing
homes, Hospitals, Private
laboratories, Medical college
hospitals, NGO hospitals
Other than the above reporting units, efforts must be made to identify key
informants in each village / ward so that prompt information of any outbreak can be
passed onto the health authorities.
Make a list of all the reporting units in your district and divide them into
public / private - urban/rural. You will need to update this on a regular
basis - once in a year at least so that the representativeness of the
surveillance system is maintained (see Annex 3.5)
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TableXXXCasedetectionbyfunctionariesatvariouslevels
How cases will be
diagnosed and
detected___________
By information from
other members in the
community like
barbers, dais,
teachers, etc._______
OP contacts, house
visits, community
informs
Diseases which can
be detected
Sub district
Level
Functionary
Frequ
ency
Community
Lay person
Sub centre
MPWs
On
occurence
of
event
Daily
MO/pharmacist
Daily
Out patients, mobile
camps, contact
tracing, etc9
MO and his
team
Once
in
three
years
Special surveys for
risk factors - BMI,
tobacco, alcohol, BP,
blood cholesterol,
blood sugar
To monitor trends of
these risk factors in
the community
District
Level
Functionary
Frequ
ency
Diseases which can
be detected
CHC,
Private
dispensary.
Corporation
I Municipal
council
dispensary
MO/lab
technician
Daily
How cases will be
diagnosed and
detected_________
Out patients,
inpatients, mobile
camps. Lab results,
etc
District
hospital.
Private
practitioner
s. Private
hospitals/
Nursing
homes.
Doctors and
specialists
working in the
OP/IP and
paediatric
wards, medical,
neurological,
and other wards
Daily
PHC
Outpatients and
inpatients.
Cases of diarrhoea,
fever, measles and
jaundice as per the
community case
definition_________
Suspect cases of
diarrhoea, cholera,
malaria, hepatitis,
measles, JE and
dengue.___________
Suspect, probable or
confirmed cases of
ADD, cholera,
typhoid, hepatitis,
measles. Dengue, JE,
TB, AFP, HIV, and
Malaria,
Suspect, probable or
confirmed cases of
ADD, cholera,
typhoid, hepatitis,
measles. Dengue, JE,
TB, AFP, HIV, and
Malaria,
Suspect, probable or
confirmed cases of
ADD, cholera,
typhoid, hepatitis,
measles. Dengue, JE,
TB, AFP, HIV, and
Malaria,
9TheMOofthePHC/CHCshouldalsofollowupanyinformationonoutbreaksprovidedbykey
informants,theMPWs,rumourregistersandmediareports.Confirmationofthesecaseswouldalso
helpinearlydetectionofcases.
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Medical
colleges
(public/pri
vate)Corpor
ation
hospital,
NGO
hospitals
District lab.
Private labs
Microbiologists
and lab
technicians
Positive lab results.
Daily
Lab confirmed cases
of diarrhoea, cholera.
Typhoid, Hepatitis,
Dengue, JE, TB,
Malaria, and HIV
Case recording
Documentation or case recording is vital for effective surveillance. The
doctors/pharmacists/nurses must ensure that they maintain clear and legible
records of all the cases seen in the OP/IP registers (sample of OP / IP register is
given in annexure 3.1). Also, records of deaths (brought-in-dead, deaths in hospital,
etc) must be meticulously maintained. The person in charge of the lab should also
record all the details in the register (see sample in Annex 3.1). The register is selfexplanatory.
It is important to write legibly in the OP / IP register, especially the
diagnosis so that it is clear to all the people concerned.
Case reporting (compilation) & transmission of data
The cases that have been detected and recorded need to be compiled and transmitted
to the next level on a regular basis. Diseases of outbreak potential are reported on a
weekly basis while the other diseases or health conditions may be reported on a
monthly basis. Finally the Risk factor surveillance is reported once in three years.
The forms A, B, C D, and L are in the Annex 3.2 and the flow in the IDSP is
illustrated in Annex 3.7
For all forms, the original to be sent to the higher level while a copy to be maintained
at the reporting unit from where it originated.
Private sector involvement in Disease surveillance
There is very little experience on the involvement of the private sector in
disease surveillance.
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The NADHI model uses postcards to get information on new cases of common
communicable diseases from private practitioners. The latter are asked to send
a pre-printed postcard to the District authorities whenever they see patients
with disease x, y or z.
The NPSP model uses informers, who are sentinel private practitioners who
inform the District Immunisation officer the moment they see a case of AFP
One can use other methods, e.g. requesting clinics or hospitals to share the
information in the OP / IP registers on a weekly basis.
For Risk factor analysis
A separate questionnaire has been developed. Sample populations will be surveyed
once in 3 years to understand the trends.
Data must be transmitted to the next level and this may be done manually using
forms, or electronically using e-mails (through computers) or by telephone/fax
(where computers are not available). Data must be compiled and collated at each
level before submission to the next higher level. A possible flow of information in the
IDSP for rural and urban areas is shown in Annex 3.3. After the forms are filled up
they need to be checked by a senior staff and then only transmitted.
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Registers - Forms - Reports in the IDSP
Case
OPslip
FormB
OPRegister
immediate
weekly
| Labslip
IPregister |
| Labregister |
v
weekly
FormA
weekly
weekly
| FormL
weekly
FormC
weekly
weekly
Computer
(atdistrictlevel)
monthl
District
Programme
Manager
monthly
FormDandLC(toState)
Form A from reporting units where there is primary collection of data e.g. SC, Hospitals,
Form B from reporting units when an outbreak is suspected
Form C from units where data is consolidated e.g. PHCs, CHCs, DSO
Form L from Labs which do the tests e.g. PHC labs. District labs
Form LC from units where data is consolidated e.g. DSO
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Remember for epidemic prone diseases10 or diseases which are in
eradication mode (AFP) the first case should be immediately reported to
the higher authorities (within 24 hours of seeing the case).
Also report any unusual clustering of cases or any health event causing
deaths in a short span of time.
Use telephone, fax, email, special messenger, police wireless ~ any
method to report immediately.
Verbal report to be followed by a written case based form
Conclusion
Data collection is the first and most important step of an effective disease
surveillance system. If case detection is properly carried out, and all functionaries are
doing recording and reporting of cases in a proper manner then the surveillance
would be efficient. The later activities would strongly depend on the quality of this
component of surveillance.
For case detection to be of good quality,
o
o
o
o
All concerned should be trained in the use of case definitions
Copies of case definitions should be easily available
Registers and forms should be available at all levels
Logistics of transmission should be working (telephone, fax, email)
10 Cholera,Measles,Dengue,Plague,LeptospirosisandJE
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Table 3.4 Procedure for reporting by various functionaries at various levels.
Functionary
Frequency*
Source / Forms
Diseases
From
To
Sub centre
PHC
MPWs
Weekly
From OP register to
Form A
Suspect cases of diarrhoea, cholera,
typhoid, hepatitis, dengue, JE,
measles, AFP, malaria
PHC / CHC
District
Surveillanc
e officer
MO / pharmacist
Weekly
From OP / IP register
and Form A (of SCs) to
Form C
Probable cases of diarrhoea,
cholera, typhoid, hepatitis, dengue,
JE, measles, AFP, malaria
Private
dispensary /
Sub district
Hospital /
Urban
dispensary
District
Surveillanc
e officer
MO / pharmacist
Weekly
From OP / IP register to
Form A
Probable cases of diarrhoea,
cholera, typhoid, hepatitis, dengue,
JE, measles, AFP, malaria
Urban
dispensary
Corporatio
n Hospital
MO / Pharmacist
Weekly
From OP / IP register to
Form A
Probable cases of diarrhoea,
cholera, typhoid, hepatitis, dengue,
JE, measles, AFP, malaria
CHC
District
Surveillanc
e officer
Lab technician
Weekly
From Lab register to
Form L
Confirmed cases of malaria, TB
PHC
District
Surveillanc
e officer
MO
Once in 3 years
From Survey forms
Risk factors for CVD
Corporation
Hospital
MOH
MO / Nurse /
Pharmacist
Weekly
From OP / IP register
and from Form A (of
Urban Dispensar to
Probable or confirmed cases of
diarrhoea, cholera, typhoid,
hepatitis, den ue, JE, measles, AFP,
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WHO
42
6/17/2002
Form C
malaria, TB and HIV.
District hospital
I Medical
colleges / NGO
hospitals
District
Surveillanc
e officer
MO / Nurse /
Pharmacist
Weekly
From OP / IP register to
Form A
Probable or confirmed cases of
diarrhoea, cholera, typhoid,
hepatitis, dengue, JE, measles, AFP,
malaria, TB and HIV.
Police stations
District
Surveillanc
e officer
Nodal officer
Monthly
From their register
Road traffic accidents
District lab /
Private labs
District
Surveillanc
e officer
Nodal lab
technician
Weekly
From Lab register to
Form L
Confirmed cases of ADD, Cholera,
Typhoid, Viral hepatitis, TB,
Malaria, Water Quality.
Programme
Managers (TB,
Malaria, HIV,
Immunisation)
District
Surveillanc
e officer
Programme
managers
Monthly
From their forms
Confirmed cases of TB, Malaria,
HIV, measles. Polio
District
Surveillance
officer
State
Surveillanc
e officer
DSO
Monthly
From Forms A, B, C to
Form D
Suspect / Probable / Confirmed
cases of ADD, Cholera, Typhoid,
Viral hepatitis. Dengue, JE, Measles,
Polio, TB, Malaria, HIV and Road
Traffic Accidents. Also the water
quality reports
From Forms L to Form
EC
Urban Hospitals
I Private
Hospitals
WHO
MOH
MO / Pharmacist
44
Weekly
From OP / IP registers
to Form A
6/17/2002
Suspect / Probable / Confirmed
cases of ADD, Cholera, Typhoid,
Viral hepatitis. Dengue, JE, Measles,
Polio, TB, Malaria, HIV and Road
Traffic Accidents. Also the water
quality reports
From Private
labs
MOH
Nodal lab
technicians
Weekly
From the lab registers to
Form L
Confirmed cases of ADD, Cholera,
Typhoid, Viral hepatitis, TB,
Malaria, Water Quality and Air
Quality
Municipal
Corporation
State
Surveillanc
e officer
MOH
Monthly
From Form A and Form
L to Form C
Suspect / Probable / Confirmed
cases of ADD, Cholera, Typhoid,
Viral hepatitis. Dengue, JE, Measles,
Polio, TB, Malaria, HIV and Road
Traffic Accidents. Also the water
quality reports and Air quality
reports.
immediate reporting for suspect cases of cholera, dengue, measles, AFP, Plague and JE. This list may be increased according to local
situations e.g. leptospirosis may be added in the coastal belt. Tel: no of person to be informed should be provided.
Note: For non communicable diseases during the surveys for risk factor surveillance which would be carried out in three year cycles
covering the same community once in three years various functionaries will be involved as per their capacity in case reporting.
If there are no cases in that week / month, do not forget to write 'zero' in the relevant row.
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ANNEX3.1
Sample OP register
No:
Name and
address of
patient
Age
Sex
Age
Sex
Provisional
Diagnosis
Lab tests
Lab
results
Final
Diagnosis
Treatment Remarks
given
2_
3
4
Sample IP register
No:
x
Name and
address of
patient
Provisional DOA
Diagnosis
Lab test
results
Final
Diagnosis
2
2
4
Sample Lab register
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6/17/2002
Treatment DOD
given
Outcome Remarks
No:
Name and
address of
patient
Age
Sex
Provisional
Diagnosis
Lab tests
ordered
Lab results
x
2
3
4
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47
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Reported
to
authority
on
Remarks
ANNEX 3.2
Form A
Week No.:
Integrated Disease Surveillance
to Saturday
(Date: Sunday
Weekly Reporting Form for all Reporting Units
Please fill-out this form on every Saturday, to reach Health Authorities on every Monday
Name & address of the Reporting Unit:
Name & designation of the person filling-out the report:
Estimated population covered by this Reporting Unit: < 5=
Sr.
No.
Suspected Diseases/ Syndromes
(New cases)
_OPD
<5
>5
>5=
Patients treated
IPD
Total
<"5
<5 I >5
>5
Diarrhoea_____________________
Cholera_______________________
Typhoid______________________
Acute Viral Hepatitis___________
AFP (in less than 15 years of age)
Dengue_______________________
JE____________________________
Measles______________________
Malaria_______________________
Fever (not included elsewhere)
Unusual Syndrome____________
Total new cases
(Communicable & Non-communicable)
1
2
3
4
5
6
7
8
9
10
11
Telephone:
Signatureoftheauthority:
Nameanddesignationoftheauthority:
Diseases/syndromesofpublichealthimportancelikeAFP, Cholera, DengueFever,
JapaneseEncephalitis,Measles,Plague,Leptospirosis, WhoopingCough,etcmust
bereportedtotheDistrictHealthAuthoritiesimmediately.
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48
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Death
>5
FillinginFormA
The nodal person in each reporting unit should summarize the data on a weekly
basis and enter it into the corresponding form (Form A or Form L).
o
The source of information for filling up Form A is the OP / IP registers at the
reporting units
o
Data should be aggregated, disease wise, into 4 categories OP and IP, under
five and five and above.
o
Only new cases should be aggregated. Include those who have been referred
to another level also.
o
In the case of two communicable diseases for the same consultation, record the
most important disease - vis-a-vis outbreak potential
o
Total cases is the total cases seen at the OP / IP during the week.
o
The week number is as per the "Universal week" - see Annex 3.6
o
The estimated mid year population for the reporting unit needs to be entered.
This is applicable only for government reporting units.
o
Form A should then be transmitted to the next level by Monday.
o
In the event of a suspect case of AFP, Cholera, Dengue, JE, Measles, Plague the
local MO should immediately inform the concerned health authority.
Subsequently s/he should fill Form B and send it to the next level.
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49
6/17/2002
Annex3.2
Form B
Case based reporting for diseases of epidemic potential
AFP
Cholera
Suspect
Dengue
Probable
JE
Measles
Plague
Others
(please specify)
Confirmed
Name and address of patient.
Immunisation status
(if applicable)
Date of onset.
Sex
Age
Present status - alive/ dead/ admitted/
If admitted - name and address of health facility
Signature of the authority
Name and designation of the reporting authority
Name and address of the reporting unit (with telephone no:)
Final diagnosis (to be filled by the District Surveillance Officer)
AFP
Cholera
Suspect
Dengue
Probable
JE
Measles
Plague
Others
(please specify)
Confirmed
Date of diagnosis.
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50
6/17/2002
Filling Form B
This is filled and reported only when a case is suspected and is a case based
reporting. The source of data will be from the patient's.
o
One form for one patient
o
If there are more than 5 patients, then the details of the first 5 patients maybe
filled up and the details of the rest maybe included in the line listing.
o
Circle the suspected disease
o
Circle whether it is suspect, probable or confirmed
o
The detailed name and address of the patient is required
o
Age and sex of the patient should be recorded. In the event of a child less than
5 years, the date of birth would be preferable
o
The date of onset indicates the date on which the patient developed the initial
symptoms
o
If it is a vaccine preventable disease, then the immunization status for that
disease including the date of the last dose should be recorded
o
The current status of the patient should be recorded.
o
Following the investigations by the concerned authorities, the district health
authority will confirm the outbreak. This will then be entered into the bottom
half of the form and filed (after entering into the computer).
WHO
6/17/2002
51
•jo S’
07399
ANNEX 3.2
Form C
Week No.:
Integrated Disease Surveillance
to Saturday
(Date: Sunday
Weekly Reporting cum Consolidation Form
Please fill-out this form on every Saturday, to reach Health Authorities on every Monday
Name & address of the Reporting Unit:
Estimated population covered by this Reporting Unit: < 5=
Sr.
No.
1
2
3
4
5
6
7
8
9
10
11
Suspected Diseases/ Syndromes*
(New cases)
Diarrhoea_____________________
Cholera_______________________
Typhoid______________________
Acute Viral Hepatitis___________
AFP (in less than 15 years of age)
Dengue_______________________
_OPD
>5
<5
>5=
Patients treated
Total
IPD
<T >5
<5
:>5
_ Death
<5
>5
JE_______________________
Measles_______________________
Malaria_______________________
Fever (not included elsewhere)
Unusual Syndrome____________
Total new cases
(Communicable & Non-communicable)
Public health
_____ sector
Rural
Urban
Private Health sector
Rural
Urban
TOTAL
No of reporting units________
No: & %age of reporting units
that reported this month_____
No: of reporting units that
have reported on time
Diseases/syndromesofpublichealthimportancelikeAFP, Cholera, DengueFever,
JapaneseEncephalitis, Measles, Plague, Leptospirosis, WhoopingCough.etcmust
bereportedtotheDistrictHealthAuthoritiesimmediately.
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Telephone:
Signature of the authority:
Name and designation of the authority:
Filling Form C
Form C is filled in by reporting units where data is consolidated e.g. PHCs, CHCs
and the MOH. It is on a similar pattern to the Form A. The additionality is the report
on the completeness of data.
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53
6/17/2002
Annex 3.2
Form D
Month:
Integrated Disease Surveillance
Monthly Reporting Form for the DSO
Please fill-out this form by the first week of every month and submit it to the State
Surveillance Officer
Name of the District:
Estimated population covered by this District:
Name & designation of the person filling-out the report:
Sr.
No.
New Cases
1
2
3
4
5
6
Diarrhoea_____________________
Cholera_______________________
Typhoid______________________
Acute Viral Hepatitis___________
AFP (in less than 15 years of age)
Dengue_______________________
Suspect/
Probable
>5
<5
Patients treated
Confirmed
Total
<5
>5
<5
>5
T JE_______________________
Measles______________________
Malaria_______________________
Fever (not included elsewhere)
TB
~
HIV__________________________
RTA_________________________
Unusual Syndrome____________
Total new cases
(Communicable & Non-communicable)
8
9
10
11
12
13
14
Public health
_____ sector
Rural
Urban
Private Health sector
Rural
Urban
TOTAL
No of reporting units________
No: & %age of reporting units
that reported this month_____
No: of reporting units that
have reported on time
Telephone:
Signature of the authority:
Name and designation of the authority:
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54
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Death
<5
>5
Filling Form D
Form D is filled by the District Surveillance Officer and sent to the State Surveillance
Officer on a monthly basis. It is proposed that at the district level, the programme
managers (e.g. the District TB officer, the District Malaria officer etc. The SP of Police,
the Pollution control Board etc.) will share their data with the District Surveillance
Officer on a monthly basis. This data will then be incorporated into Form D. This will
contain the aggregate data for the entire month. The source of information for this
Form will be the Form 1 (suspect), the Form L (confirmed) and data from the
Programme Managers.
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ANNEX 3.2
Form L
Week No.:
Integrated Disease Surveillance
to Saturday
(Date: Sunday
Weekly reporting format for Laboratory Surveillance
Please fill-out this form on every Saturday to reach the Health Authorities on every
Monday
Name of the reporting Lab.:
Address:
I
Disease
No: of tests
done
<5
>5 T
Remarks
Positive
<5
>5
T
Cholera
Typhoid
Hepatitis
A__________
E___________
B___________
Others______
(P. falciparum)
Malaria
(P. vivax)
Dengue Fever_______
Japanese Encephalitis
Tuberculosis
HIV
Others
L
(Please
2.
specify)
Signature of the authority:
Telephone:
Name and designation of the authority:
Diseases of public health importance like Cholera, Dengue Fever, Diphtheria,
Japanese Encephalitis, Leptospirosis, Plague, Whooping Cough, etc must be reported
to the District Health Authorities immediately
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Filling Form L
This is to be filled by the nodal person in the lab. The source of data are the Lab
registers. The data should be dis-aggregated disease wise as well as according to the
age. Both total tests and the positive results are noted.
I
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ANNEX 3.2
Form LC
Week No.:
Integrated Disease Surveillance
to Saturday
(Date: Sunday
)
Weekly reportingformat for Laboratory Surveillance
Please fill-out this form on every Saturday to reach the Health Authorities on every
Monday
Name of the reporting Lab.:
Address:
Remarks
Positive
No: of tests
done
Disease
Cholera
Typhoid
Hepatitis
A___________
E___________
B___________
Others
Malaria
(P. falciparum)
(P. vivax)
Dengue Fever_______
Japanese Encephalitis
Tuberculosis
HIV
1.
Others
(Please
2.
specify)
Public health
_____ sector
Urban
Rural
Private Health sector
Rural
Urban
TOTAL
No of reporting units________
No: & %age of reporting units
that reported this month_____
No: of reporting units that
have reported on time
Signature of the authority:
Telephone:
Name and designation of the authority:
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Annexure3.4
INTEGRATED DISEASE SURVEILLANCE PROGRAMME TRANSMISSION OF INFORMATION
NATIONALIDSPOFFICER
Wednesday
STATESURVEILLANCEOFFICER
MOH-Corporation
UrbanDispensaries/Privateclinics/
PrivateHospitals
DISTRICTSURVEILLANCEOFFICER
Tuesday
DistrictHospital
Epidemicinvestigationteam
PrivateHospitals
SubDistrictHospitals
Monday
MOPHC/CHC
PRIVATEPRACTIONER
(Registered/unregistered)
Sunday
PERIPHERALHEALTHWORKER
(MPW-M/F)
COMMUNITY
(AWW,TEACHER,GRAMPANCHAYATMEMBER.SHGIeaderetc.)
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59
6/17/2002
Annex3.5
List of reporting units
Includes health facilities, laboratories.
Address of
Name of
Reporting unit
Reporting
unit
Name of nodal
person who is
responsible for
surveillance data
Tel No / Fax
No: and email
address of
nodal person
Public - Rural
Public - Urban
Private - Rural
Private - Urban
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6/17/2002
Annex3.6
IDSP WEEKLY SURVEILANCE CALENDAR: 2002
Week
No.
1____
2 ____
3 ____
4 ____
5 ____
6 ____
7 ____
8 ____
9 ____
10
11___
12 ___
13 __
14 ___
15 ___
16 ___
17
18___
19
20 ___
21 ___
22 ___
23 ___
24 ___
25 ___
26
WHO
Starting
Monday
31.12.01
07.1.02
14.1.02
21.1.02
28.1.02
04.2.02
11.2.02
18.2.02
25.2.02
04.3.02
11.3.02
18.3.02
25.3.02
01.4.02
08.4.02
15.4.02
21.4.02
29.4.02
06.5.02
13.5.02
20.5.02
27.5.02
03.6.02
10.6.02
17.6.02
24.6.02
Ending
Sunday
06.1.02
13.1.02
20.1.02
27.1.02
03.2.02
10.2.02
17.2.02
24.2.02
03.3.02
10.3.02
17.3.02
24.3.02
31.3.02
07.4.02
14.4.02
21.4.02
28.4.02
05.5.02
12.5.02
19.5.02
26.5.02
02.6.02
09.6.02
16.6.02
23.6.02
30.6.02
Week
No.
27 __
28 __
29 __
30 __
31 __
32 __
33 __
34 __
35 __
36 __
37 __
38 __
39 __
40 __
41 __
42 __
43 __
44 __
45 __
46 __
47 __
48 __
49 __
50 __
51 __
52
Reporting
Monday
07.1.02
14.1.02
21.1.02
28.1.02
04.2.02
11.2.02
18.2.02
25.2.02
04.3.02
11.3.02
18.3.02
25.3.02
01.4.02
08.4.02
15.4.02
21.4.02
29.4.02
06.5.02
13.5.02
20.5.02
27.5.02
03.6.02
10.6.02
17.6.02
24.6.02
01.7.02
61
Starting
Monday
01.7.02
08.7.02
15.7.02
22.7.02
29.7.02
05.8.02
12.8.02
19.8.02
26.8.02
02.9.02
09.9.02
16.9.02
23.9.02
30.9.02
07.10.02
14.10.02
21.10.02
28.10.02
04.11.02
11.11.02
18.11.02
25.11.02
02.12.02
09.12.02
16.12.02
23.12.02
Ending
Sunday
07.7.02
14.7.02
21.7.02
28.7.02
04.8.02
11.8.02
18.8.02
25.8.02
01.9.02
08.9.02
15.9.02
22.9.02
29.9.02
06.10.02
13.10.02
20.10.02
27.10.02
03.11.02
10.11.02
17.11.02
24.11.02
01.12.02
08.12.02
15.12.02
22.12.02
29.12.02
Reporting
Monday
' 08.7.02
' 15.7.02
' 22.7.02
' 29.7.02
' 05.8.02
' 12.8.02
' 19.8.02
' 26.8.02
' 02.9.02
' 09.9.02
' 16.9.02
' 23.9.02
' 30.9.02
' 07.10.02
' 14.10.02
' 21.10.02
' 28.10.02
' 04.11.02
' 11.11.02
' 18.11.02
' 25.11.02
' 02.12.02
' 09.12.02
' 16.12.02
' 23.12.02
' 30.12.02
6/17/2002
ANALYSIS
ANALYSIS OF DATA
This section describes how to
Analyse and interpret the data received
Compare analysis results with thresholds to identify
outbreaks
Compare analysis results between regions to detect poorly
performing regions
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62
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DATA ANALYSIS & INTERPRETATION
While collection of good quality data is important for a surveillance programme,
analysis and interpretation of this data is of equal significance. Without this, all the
hard work put in by the workers becomes meaningless. Data Analysis provides four
important outcomes
•
Analysis of routine data helps in identifying outbreaks or potential outbreaks e.g. a
case of measles identified should alert the health services about a potential outbreak.
•
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; e.g. analysis of a diarrhoeal outbreak will be able to identify the
affected families and the cause of the outbreak so that corrective action can be
targeted at this cause.
•
Analysis of routine data provides information for predicting changes of disease rates
over time and enables appropriate action. E.g. the increasing trends in Road Traffic
accidents should help the public health manager raise resources and plan
interventions to reduce the same.
•
Identifies problems in the health system; so that gaps can be effectively plugged - e.g.
an outbreak of measles should alert the public health manager about the possibility of
low vaccination coverage in that region.
•
Comparison of analysed data between regions or between sectors (public and private)
helps the public health manager in improving the quality of the surveillance system
Analyses - at which level?
Analysis should ideally be done at all level from the periphery upwards. The degree
of analysis would depend on the capacity of the persons involved. For example, the
community informants would be alert for any unusual increase in the number of
fever cases occurring in the community. S/he should then be able to inform the MPW
with details of how many people, what are the symptoms, where are they located etc.
Similarly other functionaries at various levels would be able to carry out analysis as
outlined in table 1.
Data analysis should ideally be done at each level
Who will do the analysis?
There should be a designated officer at each level who is responsible for the analysis
and interpretation of the data. That person may then co-opt other members to form a
Technical committee/ who will assist him. E.g. at a District level, it should be the
District Surveillance Officer who may constitute a TC by inducting relevant
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63
6/17/2002
programme managers, the Para-medical worker who is involved in data compilation
and generation of reports, the Municipal Health Officer and interested volunteers
from the private sector. This Committee should meet weekly to review, analyse and
interpret the reports generated.
A smaller committee is more effective than a large and cumbersome one
When should analysis be done?
Analysis is done at various frequencies - daily, weekly, monthly, annually. See Table
XXX. Reports should be generated, either manually or computerized according to
this frequency.
Table XXX: Frequency of reports and analysis
No
Reports
Timeliness and completeness of reports
Description by time, place and person
Trends over time____________________
Checking for crossing of threshold levels
Comparison between reporting units
Comparison between public and private
Comparison between disease and lab
data
1_
2
3
4
5
6
7
Daily
12
Weekly
Monthly
Yearly
Z
zz
How to analyse?
As can be seen most of the analysis is done on a weekly or monthly basis. In the
event of an outbreak, of course the analysis has to be done on a daily basis. This will
be dealt in the chapter on the investigation of and response to an outbreak. In this
chapter, only the analysis of routine data will be dealt with.
When analysing the data some key points need to be kept in mind by the Technical
committee
1. The strength and weaknesses of the data collection method and reporting
process. Is the data generated reliable and valid?
2. Examine each disease separately
3. Start with crude numbers and then proceed to summarized data
4. Tables are necessary, but graphs are easier to review
5. When comparing between institutions / areas, use rates and ratios (Incidence
rate / Case fatality ratio) rather than actual numbers. This takes care of the
12lntheeventofanoutbreak
WHO
64
6/17/2002
effect of different populations in different regions e.g. if Block A has 50 cases
of malaria and Block B has 75, it does not naturally imply that the situation in
Block B is worse. If Block B has a larger population, then it could account for
the higher case load.
Some of the measures that need to be used for analysis are
•
Cases - the number of New cases that have occurred in the specified period
•
Deaths - the number of deaths that have occurred in the specified period
•
Incidence Rate - the number of new cases that have occurred in a 1000 population
over a fixed period of time.
•
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
o
Virulence of the disease e.g. a high case fatality in a particular outbreak
may be an early indication of a change in strain of the agent.
o
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.
o
The effectiveness of the health services in terms of case management e.g.
poor case management itself will increase the CFR, while good case
management will reduce the CFR.
A systematic approach to analysis will help the public health manager 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.
Steps in analysis
1.
Convene the technical committee - preferably on a fixed day every week / month
2. Ask for the reports (see below for details of each report) - a minimum of 4 reports on
a weekly basis and 7 on a monthly basis
3. Review the reports disease wise and interpret it appropriately.
4. Prepare a summary, which is to be shared with colleagues at the same level as well as
with the concerned officers at the higher level. This summary report, especially the
monthly report should be also used as a tool for feedback.
5. Take action where necessary
The details of the reports that need to be generated are as follows:
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65
6/17/2002
Report 1 - Completeness and Timeliness of data
This is one of the first report that has to be generated. It is a reflection on the
performance of the reporting units. For this one needs to have a list of the reporting
units. The MO then monitors which of the reporting units are sending complete
reports on time. A simple tool to monitor the Completeness and Timeliness of the
reporting units is provided in Annex XXX.
A report (from a reporting unit) is said to be on time, if it reaches the designated level
within the prescribed time period. If it reaches, later, then the report is considered to
be late (and of lesser public health use). The timeliness of a reporting unit can be
calculated by assessing how many of its expected reports have come on time.
A report is said to be Complete if all the reporting units within its catchment area has
submitted the reports on time. If 8 out of 10 only have submitted, then the report is
said to be incomplete (or 80% complete).
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.
There are various scenarios possible:
Scenario___________________________
Reporting unit A is timely and complete
Reporting unit B is timely, but regularly
incomplete
Reporting unit C is late, but reports are
complete
Reporting unit D is late and the reports
are incomplete.
WHO
66
Interpretation_______________________
an ideal scenario, everything is working
well________________________________
The MO of B has understood the
importance of reporting on time. But
there are some reporting units under the
jurisdiction of B who are not reporting on
time. B's MO has to find out what the
problem is.__________________________
The MO of C has not understood the
importance of reporting on time. S/he
needs to be impressed about the
significance of timely reporting.________
Major problem in this reporting unit neither the MO of D nor the MOs of the
reporting units under D have understood
the importance of surveillance and timely
data.
6/17/2002
Table 1: Data analysis by functionaries at various levels
Level and
(functionary)
Community
(Lay person,
key
informants
etc)________
Sub center
(MPWs/
Urban Link
workers)
PHC/CHC/
Urban
dispensary
(MO/
Pharmacist)
On
occurrence of
event
o
On
occurrence of
event
o
Weekly
o
On
occurrence of
event
o
Weekly.
o
o
o
o
Monthly
Daily in the
event of an
outbreak
o
o
Private sector
(MO)
District
WHO
On
occurrence of
event
On
Action
Analysis
Frequency
o
o
o
o
o
67
lsalerttocasesofmeasles,AFPorunnaturaldeathsinthe
community.
Looksoutforobviousincreaseincasesoffever.diarrhoeaand
jaundice, clearlyinexcessofthenormaloccurrence
Is alert to single cases of suspect cholera, measles, AFP or
unnatural deaths in the community.
Reviews the list of cases seen to pick up any increasing trends
in diarrhoeal diseases, fever cases, jaundice cases
Is alert to a sudden increase in cases
Is alert to single cases of probable cholera, measles, AFP,
dengue, JE or plague.
Is alert to any unnatural deaths in the institutions or
community.
Reviews the weekly and monthly reports and monitors the
timeliness and completeness of reports; and the trends in
individual diseases especially diarrhoeal diseases, typhoid,
jaundice, malaria, TB and HIV.
Is alert to any sudden increase in a particular disease,
especially if it is in clear excess of previous weeks/ months/
years.
Is able to describe the status of the disease in the community
vis-a-vis the people affected, the time when affected and the
site affected.
Monitor the quality of data by comparing it with sentinel sites.
Is alert to single cases of probable cholera, measles, AFP,
dengue, JE or plague.
Is alert to any unnatural deaths in the institutions or
community.
Is alert to any sudden increase in a particular disease_________
Is alert to single cases of probable cholera, measles, AFP,
6/17/2002
Informs MPWs/Link
workers /
Mos
Assists the medical team in
the investigation and action
Informs MO PHC/MO
Urban dispensary
Immediately if there is
anything unusual.
Assists the medical team in
the investigation and action
Forwards the analyses to the
DHO/DSO by quickest
means i.e. by Phone / Fax / email / courier.
In Urban areas, forwards the
analysis to the MHO.
Investigates, confirms and
takes necessary action
Immediately informs the MO
-CHC/DSO/MHO
Submits the nports to the
Hospitals/
Municipal
Corporations
Hospitals /
occurrence of
event
o
Weekly.
o
Monthly
Annually
o
Daily during
an outbreak.
o
o
Level________
District/
Municipalitie
s / Municipal
Corporations
(DSO/MHO)
Frequency
On
occurrence of
event
o
o
Weekly.
o
Monthly
o
Daily in the
event of an
outbreak
o
o
o
o
o
State
(SSO)
Monthly.
Daily during
epidemics
o
o
WHO
68
dengue, JE or plague.
DSO/MHO
Is alert to any unnatural deaths in the institutions or
community.
Investigates, confirms and
Reviews the weekly and monthly reports and monitors the
takes necessary action
timeliness and completeness of reports; and the trends in
individual diseases especially diarrhoeal diseases, typhoid,
jaundice, malaria, TB and HIV.
Is alert to any sudden increase in a particular disease,
especially if it is in clear excess of previous weeks / months /
years.
Is able to describe the status of the disease in the community
vis-a-vis the people affected, the time when affected and the
site affected.
Monitor the quality of data by comparing it with sentinel sites.
_______________________ Analysis___________________________ Action_____________________
Peruses all the reports received from all levels and all sectors
Submits the report to the
(public and private), as well as from the labs.
DHO and State Nodal officer
Monitors the completeness and timeliness of the reports of the on a monthly basis.
reporting units.
Compares the previous weeks reports to identify any
In the event of an outbreak
J
Alerts the EIT
increasing trends.
Compares the weekly data with that of the corresponding week
and requests them to
in the previous year.
investigate the outbreak
J
Monitors the
Compares data from different blocks, labs, sentinel centres,
progress of the outbreak
sentinel labs to identify any discrepancies
Compares the trends in the public/private/lab data to identify /
If necessary,
any discrepancy.
inform the State
Check to see if the threshold is crossed.
surveillance officer for
support and help.
Keeps a watchful alert on disease outbreaks in neighboring
districts/states to prevent spillover to his district
Makes GIS maps using Health Mapper
Compile and analyze the district profiles and alert the DSOs to
any suspected outbreaks or when neighboring districts are
affected
Analyze the data of the entire state for person, time and place
distribution and make suitablepredictions/disease trend
6/17/2002
Central health authority
o
o
o
o
o
o
WHO
69
analyses
Makes GIS maps using Health Mapper
Identify high risk districts/towns/cities in the state
Compare data from different districts, district labs. Public
health Institutes, sentinel centres, medical colleges, etc to
identify any discrepancies in data
Keep a watchful alert on disease outbreaks in neighboring
states to prevent spillover to his state
If outbreak is of epidemic proportion then alerts the central
health authorities for assistance
Provides feedback of the analyses to the districts through
monthly bulletins
6/17/2002
r^i
'O
o
O
I
Report 2 - Descriptive report
This is the 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. Some samples are shown in Annex XXX.
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 graph to identify the incidence of diseases and deaths; pie graphs to
show the load of diseases
As can be seen, the tables are cumbersome to read and interpret. However it is
necessary for the sake of records. In the event of computerisation, once the data is
entered, various tables to suit the need of the individual surveillance officer can be
obtained. Preferably data should be presented in a graphical manner so that the MO
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.
Incidence rate of disease A:
No of new cases of disease A X1000
Population in the catchment area
Gase fatality ratio for disease A:
No: of deaths from disease A X100
No: of new cases of disease A
In the case of hospitals / private sector one cannot calculate the incidence rate as
there is no catchment area,
For the sake of clarity, initially separate tables and graphs should be made for data
from the public and private sector.
This preliminary analysis should give the MO an idea of the health problem under
his/her jurisdiction in terms of basic epidemiological parameters (time, place and
person). It thereby helps the MO to focus on problems that need further analysis.
GIS
Analysing data by place gives information about where the disease is occurring. This sort of
analysis maybe done manually or by using computers and GIS software (WHO's Health
Mapper is an example). It allows the MO to
•
detect any clustering of cases - e.g. if there is any increase in the number of diarrhoea
cases, the GIS will help in checking whether this is a sporadic increase or whether there is
a 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
WHO
71
6/17/2002
1
source, then one can hypothesise 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 of water borne disease.
Some of the interpretations from this report(s) are
•
Any increase or decrease in incidence of a disease for a particular reporting unit, (as
compared to other reporting units).
•
Any increase or decrease in deaths from a disease for a particular reporting unit (as
compared to other reporting units).
•
Age group of cases (under 5 or 5 and above).
•
Place where the events are occuring
•
Any clustering of cases (from the spot map).
Report 3 - Comparison with previous weeks/months/years
This report helps the MO to detect the trend of the disease over time. It needs to be
done for each disease and should done on a weekly, monthly and annual basis.
Weekly analysis: should compare the current week's data with the data 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 the
previous 3 weeks. An example is shown in Fig XXX. As can be seen from the
example, there seems to be an increasing trend in the number of cases of malaria.
This should alert the district authorities to take the necessary preventive action.
Monthly and yearly analysis looks at the secular trends and tries to identify the
months in the year when the disease tends to peak. This should alert the Public
health manager about the possibility of intervention to prevent the peaks. An
example is given in Fig XXX
WHO
72
6/17/2002
Fig XXX - Number of cases and deaths due to malaria in Keonjhar District - Orissa - 2001
7
450
400
• 6
350 ;
f5
300 i
4
£ 250
ro
0)
3 Q
W
ro
O 200 -
I
150
If?
4- 2
■
100 41
50
B
0
week32
week34
week33
^Hi Numberofcases
- o
week35
—Numberofdeaths |
Fig XXX - Incidence rate of dysentery in Orissa - 2001
Weekly Incidenceof Bloody Diarrhoeaf ortheYear2001-Oris saState
8,00
7.50
7 00
•s.o 6 50
o
o
o"
T-
a>
a>
6 00
5.50
5.00
4 50
4.00
3.50
3.00
2.50
o
2.00
5 150
'5 1.00
0.50
0.00
JAN01
FEB01
MAR01
APR01
MAY01
jlUNOI
JUL'01
A JG01
SE-’TOI
NO </01
CCT01
DECpi
Re portingWee ks&Months
The main purpose of this report is to understand the trends over time.
Some of the possible interpretations are
Scenario
Interpretation
Increasing trends
o
Could be a potential outbreak
o
Could be better reporting
o
Could be a change in the detection and reporting
WHO
73
6/17/2002
Decreasing trends
Plateau of the graph
o
Could indicate improved control measures
o
Could indicate under reporting because of incomplete
reports
o
Could indicate a change in the detection and reporting
o
Could indicate stable situation
o
Has to be corroborated with the completeness report.
Report 4 - Crossing threshold values
This report helps to identify outbreaks early enough. The weekly / monthly data
should be always compared with established threshold levels. These can be obtained
in the following manner:
1. Pre-existing National / Internationally developed thresholds e.g. a single case of
measles in a tribal area is considered as an outbreak and reason for action
2. 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).
3. Increasing trends of the disease over a short duration of time (e.g. in weeks)
Some examples of thresholds are given below in Table XXX
Table XXX - Threshold levels for common epidemic prone diseases
Action to be taken
Disease
Threshold level
A single suspect case of
Cholera
•
Immediate reporting the next
level to alert them.
•
Investigation and confirmation
of the existence of case
Dengue
JE
Measles
Plague
Lab confirmation where
possible
AFP
•
If the number of cases Diarrhoeal disease
exceed the mean number of Typhoid
cases from the previous
Hepatitis
non-epidemic years
Malaria
Water pollution
Air pollution
WHO
74
Specific response if
confirmed
epidemiologically and/or
by lab.
•
Immediate reporting the next
level to alert them.
•
Investigation and confirmation
of existence of cases
•
Check for epidemiological
linkages
•
Reviewing the past data
•
Lab confirmation where
6/17/2002
possible
•
If the number of cases or
deaths are increasing over a
short period of time
Diarrhoeal disease
•
Immediate reporting the next
level to alert them.
•
Investigation and confirmation
of existence of cases
•
Check for epidemiological
linkages
•
Reviewing the past data
•
Lab confirmation where
possible
•
Specific response if
confirmed epidemiologically
and/or by lab.
Typhoid
Hepatitis
Malaria
TB
HIV
Water pollution
Specific response if
confirmed
epidemiologically and/or
by lab.
Air pollution
Interpretations that are possible are:
Scenario
Interpretation
Number of cases much below the threshold
o
No reason to worry
o
Check for under reporting
o
Review the threshold value
Potential outbreak
Trends approaching threshold
N umber of cases have crossed the threshold
Outbreak situation, to take necessary
action
Report 5 - Comparison between the reporting units in the region
This is a useful report and is a good proxy indicator for the quality of the data
generated. One compares the Incidence rates and Case Fatality Ratios for the current
month between the various reporting units. This should ideally be done from the
Block and above level. If there are sharp rises or falls in the incidence rates (where
one is not expecting one), then one should look more carefully at the veracity of the
reports from that reporting unit. In a given region, one will not expect a major
difference in incidence rates etc unless there are some specific interventions there. An
example of this, comparing the 10 coastal districts of Orissa is given in Fig 2.3
WHO
75
6/17/2002
Fig 2.3 Comparison of the Incidence rate for malaria for the week 27 (2001) for the
10 coastal districts of Orissa.
3.5 -|
31
VerylowlR
0) 2.5
ra
QI
2J
Q
c
0)
1.5
'6
_c
1
°-5 1 ■
0 ■ I—
z
z
I ~ ]I
z
O'
z
4^
Here one can see that Jagatsinghpur has a very low incidence rate as compared to its
neighbouring districts. As there are no particular intervention programmes in this
district, one may need to look carefully at the data from this district.
This report needs to be generated on a monthly basis.
Possible interpretations are:
Scenario
Interpretation
IR and CFR in the various reporting units are
similar
Maybe indicative of good reporting
mechanism
Markedly low IR / CFR in a reporting unit
Quality of data from this unit needs to be
reviewed - possibility of under reporting
Markedly high IR / CFR in a reporting unit
Quality of data from this unit needs to be
reviewed - possibility of an outbreak or a
data entry error.
Report 6 - Comparison of reports received from private sources with that of public
sources
The data from the 2 independent sources is a good proxy indicator of the quality of
data generated from the two sectors. The trends in the incidence of new cases /
deaths in the public and private health sector may be analysed to see if they are
following a similar pattern. If there is correlation between the two sources, then one
can assume that the quality of data is good and it represents the events in the
community. In case there is discordance between the two data sets, one has to do
further operational research to identify which data source is more reliable and
measures to correct the unreliable source.
WHO
76
6/17/2002
Report 7 - Comparison of reports received from the public health sources and the
lab sources
It is important to correlate the findings of the data analysis with the availability of
other data obtained from labs. This comparison may be vis-a-vis
•
the cases diagnosed in the labs and the number of cases seen by the providers.
•
The water quality reports and the cases of water borne diseases. For example
contamination of a water source may be detected by the routine water testing
and the resultant outbreak of jaundice may be well within the incubation
period of the disease, thus pointing to a single source epidemic.
•
The entomological data and the cases of vector borne diseases. For example a
high vector density of aides mosquitoes could clearly link to an outbreak of
dengue fever in that area.
Once again this sort of comparisons should validate the data as well as identify
potential areas of problems in data collection and generally in the surveillance
systems.
On a weekly basis, the first 4 reports need to be generated and reviewed. This can be
done by a technical committee comprising of the MO in charge of surveillance and
some other Medical and Para-Medical workers. The review should try and identify
•
•
The presence of any outbreak (through Reports 2-4)
Any lacuna in the system (through Report 1)
Based on the review, a summary should be prepared which should be sent to the
next level on a weekly basis alongwith the compiled data. At the district level, only
the weekly summary will reach the State level.
On a monthly basis, at least 7 reports need to be generated and reviewed. The
technical committee maybe the same and the purpose would be the same. However,
here the Reports 5-7 would help the MO to better review the performance of the
surveillance system.
Also the data from the other disease (TB, HIV, Malaria, Road Traffic Accidents)
should be incorporated and analysed in a similar way.
A summary should be prepared for the month which should be shared with the
concerned officers at that level; e.g. at the district level, the summary should be
shared at the monthly meeting of the MOs, with the Programme Managers and with
the District Collector / Magistrate. This summary sheet should then be forwarded to
the next level for information.
WHO
'll
6/17/2002
CONCLUSIONS
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 take focused action so that unnecessary morbidity and mortality are
prevented.
While it is important to analyse the data, it is also important that the analysed reports
are sent to the appropriate authorities, both at a 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 also a good motivator.
However, while doing the analysis, one must be aware of the 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 cases. In
depth analysis on poor quality data is not of much use
There is a time lag between detection, reporting and analysis. The ground
situation may 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 to increase
the sources of data, including the private sector and the NGO sector etc.
o
Data must be analysed carefully and interpreted prudently
o Ability to effectively analyse, interpret and present surveillance data is an
important skill for the Public Health Manager.
WHO
78
6/17/2002
»
WHO
79
6/17/2002
Annexure XXX
Sample form for recording Timeliness and Completeness of weekly reports
(to be used from Block upwards)
Date by which report should have received:
Block / District / State:
Reporting
units:
1st
2nd
3rd
4th
5th
6th
yth
8th
gth
lOth
11th
l2th
CD
QJ
RU1
RU2
RU3
RU4
__
f- ------__
Total No. of
reports expected
(N)____________
Total no: of
reports sent on
time (T)________
Total no: of
complete reports
©
Timeliness of
reporting =
100*T/N_______
Completeness
of reporting =
100*C/N
Both Complete
and timely report
________ Key
Timely but
incomplete
Neither complete
nor timely report
No report within a
specified period
WHO
80
Late but
complete
6/17/2002
Total
RAW COLLATED DATA OF ORISSA MDSS
Cases < Deaths Cases > Deaths Cases - Deaths Total Total
5
>5
5
<5
Week ending District Disease
Simple
772
292
480
0
0
0
ANGL diarrhoea
03.05.2002
Severe
94
1
49
0
45
1
03.05.2002
ANGL diarrhoea
0
349
142
0
491
0
ANGL Dysentery
03.05.2002
0
37
0
19
0
18
ANGL Jaundice
03.05.2002
Sus.
2
2236
2
2955
719
0
ANGL Malaria
03.05.2002
887
I
1420
I
533
0
ANGL ARTI
03.05.2002
9
0
0
10
0
19
Measles
03.05.2002
ANGL
0
0
0
0
0
0
ANGL NNT
03.05.2002
Sus
21
o
0
2
0
0
ANGL Meningitis
03.05.2002
0
0
1
0
1
0
11
1480
0
1
22
5099
1
18
33
6579
_l
19
458
0
1131
0
1589
0
20
0
68
0
88
0
Dysentery
Jaundice
Sus.
Malaria
ARTI
Measles
NNT
Sus
Meningitis
201
2
0
0
632
3
0
833
5
0
0
247
617
_1
0
0
0
0
0
1429
1456
0
Ll
1676
2073
_2
0
0
0
0
0
0
0
0
0
0
0
0
0
3
0
3
0
0
3397
0
8
____ 0
13100
_0 ____ 0
388
0
BRGR
Heat stroke
Unusual
syndrome
Others
Simple
diarrhoea
Severe
diarrhoea
75
0
BRGR
Dysentery
03.05.2002
ANGL
03.05.2002
03.05.2002
ANGL
ANGL
03.05.2002
BLSR
03.05.2002
BLSR
03.05.2002
03.05.2002
BLSR
BLSR
03.05.2002
03.05.2002
03.05.2002
03.05.2002
BLSR
BLSR
BLSR
BLSR
03.05.2002
BLSR
03.05.2002
BLSR
03.05.2002
03.05.2002
BLSR
BLSR
03.05.2002
BRGR
03.05.2002
03.05.2002
WHO
Heat stroke
Unusual
syndrome
Others
Simple
diarrhoea
Severe
diarrhoea
159
81
1)
0
p
0
14
16497
0
22
1042
0
1430
0
202
0
277
0
404
0
563
0
6/17/2002
Data according to Districts
Orissa State Disease Surveillance Report for the Week ending 03.05.2002
ANGUL
DISTRICT
DISEASE___________
Simple Diarrhoea
Severe Diarrhoea
Dysentry___________
Acute Jaundice______
Susp. Malaria_______
ARTI_______________
Measles_____________
NNT_______________
Susp. Meningitis
Heat Stroke_________
Unusual Severe Synd.
Others
Total
>= 5 Years
< 5 Years
Cases Deaths Cases JDeaths Cases Deaths
772 _____ 0
292
480 ______ 0
0
94 _____ 1
____ 45 ______ 1 ____ 49 ______ 0
0
491 ______ 0
349
142 ______ 0
0 ___ 37 ______ 0
____ 18 ______ 0 ____ 19'
2
719 ______ 0 2236 ______ 2 2955
1420
1
887
1
533 ______ 0
19
0
10 ______ 0 _____ 9 ______ 0
_0
_____ 0 ____ _0 _____ 0 ______ 0 ____ 0
0
2 ______ 0 _____ 0 ______ 0 ____ 2
___ 1
____ 0 ___ 2 _____ 1
33
1
____ 11 ____ 0 ___ 22 ______ 1
19
18 6579
1480
1 5099
___ p
_p
____ 0
Total
3252
2
9151
BHADRAK
DISTRICT
Total
>= 5 Years
< 5 Years
DISEASE
_0
24
22 12403
Cases Deaths Cases Deaths Cases Deaths
Simple Diarrhoea
606
0
1070
0
1676
0
Severe Diarrhoea
31
0
82
0
113
0
Dysentry
375
0
818
0
1193
0
Acute Jaundice
o
0
4
0
4
0
Susp. Malaria
304
0
1092
0
1396
0
ARTI
1020
1
2066
0
3086
1
Measles
5
0
1
0
6
0
NNT
0
0
0
0
0
0
Susp. Meningitis
0
0
0
0
0
0
Heat Stroke
0
0
1
0
1
0
Unusual Severe Synd.
0
0
0
0
0
0
3539
5
9544
13
13083
18
0
0
20558
19
Others
Total
5880
WHO
82
6
14678
13
6/17/2002
Data according to Disease
NUMBER OF CASES OF REPORTED DISEASES IN THE DISTRICTS OF ORISSA DURING THE WEEK ENDING 03.05.02:
< 5 YEARS AGE GROUP
SUSP. HEAT UNSV
SIMP SEVR DYSEN ACUTE SUSP.
OTHR
ARTI MSLS
NNT
MALR
MENI STRK SYND
DIAR
DIAR
T
JAUN
DISEASES »»
DISTRICTS
2
0
533
10
0
11
1480
292
45
142
18
719
ANGUL_______
201'
247'
0
2
3397
617
0
o'
_0
BALASORE
458
20
3’
_o’
159~
417'
0
1949
497
0
75
BARAGARH
388
0
375'
304'
3539
0
_0
1020
0
0
_0
606
31
BHADRAK
189~
454~
0
1788
48
552
o'
0
_1
567
11
BOLANGIR
55'
984
0
o'
0
169
208
_0
BOUDH_______
148
_3
_0
4
0
o'
0
_0
4010
_3
540
1133
_5
CUTTACK
_8
335
626
o'
0
560
_0
29
_0
426
145
0
0
136
DEOGARH
_3
0
2741
_0
14
247
600
864
0
0
385
DHENKANAL
_0
o'
0
_0
718
251
92
361
353
3
0
13
GAJAPATI
466'
0
0
_0
4265
569
1654
1029
0
GANJAM
38
90'
0
_0
0
1810
279
38
416
_3
0
JAGATSINGPUR
0
257'
0
0
0
_2
2018
1035
_0
0
490
211
17
JAJPUR________
209
’
0
0
4
908
6
378
0
0
187
24
45
JHARSUGUDA
J.
o
KORAPUT
MALKANAGIR
ORISSA TOTAL
WHO
435
218
13598
11
5
681
150
93
5459
83
0
b
71
875
281
15527
626
236
20986
2
_0
78
6/1 7/2002
0
0
1
0
0
2
0
4
6
J.
_0
29
1196
377
59349
ALL
3252
4943
3491
5880
3611
1571
6660
1299
4852
1791
8023
2643
4030
1761
3296
1220
115787
Incidence rate according to District
INCIDENCE RATE OF REPORTED DISEASES IN THE DISTRICTS OF ORISSA DURING THE WEEK ENDING 03.05.02:
(PER 1000 POP)
< 5 YEARS AGE GROUP
DISEASES »» SIMP SEVR BLDY ACUTE SUSP.
NEO. SUSP. HEAT UNSV
ARTI MSLS
OTHR
DIAR
DIAR
DIAR
JAUN
MALR
TETN
MENI STRK SYND
DISTRICTS
2.24
0.35
ANGUL_______
1.09
0.14
5.53
4.10
0.08
0.02
0.08
11.37
0.00
0.00
BALASORE
2.03
0.09
0.89
1.09
0.01
o.oo' o.oo' 0.00
0.00
o.oo' 15.03
2.73
0.97~
BARAGARH
2.37
0.46
0.02
2.55
11.92
0.02
0.00
0.00
0.00
0.00
3.04
0.00'
BHADRAK
0.21
2.55
6.94
2.07
4.12
0.00
0.03
0.00
0.00
0.00
24.07
0.01'
3.40
0.29
0.07
2.72
BOLANGIR
1.13
3.31
0.01
0.00
10.73
o.oo'
0.00
0.07
3.44
BOUDH_______
1.28
4.84
3.93
0.09
0.00
o.oo'
0.00
0.00
o.oo' 22.88
1.27'
0.02'
CUTTACK
0.03
2.05
4.31
15.25
2.38
0.01
o.oo'
0.00
0.00
0.00
O.OO'
DEOGARH
4.29
0.09
0.91
13.43
4.57
0.00
o.oo'
0.00
0.00
o.oo' 17.66
0.01'
DHENKANAL
3.06
0.11
6.86
1.96
0.00
4.76
0.00
0.00
0.00
0.00
21.75
0.21'
0.05'
GAJAPATI
4.11
5.92
1.51
0.00
5.79
0.00
0.00
0.00
o.oo' 11.77
2.86
0.11
4.59
GANJAM
1.29
0.00
1.58
o.oo' 0.00
0.00
0.00
o.oo' 11.85
0.05'
2.07
0.67
IAGATSINGPUR
0.00
3.08
0.02
0.28
0.00
0.00
0.00
o.oo' 13.41
JAJPUR________
2.65
0.09
1.14
1.39
5.59
10.91
0.00
o.oo' o.oo' 0.00
0.00
0.01
6.25
JHARSUGUDA
3.09
0.40
0.74
0.07
0.10
3.46
0.00
0.00
0.00
0.00
15.01
0.22
’
KALAHANDI
4.08
3.82
5.05
1.23
0.00
0.00
0.00
0.00
0.00
o.oo' 15.78
KORAPUT
MALKANAGIR
ORISSA STATE
WHO
3.12
3.82
3.20
0.08
0.09
0.16
1.08
1.63
1.28
84
0.00
0.11
0.02
6.27
4.92
3.65
4.49
4.13
4.94
0.01
o.oo'
0.02
6/17/2002
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.07
0.00
0.01
0.00
0.01
8.58
6.60
13.96
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OUTBREAKINVESTIGATION,RESPONSE&
CONTROL
This section covers
• Defining an outbreak/epidemic
• Detecting an outbreak
• Investigation of an outbreak
• Response to an outbreak and control measures
WHO
Page78
6/17/2002
WHY AN OUTBREAK HAS TO BE INVESTIGATED?
Analysis of the data reveals potential or actual outbreaks. These need to be
investigated and if verified, needs to be controlled. This is the basic essence of this
chapter. The purpose of an investigation is to
Verify the outbreak
Identify and treat additional cases that have not been reported or recognised
Collect information and lab specimens for confirming the diagnosis
Identify the source of infection or cause of the outbreak
Describe how the disease is transmitted
Select appropriate response activities to control the outbreak.
Strengthen preventive activities to prevent future recurrence of the outbreak.
It is also an excellent opportunity for training of staff.
DEFINITION OF AN OUTBREAK:
An outbreak or epidemic is defined as the occurrence in a community of cases of an
illness clearly in excess of expected numbers. While an outbreak is usually limited to
a small focal area, an epidemic covers large geographic areas and has more than one
focal point.
There is yet another definition of an outbreak - occurrence of two or more
epidemiologically linked cases of a disease of outbreak potential (e.g. measles,
cholera, dengue, JE, AFP or plague).
DETECTING AN OUTBREAK:
There are various ways in which outbreaks can be detected. Some of these are:
Review of routine data
The 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. Details of this are provided in the previous chapter. If the
cases are approaching the threshold level or has crossed it, then an outbreak should
be suspected. Remember to review the lab data also.
One another method is to be alert for any unusual events that maybe reflected in the
routine data. Some examples are given below in Box XXX
WHO
Page79
6/17/2002
Box XXX - 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, Plague, dengue or JE
•
Acute febrile illness of unknown aetiology
•
Occurrence of two or more epidemiologically linked cases of
meningitis, measles
•
Unusual isolate
•
Shifting in age distribution of cases
•
High vector density
•
Natural disasters
Rumour register
The rumour register (sample in Annex XXX) is to be maintained in each public health
institution. Source of information from the community should be verified to identify
outbreaks. It is an important source of information and should not be neglected. On
the other hand, key informants in the community should be assiduously cultivated,
so they become the eyes and ears of the health services in the community.
Media
The media is an effective source of information on any unusual health event in the
community. This important source is unfortunately neglected and ignored by the
health services. It may help to tap this source.
WHO RESPONDS TO AN OUTBREAK
At the PHC and CHC level, the MO of the concerned institution will be the nodal
officer who will respond to an outbreak. At the district, the Corporation, the State
level and the Central level special Rapid Response Teams need to be formed whose
prime responsibility is to investigate outbreaks.
The Rapid Response Teams (RRT):
The RRT is a multi faceted team that looks into the various aspects of an outbreak. IA
suggested composition of this team is
1. The Epidemiologist - the team leader. Usually with public health training and
experience. In districts, this should be a programme manager with public
WHO
PageSO
6/17/2002
health experience. It should not be the District Surveillance officer as the DSO
should be overall in charge and not limited to a specific function.
2. The Clinician - either a physician or a paediatrician who is able to make a
clinical diagnosis from the cases. At the district level, this could be the
clinician from the District hospital or a Medical college.
3. The Microbiologist - to collect the specimens and to transport it appropriately.
Many districts may not have a microbiologist and so a Lab technician may be
substituted. Where necessary, the State team should also include an
entomologist in the team.
4. Two Health Assistant - his role is to assist the team in the community, do
surveys, make community contacts and mobilise the community when
necessary. He would also be responsible for organising the logistics.
It is to be noted that the RRT is not a permanent team who are 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. Ideally many
staff in each category should be nominated as a RRT member and at the time of an
outbreak, the available people should be called to form a truly Rapid response team.
The members of this team will be constituted from within the public health sector,
but if there are motivated personnel in the private sector or a nearby Medical college,
then the District Health Officer may utilise their services.
The main role of the RRT will be to investigate and confirm outbreaks. They should
work in close coordination with the local health staff in the event of an outbreak.
While they will help and support the local staff in the management and contol of the
outbreak, the prime responsibility for implementing control measures rests with the
local health staff (with additional support from the district health authorities).
The RRT will need some resources to be effective. At the least, they will need
•
Training in investigating an outbreak and instituting preliminary control
measures
•
A dedicated and functioning vehicle so that they are able to visit the site at
short notice. Fuel and driver should be also available.
•
Drugs so that they can start the preliminary treatment
•
Diagnostic reagents and kits for doing preliminary diagnosis
•
Reagents to transport the samples
•
Effective communication channels between the RRT and the district health
authorities.
The names, addresses and telephone numbers of the RRT members should be
available with the District surveillance officer at all times, so that they can be
WHO
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6/17/2002
activated as soon as possible. Members who have been transferred etc should be
replaced with competent people as soon as possible.
Preparatory action before an outbreak
•
Formation of the RRT
•
Training for the RRT
•
Regular review of the data
•
Identifying 'outbreak seasons'
•
Identifying 'outbreak regions'
•
Ensuring that these regions have the necessary drugs and materials
(including transport media) prior to the 'outbreak season'
•
Identifying and strengthening the appropriate labs
•
Designating vehicles for outbreak investigation and ensuring that it is in
working condition
•
Ensuring that communication channels like telephones are in working
condition.
INVESTIGATING AN OUTBREAK
Remember that an outbreak is a sudden and unexpected
event usually. There is a need to act quickly. So a
SYSTEMATIC APPROACH needs to be adopted.
When the DSO suspects an outbreak, he/she should initiate the following steps
immediately.
Step 1 - Verification of the outbreak
The preliminary step of the outbreak investigation would be to verify the outbreak.
Much time may be wasted due to a false alarm. Even if the outbreak is suspected
from the routine surveillance data, it must be verified (lest it may be a data entry
error). The fastest way to verify is to contact the MO nearest to the location of the
outbreak and request him/her for confirmation. This may be done telephonically or
through a special messenger. If there is evidence of an outbreak, then next step is
initiated.
WHO
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6/17/2002
Step 2 - Sending the RRT
The RRT members should be immediately contacted and a RRT formed with those
readily available. As stated above, it should have the minimum 4 categories of
professionals.
Resources (vehicles, drugs, reagents and forms) should be made available to the RRT
and they should proceed to the location. At the location the RRT members alongwith
the local health staff should initiate a Medical / Epidemiological / Laboratory
investigation simultaneously.
•
Medical investigation - The physician / paediatrician will clinically examine the
available cases (in the hospital or the community) and make a clinical diagnosis.
The history will include questions that will identify the possible source, routes of
transmission and contacts. He will also review the case management (as per the
recommended protocol) and recommend suitable amendments to the therapy if
required.
•
Laboratory investigation - The microbiologist will perform the appropriate lab
investigations. S/He will advise on what samples are required, mode of collection
and method of transportation and also to which lab it has to be sent. S/He will be
responsible for the lab confirmation of the outbreak. If the outbreak warrants
entomological investigation, this will also be carried out by the microbiologist.
It is not necessary to collect specimens from ALL cases;
just enough to confirm the diagnosis.
•
Epidemiological investigation - The epidemiologist will carry out a detailed
epidemiological investigation that will look into the epidemiological and
environmental aspects of the outbreak. The basic aim of the epidemiological
investigation is to identify the source of the problem and the routes of
transmission. For this he may ask for further tests like water analysis,
entomological survey, etc. He will also recommend prevention and control
measures - like provision of safe water supply, reduction in vector density,
immunization against further spread of measles, etc. to be implemented by the
MO of the peripheral health institution. The detailed steps in the epidemiological
investigation are given in Annex XXX:
•
Formulation of hypothesis: The RRT will 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:
•
•
•
WHO
What was the causal agent
What was the source of infection
What was the transmission pattern
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•
Specific response measures: Based on the above hypothesis, the RRT will
recommend suitable control measures to be immediately implemented by the
local PHC staff to curtail the epidemic. If the team feels that the PHC staff need
any support, then they will request the District to provide the necessary help.
Similarly
Call the State or Centre if:
•
the outbreak is unusual, or
•
the CFR is high, or
if the aetiology cannot be determined
•
'
•
............................................. ............
.
"
■
-
■
"
:
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 then the Hypothesis
would have to be reviewed after further analysis. In some cases where the cause
cannot be easily identified 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 not. See Box XXX
Box XXX: Investigate or control?
SOURCE / TRANSMISSION
c
£
o
c
O
o
u
O
>—<
H
W
£o
c
c
Known
Unknown
Control +++
Investigate +
Control +
Investigate +++
Control +++
Investigate +++
Control +
Investigate +++
ci
•
Interim report: The RRT should file an interim report, giving details of the
investigation and the diagnosis and also the control measures initiated. A
format is given in Annex XXX.
•
Follow-up Visits: Once the outbreak is coming under control, the RRT can
leave but should make follow up visits to ensure that the control measures are
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being implemented adequately. Also these follow up visits help to identify
any new information that may have been missed in the first visit.
Step 3: Monitoring the situation
The DSO / MHO 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 State. The main points to monitor are:
o
o
o
o
o
o
The trends in the cases and deaths.
The containment measures that are being implemented
Drugs / vaccine stock
Logistic issues - communications, vehicles.
Community involvement
Media response
This should continue till the outbreak is officially declared to be over.
Step 4: Declaring the outbreak to be over
The DSO / MHO 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 report
The DSO / MHO should receive the final report from the PHC MO 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 need to be rectified.
RESPONSE TO AN OUTBREAK
Even as the outbreak is detected, and is being investigated, control measures need to
be instituted. These may be divided into
1. General measures - till the specific source and route of transmission is
identified. For example, if one is suspecting a 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
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•
Identification and nullification of the source of the outbreak
•
Minimising transmission and so further exposure as soon as possible
•
Effective case management
General measures:
•
Logistic support to the field teams: This would start immediately when the
outbreak is reported without waiting for verification, etc. The emphasis should be
on saving lives. Some of the resources that would be necessary are
> Human resources - Additional MO's, lab technicians and nursing staff
(depending on the number of cases/deaths reported) may be sent from the
block/ district hospital to strengthen in-patient treatment facilities in the
nearest health facility, like the PHC. They will assist the MO health facility in
providing emergency health care to the patients. Assistance from local
practitioners/ specialists should also be sought for better on the spot
management of cases. If situation demands 'camp hospitals' should be
established in school buildings or similar structures.
> Drugs - In the event of an outbreak, there should be an uninterrupted flow of
medicines to the area. Emergency medicine stocks should be mobilised and if
necessary medicines should be relocated from unaffected regions for the use
of the affected region.
> Equipment and supplies - this is also important and the district health
manager should ensure that this takes place.
Vehicles and mobility - this is of utmost importance as the teams need to
move as fast as possible to the affected areas.
> 24-hour Communication channels to be established between the District and
the team leader at the outbreak location.
•
IEC to sensitise the community about the problem, give them the correct
messages and enrol their help in containing the outbreak.
Health Education: Health education and public awareness and co-operation are
important to control an outbreak. Simple key messages for the selected diseases
must be made available in the local language and these must be displayed
whenever an epidemic occurs or threat persists. Recognition of early features of
the disease by the community members and the importance of early treatment for
effective management needs to be emphasised. Vigorous IEC activities diffuse the
fear and confusion, if any in the community. Household contacts, particularly
those sleeping in the same room as the patient, should be warned about the need
to obtain immediate medical attention at the first sign of symptoms. Few sample
health education messages are shown in annexure XXX
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•
Handling of the media - this is an important task and needs the appointment of a
special officer whose main responsibility is to update the press on a daily basis.
This will reduce the stress for the district managers and will go a long way in
communicating the right message to the community.
•
If one is suspecting a water borne outbreak - then one has to ensure
> Access to safe drinking water: Ideally it would be best to communicate to
the people not to use any of the local sources for drinking purposes and to
supply safe water in sachets or through water tankers for the duration of
the epidemic. All wells in the area should be cleaned by frequent emptying
out of water by portable pump sets and then chlorinated with fresh
bleaching powder.
> Sanitary disposal of human waste: This is a major source for water
contamination and a major cause for outbreaks. Sanitary disposal of faeces
and other human waste during an outbreak is a major task and must be
well planned out.
> Frequent hand washing.
> Adopting safe practices in food handling.
•
If one is suspecting a vector borne outbreak, then one has to ensure
> Vector control: Integrated vector control i.e. use of environmental methods
(draining of water collections/ stagnation, filling, etc), biological (use of
larvivorous fish. Bacillus thuringensis, etc) and chemical (larvicidal abate/ baytex, anti-adult-space sprays, fogging only if absolutely essential,
and indoor residual spray with appropriate chemicals) should be
implemented on priority under guidance by the entomologist (if available).
> Personal protective measures: Prevention of exposure to mosquito bites by
using repellents (including neem oil) and use of mosquito nets at night
(plain or impregnated) would significantly reduce risk of infection during
an outbreak.
•
If one is suspecting an outbreak due to VPD, then one has to ensure
> Adequate supply of vaccines, syringes and needles
> Adequate staff who are able to administer the vaccines.
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Specific measures:
This depends on the causative agent, the source of the agent, the method of
transmission, the host response, the local conditions including the environment, the
effectiveness of the health services etc. A framework for specific intervention is given
in Annex XXX and each individual disease is tackled in Chapter XXX.
What is important is to nullify the source as soon as possible, stop (or minimise)
transmission and effectively manage the existing cases.
To summarise, general measures should instituted immediately and specific
measures on confirmation. The DSO / MHO should also make a decision as soon as
possible whether they need the support of others e.g. the nearby medical colleges, the
State or the Centre.
REPORTS
It is important for the concerned officials to make appropriate and timely reports to
higher authorities. This has two main uses
1. It keep the authorities at the higher level informed so that they can make the
appropriate decisions
2. It helps to review the outbreak and response, identify system failures and take
corrective measures so that similar events are not repeated.
Thus reports are an important learning tool and should not be seen as a mindless
chore. But for this to happen, the authorities at the appropriate level should read the
reports and take the necessary action.
Some of the reports recommended are:
Preliminary report by nodal MO:
The nodal MO of the peripheral health facility who first reports the outbreak should
submit a preliminary report to the next level. 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 patients,
likely suspected source, immediate control measures implemented, etc. A sample
report form from Maharashtra is shown in Annex XXX
Daily situation updates:
During the period of the outbreak the nodal MO should continue to give daily
situation updates of the outbreak to the next level. This should continue even when
the EIT has started its investigation and should include the list of new cases, lab
results received, any new findings, any containment measures taken etc. This daily
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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 - thereby sparing the MO unnecessary work.
Interim report by RRT:
The RRT will 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 patients, likely suspected source, immediate control measures
implemented, etc. The report will include reports by the physician and
microbiologist, and entomologist (where applicable). The 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 outside help is necessary.
Final report:
Within one week after the outbreak has ceased (double the incubation period of the
disease without a single case) a final outbreak investigation report must be submitted
by the local health authorities. 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
trends, areas affected and direction of spread of the epidemic. It should have
complete details of lab results including regional 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 the lower levels and also
other districts. Publication in a journal will ensure wider circulation of the lessons
learnt.
CONCLUSION
Surveillance has no meaning if there is no action taken. So the response mechanism is
necessary to ensure an effective surveillance system. Response has two objectives,
one is to contain the outbreak, while the other is identify problems with the health
systems so that repetitions of the outbreaks do not occur.
There are certain principles of outbreak response that is common to most outbreaks
and if applied will be effective in most situations.
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Box XXX gives the sequence of events if there is a successful investigation of and
response to an outbreak.
Response
9
8
C
a
s
e
s
1st
case
cases
7
6
5
I
4
I
3
2
*
DYS
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Annexure XXX
Rumour Register
Record verbal or written information from lay reporters (community representatives,
Anganwadi workers, teachers) about suspected outbreaks, rumours, or reports of
unexplained events.
c
.o
■4-
a
o .y
5£-g
WHO
Suspected
Disease
(signs and
symptoms if
diagnosis is
not
available)
Location
No. of
cases
Page80
Date
No:
of
of 1st deaths
case
Treatment
centres
Comments
6/17/2002
Annexure XXX
LINE LISTING OF CASES
Date of
onset of
illness
N
o
JZ)
1/
£
z
x
<
CD
1
1
u- c
Cfi
SYMPTOMS &
SIGNS
2
4
1
3
Comments
tu
5
-5
<
sU 75
£ £
Si S
h Si
■c
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s
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o
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□H
I—I
-H
u
X
Key to the form
No: serial number
Name: of all the suspected cases
Age: if there are small children involved, then better to record the age in months for ALL
Father's name: if identification is a problem through name only
Address: as detailed as possible so that later there is no problem while mapping
Date of onset of symptoms: as accurate as possible as this gives an idea of the incubation period.
Symptoms and signs: list the common symptoms and signs in each column. It should be filled as yes and no
Treatment received: the details as well as the place at which it was received. Details include the medicines received
Lab reports: the details as and when they are available. Till then, the samples taken should be filled into this column
Outcome: whether the person is alive and well or whether the person is dead or whether the person is still sick
Exposure to risk factors: Initially this may not be clear, but as risk factors are identified, exposure to them needs to be checked.
This may necessitate going back to the initial cases and checking.
Comments: any comments related to the outbreak
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Annexure XXX
SAMPLE MESSAGES FOR HEALTH EDUCATION
Message:
ARE YOU PROTECTED FROM DYSENTERY (blood diarrhoea)?
Washing you hands protects yourself and other from disease.
Always wash:
• After defecation
• After cleaning a child who has defecated
• After disposing of a child's stool
• Before and after eating
• Before preparing of handling food
Message:
ARE YOU READY FOR HAND WASHING?
Do you have:
• Clean water
• Soap (or if you do not have soap, use ash or earth to scrub your hand)
• Clean cloth for drying
Message:
DO YOU PREPARE FOOD SAFELY?
Cooking kills germs:
• Thoroughly cook all meats, fish and vegetables
• Eat cooked meats, fish and vegetables while they are hot
Washing protects from disease:
• Wash you hands before preparing or serving food
• Wash your dishes and utensils with soap and water
• Wash your cutting board especially well with soap
Peeling protects from disease:
• Only eat fruits that have been freshly peeled (such as bananas and oranges)
KEEP IT CLEAN: COOK IT, PEEL IT, OR LEAVE IT.
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17. Stock position
Sr. No.
Name of the medicine
1
Furazolidine
2.
Tetracycline
3.
O.R.S. packets
4.
Ringer's lactate
5
I.V. Normal saline
6
IV sets
7
Bleaching Powder
8
Halogen tablets
9
Tab. Co-trimoxazole
Stock
18. Information of control measures :
Action taken
Sr. No.
Control Measures
1
Place of the treatment
2
Names/s of the attending staff
3
If isolation ward is opened, please
mention date of opening and place where
opened
4
Date of starting active surveillance
5
Name/s and designation/s of the staff
involved in the active surveillance
6
Date-wise information of the patients
detected in Active surveillance along
with population surveyed
7
Date-wise water sample collection after
beginning of the outbreak
Signing Authority
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Age - sex distribution of the cases and deaths.
_____ Female
______ Male
Age
Death
Attacks
Group
Death
Attacks
Total______
Attacks
Deaths
0 to 1
2 to 5
6 to 14
Above 15
Yrs.
Total
Dates of visits to the affected town in the previous month before the outbreak
M.O.
Health Assistant
A.N.M.
M.P.W.
(Male)
Female
Male
Information of any outbreak reported within last one year from the same town /
village
Deaths
Cause of
Duration
Attacks
Type of
outbreak
outbreak
Information of water sources in the affected town / village
In the affected
Type of water supply
"sT
area
No.
WHO
1.
Water Supply scheme
2.
Public Wells
3.
Private Wells
4.
Bore-wells
5.
Lakes
Page86
In the remaining
part of the town /
village
6/17/2002
6.
River / springs
7.
Others
Information of water examination in the preceding month
Action taken
Sample tested
•
Name and designation of the person
responsible for water dis-infection
•
Water dis-infection is regularly done by
Grampanchayat
(Yes / No)
•
Water dis-infecttion was done for 8 days
prior to the date of onset of outbreak
(Yes / No)
Stock of Medicine_________
Name of the medicine
Sr.
No.
WHO
Samples
contaminated
Date
Stock available on
the first day of the
outbreak
1.
I.V. Ringer's lactate
2.
I.V. Normal saline
3.
Tab. Furazolidine
4.
Cap. Tetracyline
5.
Cap. Ampicillin
6.
Tab. Paracetamol
7.
Tab. Co-trimoxazole
8.
O.R.S. Packets
9.
Bleaching Powder (Kg.)
10.
Liq. Chlorine
11.
C.B. Media
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District level
supply during the
outbreak
6/17/2002
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Formato.2
Detailedinformationoftheoutbreak(lnformationandVisits)
Nameofthe
placeinforming
theoutbreak
Whogavethe
informationand
how
Dateof
information
Medicalofficer
Datesofvisit
Districtlevel
officer
Statelevelofficer
PrimaryHealth
Center
DistrictHealth
Office
StateHealth
officer
Others
-Reason-
Causeoftheoutbreak(Detailinformationofthereasons
ofwatercontamination)
MeasurestakenforPortablewatersupply(Repairsto
leakages/valves.waterdis-infection.useoftankersfor
portablewatersupply)
Signature
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Formato.3
InformationofLaboratoryxamination
Date
WaterSamples
StoolSamples
Bloodsamples
Tested Contam
inated
Tested Contam
inated
Tested
OtherSamples
Contam
inated
Tested Contam
inated
Informationof
contaminatedstool
______ samples
NonTotal
Vibrio
Cholerae 0-1
Signature
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Formato.4
Spotmapoftheaffectedtown
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Formato.5
Informationofactivesearchforcasesandmanaqement
Isolation ward / Special ward /Treatment ward
Date-wisereportingof
cases
Date
Cases
Placeoftheward
Duration
InformationofthePatients
O.P.D.
Total
I.P.D.
Information of case distribution according to treatment center
Isolation
ward
P.H.C.
District
Hosp.
C.H.C.
T otalNo.ofcontacttreatment
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Private
Practitioner
Detailsofthetreatment
6/17/2002
No
treatment
Formate.6
Detaillnformationofthepatients
Sr.No.
Nameofthe
Patient
Age
Sex
Dateof
onsetof
illness
Signature
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Dateof
recovery
Dateof
Death
Placeofthe
treatment
Format No. 7
Report of Dealth Investigation
1.
Name of the diseased
2.
Age:
3.
Complete address
4.
Symptom
5.
Date of onset illness
6.
Treatment received from whom and where
7.
If admitted, and date and time of admission
8.
Date and time of onset of treatment
9.
Condition of the patient at the time of the
admission
Sex :
10.
Details of the treatment
11.
Date and time of death
12.
Place of death (Home / Hosp, etc.)
13.
Whether stool sample was taken ?
(If yes, result)
14.
Medical Officer's opinion
Signature
15.
District Health Officer's opinion
Signature
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Format No. 7
Detail Information on the patient
Sr.
No.
Nameof
thePatient
Age
Sex
Dateof
onsetof
illness
Dateof
recovery
Dateof
Death
Placeof
the
treatment
Signature
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DETAILS OF INVESTIGATION
•
Description of the existing cases in terms of person, place and time. That is - who
is affected (age, sex, occupation etc), where do the affected people stay and when
did they get affected.
•
Based on this a working case definition is developed e.g. During an outbreak
investigation in Bangladesh, the following case definition was made
“Anybody with fever and cough / vomiting / reduced consciousness
between the 15th of April and the 30th ofMay 2001"
Ideally a case definition initially must be sensitive enough to pick up as many
cases as possible that remotely resemble a true case. So initially there may be
many false positives. This can be later pruned to identify the true positives.
Initially the case definition will be of 'suspect' category, as the investigation
progresses, the case definition maybe further refined to probable and even
confirmed category.
•
Active search for all cases in the community using this case definition. The search
should include health institutions (private and public), laboratories as well as
active search in the community.
Active Case Search:
The team will perform a quick house-to-house search by enquiring from
the community and attempt to identify additional cases. They would
require to cover the entire village or at least the surrounding 300
households, if the village is too large. They will also make enquiries
from all the surrounding health facilities (medical shops, nursing
homes, practitioners of all systems of medicine, etc) institutions and
laboratories to identify cases that were missed. During the period of the
outbreak, all the cases of the disease under consideration occurring in
that area should be identified and listed. This may include visits or
telephone calls to the medical facilities or private practitioners that
might expect to admit or attend cases of the disease. Active surveillance
through peripheral health personnel from other government
departments, NGO's and key community representatives provides
additional information about cases that may not have been seen at govt,
health facilities. Valuable information can be obtained by contacting key
community representatives.
•
A line listing should be made of all the cases identified (annexure XXX). The list
basically contains information about the patient's identification, date of onset of
illness, important signs and symptoms, lab samples taken and its details, the
outcome of the illness and exposure to any relevant risk factors. In the event of a
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Vaccine preventable disease, immunisation status is important. It is the database
on which the epidemiological diagnosis is made.
•
Analysis of the line listing helps in describing the outbreak in further detail.
Usually one describes the outbreak in terms of person - place and time. This is
described in detail in Section 2 but mentioned briefly here.
Distribution by Person: Cases should be described in terms of age, sex, caste,
occupation, socio-economic status, migration, immunisation history, etc. It is
usually sufficient to group cases by age groups- 0-11 months,l-4 years, 5-14 years,
15-44 years and 45 years and above. Other groupings can also be done depending
on the disease and the age group involved. While preparing tables the population
characteristics should be grouped accordingly (e.g. age and sex). This would give
an idea of who are the high risk groups, whether it is the children, whether it is
women, whether it is people belonging to a particular community, whether it is
people who rear pigs etc. E.g. in an outbreak in Siliguri, one of the risk factors
discovered was a visit to a nearby nursing home.
Distribution by Time: The onset of illness of the cases should be graphed by
hours, days, weeks or months, as appropriate. This is commonly referred to as an
epidemic curve. The curve helps in identifying the index (first) case, in calculating
an approximate incubation period and may even suggest patterns or modes of
transmission. It also documents the trend of the epidemic and helps to monitor
the effectiveness of the containment measures. While analysing, also look into the
time lag at each level, between the date of onset and the date of detection, the
declaration of an outbreak, the initiation of response mechanism and the last case.
This will give an idea about the effectiveness of the surveillance and response
system.
Distribution by Place: A spot map of the area (even a rough sketch) should be
drawn to show where each case resides to indicate geographical distribution of
cases and to identify high-risk pockets (showing clustering in space). In some
situations serial spot maps by week or by month, may provide insight into the
pattern of spread of disease over time. It also helps to identify the source of the
infection.
Calculation of Attack rate and Case Fatality Ratio: these indicators give an idea of
the virulence of the agent, its spread and also is an indication of the effectiveness
of the control measures. In areas where the health services are effective, attack
rates are low and so is Case fatality.
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Attack rate = No: of new cases during that outbreak X1000
Total number of susceptibles to that disease
Case fatality ratio = No: of patients who died due to the disease X100
Total no: of patients suffering from that disease.
•
Make an epidemiological diagnosis based on the analysis. This diagnosis should
keep in mind the locale, the prevalence of the disease in the region, the natural
history of the disease and the conditions that exist. At the end, one should have
answers to the following questions:
Description of Environmental Conditions: The study of environmental
conditions and the dynamics of it's interaction with the population and
causative agents will help in the formulation of the hypothesis on genesis
of the epidemic, which will be the basis for control measures to be taken.
Data on rainfall, humidity, and temperature must be immediately
accessed from the meteorological department. Information about recent
floods, drought, earthquakes, cyclone also needs to be collected.
Information on sources of drinking water and environmental sanitation is
also vital.
Laboratory Investigations: Lab investigations are vital for confirming the
diagnosis of the cases. Results of lab investigations should be included in
the outbreak investigation. Results of some tests would be available
locally and should be included (water testing, microscopy, etc). Other
tests will have to be carried out at the district (either District Lab or
selected Private lab/ Microbiology department of Medical college).
Differentiation of strains would be done at the regional lab. Details are
covered in Section 4.
Entomological Investigations: Where an outbreak is suspected due to a
vector borne disease entomological investigations are vital. The
entomologist would look at all the likely water collections (natural and
artificial) for larvae and also carry out catching of adult mosquitoes for
identification of the species. Various mosquito indices will be calculated
to give an indication of the vector involved, vector density and vector
bionomics. High vector density is a warning signal for outbreaks and
vigorous control measures would be required to control the outbreak.
Vector surveillance should continue even after the epidemic has been
controlled.
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Box XXX: Principles in control and containment
Uninfected person
xposure
ment
Infected person
Death
Depending on the disease, the most effective specific measures are instituted.
No:l, 2 - Strengthen the host
The various steps under this heading are:
1. Immunisation to protect the susceptible from being infected, e.g. in measles, ring
immunisation protects the susceptibles and prevents further new cases from
developing.
2. Chemoprophylaxis is also a measure that is commonly used to protect the
vulnerable. In meningitis, rifampicin is used to protect the exposed from
developing disease.
These measures prevent the susceptible from being infected or diseased
WHO
Page99
6/17/2002
No: 3 - Prevention of mortality and disability.
The various steps under this are
1. Effective Treatment e.g. effective treatment of typhoid will prevent deaths
2. Rehabilitation e.g. early rehabilitation will minimise disability in polio
These measures prevent death and disability.
No: 4 and 5 - Control the source of pathogen
The various steps under this heading are
1. Early detection and treatment as in TB
2. Isolate or treat the infected person e.g. in measles or in typhoid
These measures reduce the possibility of further transmission
No: 6 and 7 - Interrupt transmission
The various steps under this are
1.
2.
3.
4.
Interrupt environmental transmission - e.g. replace the infected water source
Control vector transmission - e.g. vector control
Improve personal sanitation - e.g. hand washing by food handlers
Personal protection e.g. bed nets
This will also prevent the uninfected from being exposed.
WHO
6/17/2002
Page100
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SPECIMENCOLLECTIONANDTRANSPORTATION
Thissectioncovers
•
•
WHO
Teststhatshouldbeconductedatvariouslaboratories
Colleetion.PreservationandTransportationofspecimen
Page101
6/17/2002
INTRODUCTION
Confirming diagnosis of communicable diseases is an essential component of disease
surveillance. The lab results are used to accurately diagnose the patient so that
appropriate therapy can be given, as well as verify the cause of suspected outbreaks.
NETWORKING OF LABORATORIES
The peripheral labs are located at the point of first major contact of patients with the
healthcare services. These are available at primary health centres (upgraded) /
Community health centres. These labs are capable of only carrying out basic
microscopic diagnostic tests like blood slides for malaria parasite or AFB in sputum
and usually have a single lab technician.
The district labs are expected to undertake tests of public health as well as clinical
relevance. Tests for confirmation of epidemic prone diseases and also water quality
testing are carried out at these labs. The district lab should be able to perform the
tests listed in Box 4.1 for effective surveillance. If the tests mentioned in the box are
not available at the district laboratories then arrangements need to be made with the
nearest microbiology department of the medical colleges or private laboratories. In
the meantime the district lab should be upgraded so that the listed tests may be
performed. List of reference laboratories should be available at all health facilities so
that they are aware of how and where to send the required samples for lab
confirmation. Modalities of reimbursement of expenses incurred for carrying out
testing of samples received from the field needs to be worked out.
The regional labs are usually located at the state headquarters and are able to confirm
the diagnosis from the lower level labs as well as conduct sero-typing and strain
identification. Where possible, use of the medical and private sector labs should also
be used so that reference labs are available as close as possible to the outbreaks and
minimum time is lost in transportation.
It should be ensured that the labs at all levels provide results which are reliable,
sensitive, specific, rapid, easy to perform and cost effective.
The lab specimens should arrive in the lab in good condition. Specimens should be
collected safely, stored in appropriate media, and kept within a specific temperature
range. The reference chart (annexure 4.1) lists the recommended tests for the selected
diseases and contains information about:
•
•
•
•
•
WHO
The diagnostic test for confirming the disease
The specimen to be collected
When to collect the specimen
How to prepare, store and transport it
When to expect the results
Page102
6/17/2002
BOX 4.1: LABORATORY CONFIRMATION____________________
The district laboratory should be able to perform the following confirmatory
tests:
1. Bacteriological culture of stool
> Cholera (including sero-typing)
> Acute Diarrhoeal Diseases
> Dysentery
2. Confirmatory testing of blood slides for Malaria.
3. Estimation of serum bilirubin and Alanine amino-transferase (ALT) for
Acute Viral Hepatitis and further typing of types A to E.
4. Rapid diagnosis by detecting elevated serum antibody titres (IgG or IgM,
by ELISA or non -ELISA) in
Measles
Japanese Encephalitis
Dengue Fever
5. Water quality Testing
COLLECTION, STORAGE AND TRANSPORTATION OF SPECIMENS
For labs to be effective, the appropriate specimens must reach them safely and in
good condition. This implies that the correct sample should be collected and
transported to the correct lab. This matching of specimen and lab is very important,
else much time is wasted and sometimes even precious specimens have to be
discarded for want of correct handling.
In Keonjhar - Orissa, there were 5 children who died under
mysterious conditions in 2000. The MO of the local PHC finally
did an autopsy of the 5th child and sent the organs to the District
Hospital in too little formalin. This meant that chemical analysis of
the organs could not be done. Worse the District Hospital did not
know what to do with the samples and left it in a corner, leading
to many days delay. And finally this was important as the
provisional diagnosis by a special team from the State capital was
'Homicidal poisoning'. And by the time the organs were
discovered and sent to the Capital, they had undergone
putrefaction and could not be analysed.
WHO
Page103
^1^7/2002
Specimen collection:
Specimens obtained in the acute phase of the disease, preferably prior to
administration of anti-microbial drugs, are more likely to yield detectable
concentrations of antibody, antigen or infective pathogen. Before specimen collection
the procedure should be explained to the patient and relatives. Avoid contamination
and take sufficient quantity of material. Appropriate precautions for safety during
collection and processing of samples should be done so as to protect the collector.
Lab specimens required for selected diseases are given in annexure 4.1
For stool samples, the health worker should collect a specimen of stool. If this is not
readily available, then a rectal swab will suffice. The specimen is then placed in a
cold box and transported to the lab as soon as possible (using reverse cold chain as in
AFP surveillance).
Blood slides can be prepared by the health worker, and other blood samples can be
taken by the MO/Lab technician/health worker at the peripheral health facility.
Labelling and identification of specimens:
The lab form should be filled and accompany every sample collected. The collecting
person could give each patient a unique ID number. This No. should be a link
between the specimen the patient, the line list and the lab result and used as a
common reference.
Label specimen container /slide: Every specimen has to be properly labelled and
permanently affixed to the container/slide. It should contain the
•
•
•
•
Patient's name
Unique ID number
Specimen type, date, time and place of collection.
Name/initials of collector.
Storage of specimens: To preserve bacterial or viral viability in specimens for
microbiological culture or inoculation, they should be placed in appropriate media
and stored at recommended temperatures. These conditions must be preserved
through out transport to the laboratory and will vary according to transportation
time.
Transportation
The specimen needs to be transported to the nearest lab for processing and diagnosis
Each specimen has a separate technique as is given in Annex 4.1
The important principle to be remembered while transporting samples where
biological agents are the probable causative agent is to maintain the cold chain.
WHO
Page104
6/17/2002
Processing
??? Should one get into this here???
CONCLUSIONS
The lab component is important for confirmation of the diagnosis. This helps the
public health managers in taking the necessary corrective action with confidence.
It is not necessary to collect specimen from all cases, as it is not essential for the
outcome of outbreak investigations and control measures. Collection of samples is
only required to establish the diagnosis and hence after that is established only a few
samples a day could be collected for identifying the end of the epidemic. Avoid
placing a heavy load on the laboratory.
WHO
Page105
6/17/2002
Annexure 4.1
SPECIMENS FOR LAB CONFIRMATION FOR SELECTED DISEASES
Suspect disease
Diagnostic test
Specimen
Cholera
Isolate Vibrio
cholerae from stool
culture and
determine O1 and
0139 serotypes using
polyvalent antisera
for Vibrio cholerae.
Dysentery
Isolate shigella
dysenterae type 1
(SD1) from stool
culture to confirm
outbreak. If SD1 is
confirmed perform
Fresh stool specimen
or rectal swab.
Collect stool sample
from the first
suspected cholera
case. If more than one
suspected case collect
from 5-10 cases.
Collect stool from
patients fitting the
suspect definition
and
• Onset within last
5 days
• Before antibiotics
treatment has
started.
Specimens can be
collected after
rehydration.________
Stool or rectal swab
Collect sample from
5-10 patients of the
suspected case
having bloody
diarrhoea.
WHO
Page106
How to prepare,
Results
store & transport
Place specimen in a
Culture results
clean leak proof
usually take 2-4 days.
container and
Cary Blair medium is
transport to lab
stable for up to one
within 2 hours.
year and does not
If more than 2-hour
require refrigeration
delay is expected
if kept in a properly
sealed container.
then place in CaryBlair transport
medium. If Cary Blair
not available
transport under
refrigeration (4-8 C).
Collect stool in a dry
container (do not
contaminate with
urine) select portions
with blood and
mucus. Transport in
6/17/2002
Culture results
available 2-4 days.
SD1 isolates should
be characterised by
antibiotic sensitivity
tests.
Send specimen to
The District lab.
The District lab
antibiotic sensitivity
tests for appropriate
antibiotic.
Acute Diarrhoeal
Diseases (in cases
above 5 years of age)
Isolate causative
agent from stool
culture to confirm
outbreak.
Malaria
Presence of malarial
parasites in blood
films for suspected
cases
Dengue
fever/DHF/DSS
4 fold increase in IgM
and IgG antibodies
against dengue
WHO
Page107
•
Onset within last
4 days
• Before antibiotic
treatment started
Stool or rectal swab
Collect sample from
5-10 patients of the
suspected case
having diarrhoea.
• Onset within last
4 days
• Before antibiotic
treatment started
Blood
Blood smear from all
suspected cases
Whole blood or blood
clot, serum or plasma
Collect specimens
Cary-Blair medium
or under
refrigeration. .
Collect stool in a dry
container (do not
contaminate with
urine). Transport in
Cary-Blair medium
or under
refrigeration..
Culture results
available 2-4 days.
The District lab
Collect blood directly
onto clean and
labelled microscopy
slides and prepare
thick and thin
smears.
• Allow smears to
dry thoroughly
• Stain using the
appropriate stain
and technique
• Store stained and
dried slides at
room temperature
out of direct
sunlight.________
Refrigerate serum or
clot
Thick and thin smear
results can be
available within a
few hours.
Microscopic
examination of
malarial slides would
reveal the malarial
parasites
(trophozoites and /or
gametocytes stage)
The PHC / District
lab
Results are usually
available within one
day.
The District /
Medical College /
Reference lab.
6/17/2002
viruses in serum
Japanese
encephalitis
4 fold increase in IgM
and IgG antibodies
against JE viruses in
serum
Measles
Presence of IgM
antibodies to measles
virus in serum.
WHO
Page108
from 5-10 suspected
cases_______________
Whole blood or blood
clot, serum or plasma
Collect specimens
from 5-10 suspected
cases_______________
Serum
Collect blood samples
on 5 suspected
measles cases
Refrigerate serum or
clot
Results are usually
available within one
day.
The District /
Medical College /
Reference lab.
For children collect 1- The specimen should
5 ml of venous blood arrive at the lab
depending on size of within 3 days after
child. Collect into a
collection.
test tube or capillary
Results are usually
tube. Separate blood
available within one
cells from serum:
day.
• Let clot retract for Avoid shaking of
specimen before
30-60 minutes at
serum has been
room
collected. To prevent
temperature.
Centrifuge at 2000 bacterial overgrowth
use clean test tube
rpm for 10-20
minutes and pour (sterile tube not
required) and
off serum into a
transport in vaccine
clean glass tube.
carrier.
• If no centrifuge,
put sample in
refrigerator
overnight (4-6
hours) until clot
retracts. Pour off
serum next
morning.
Transport serum
The Reference lab
6/17/2002
Acute Hepatitis
WHO
s. bilirubin
IgM antibodies
against Hepatitis A E
Page109
Whole blood or blood
clot, serum or plasma
Collect specimens
from 5-10 suspected
cases
samples in a leak
proof container
preferably at 4 C.
Refrigerate serum or
clot
6/17/2002
Results are usually
available within one
day.
The District /
Medical College /
Reference lab.
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MONITORINGANDSUPERVISION
Thissectioncovers
•
•
WHO
Supervisionofasurveillancesystem
Monitoringsurveillanceactivitiesatalllevels
Pagel 11
6/17/2002
INTRODUCTION
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.
MONITORING
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. Indicators may also be
classified according to the periodicity of review, e.g. weekly, monthly and
yearly.
Weekly indicators
These indicators will be reviewed every week when the data is collaged and
reports generated. They reflect the effectiveness of data collection and
transmission. There are 2 main indicators:
•
•
Timeliness of reports
Completeness of reports
These are already dealt with in Section 2.
The above 2 indicators will apply for all the levels e.g. the PHC MO can monitor
whether all his Subcentres have reported (completeness) and on time (timeliness).
This same can be done at the CHC/Districl/State/National level.
Similarly one can do it for both routine/sentinel sites; public/private sectors and in
both the rural/urban settings.
These indicators help the programme manager to identify non-functional or
poorly functioning reporting units so that necessary action can be taken.
WHO
Pagel 12
6/17/2002
Monthly / Quarterly indicators
These indicators allow for mid term 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 specified period
Total no: of reporting units
•
Timeliness of report for the period XXX
No: of reporting units that have been on time during the specified period
Total no: of reporting units
•
Percentage of outbreaks that have been detected
No: of outbreaks detected by the surveillance system
Total no: of outbreaks during that period
Annual indicators
These indicators give an idea of the overall performance of the programme
and help the programme manager identify gaps. Many of the indicators are
similar to the monthly / quarterly ones but help by giving a long term
perspective.
•
•
•
•
Completeness of report for the year
Timeliness of report for the year
Percentage of outbreaks that have been detected
Percentage of newsletters published
Over and above this, some other performance indicators that may be used are:
Input indicators
Some of the useful input indicators that need to be monitored are
•
•
•
•
•
WHO
Percentage of staff at each level trained
Percentage of reporting units at each level with functioning computers
Percentage of reporting units using case definitions
Percentage of districts with functional EITs
Percentage of districts with functional labs
Pagel 13
6/17/2002
Outbreak response indicators
•
•
•
•
•
•
Percentage of outbreaks 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
Percentage of outbreaks that have a CFR within the accepted norms
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.
More examples of the indicators are given in 6.2,6.3 & 6.4
Performance indicators should be fed back to the local staff so that the quality
of surveillance in areas performing poorly could be improved.
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 work together to review progress, identify problems, decide
what has caused the problem and develop feasible solutions.
Pre-requisites for supervision
•
•
•
WHO
[ob Descriptions: For effective supervision each category of health staff
should have job descriptions (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 vehicle,
fuel, funds 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.
Pagel 14
6/17/2002
Steps in supervision
The following are the steps in supervision:
•
•
•
•
•
Supervisory plan: A supervisory plan should be prepared and at least
each reporting unit visited quarterly. Supervisory visits of the
reporting units are vital to rectify any problems like shortages of
reporting formats, etc. and hence mobility of the supervisor is
critical. This plan must be informed to the field staff so that they are
prepared for the visit.
Make a checklist: A checklist is a tool to help the supervisory team. A
sample of this is provided in Annex 6.1 & 6.5. This checklist helps
the team to review most of the important activities
Review the previous supervisory visit report: This is so that the
supervisory team is apprised about the situation in the field. It will
also make them review the follow up actions taken from the
previous visit. This will also help them review the performance by
the field unit.
Supervision visit: The supervisory team should then visit the field and
using tools like checklist, observation methodology, review of
records and Focus group discussions 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.
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.
Conclusion
Good supervision helps health staff to perform their best. During supervision
one must just observe and reinforce stipulated practices in surveillance. The
crux of supervisory visits should be on education, coordination, motivation,
facilitation and guidance with the overall objective of implementing
corrective action. Monitoring is also a vital component of any surveillance
programme and would determine the efficacy and effectiveness of the
surveillance mechanisms in place. The various indicators should be
continuously and vigorously monitored at different levels.
WHO
Pagel 15
6/17/2002
Annexure 6.1
Checklist for supervising surveillance and response activities at the health facility
Health facility:
Date of Supervisory visit:
Activity
Supervisory question
Identify suspected
cases
How often do you collect information from the community
about reports of suspected cases or deaths due to a selected
disease?_______________________________________________
Are diagnoses of cases of selected diseases recorded in the
clinical registers according to the standard case definitions?
Do health staff use a standard case definition to report the
suspected cases and outbreaks?
Register cases
Report
Analyse and
interpret
Answer
Comment
Yes
No
Yes
No
Do you record information about large No. of cases of a
selected disease on a case form or line list and report Yes
immediately?___________________________________________
Do you plot the No. of cases and deaths for each selected
disease on a graph? (check)
Yes
No
No
Do you plot the distribution of cases on a spot map?(check)
Investigate and
confirm reported
cases and
outbreaks
If an epidemic -prone disease was suspected, was it reported
immediately to the district office?
For the cases of selected diseases needing lab results ( seen
since the last visit) how many had lab results?
Are appropriate supplies available for collecting
specimens during an outbreak (check availability)
WHO
Pagel 17
lab
6/17/2002
Yes
No
Yes
No
No. of results obtained/
expected
Respond
Provide feedback
Evaluate and
improve the
system
Epidemic
preparedness
WHO
Yes
No
Are appropriate supplies available for responding to a
confirmed case or outbreak? (Check supplies for
recommended response.)
Yes
No
Who is the outbreak co-ordinator for this facility? Is he aware
of his responsibilities & role during outbreak?
Name
Designation
How often do you provide on-the- job training in outbreak
response to staff of this facility?___________________________
How often do you report information to the community?
Report it
Do you receive the quarterly surveillance bulletin? (check)
Were the last 3 routine weekly reports sent to the district
office, and whether on time?
Yes
No
Yes
No
What precautions do health staff (incl lab staff) take routinely
while handling infectious cases?
Minimum level of
standard precautions-
How do you estimate the amount of supplies required during
an outbreak?
How supplies are
estimated:---------
Pagel 18
6/17/2002
Annexure 6.2
Indicators for monitoring the quality of surveillance activities at district level (Performed by SSO)
(To evaluate the quality of surveillance functions listed in column 1 below, regularly monitor and observe the progress for the following
indicators listed in column 2. When comparing several health facilities at the same level of the health system, use proportion or rates.)
For this surveillance
function:____________
Maintain readiness for
epidemic response
Identify suspected cases
Investigate
and
reported outbreaks
confirm
Regularly monitor the number of districts that:
•
•
•
•
•
•
•
•
•
•
Report data
•
•
Analyse data
WHO
•
•
•
Have the District Surveillance Officers Effectively implemented the IDSP and are familiar with the
plan for outbreak response.
Have kept in reserve emergency stocks of drugs and supplies for expected outbreaks.
Have earmarked special funds from the district for outbreak response.
Have a team trained to conduct an outbreak investigation._______________________________________
Have been effectively co-ordinating surveillance activities.
Have the review of case registers, logs, rumour register, lab results, etc of reporting units and labs
been done on a regular basis._________________
Investigated all reported outbreaks during the last one year (list them).
Identified all the labs within the district that have the capacity to confirm suspected cases of the
selected diseases (how many actual cases confirmed).
Confirmed the selected diseases within a reasonable time.
Able to demonstrate safe handling, packaging, storing, and transport of specimens from the periphery
to the higher level lab._______________________________________________________________
Have all RU's in the district reliable supply of recommended formats at all times, over the last six
months.
Submitted all required reports to the next highest level, complete and on time, during the last 6
months._____________________________________________________________
Analysed outbreak data by time, place and person.
Performed trend analysis by health facility as well as at the district level.
Have the threshold levels for each selected disease and a defined response action for each level been
explained to all health staff and being followed.
Pagel 19
6/17/2002
Response
•
•
•
Provide feedback
•
Supervision
Training
Resource and personnel
WHO
Responded within 24 hours of confirming the case.
Met with community about their health problems at least once every 6 months
Kept the CFR within the acceptable limits during the recent outbreaks
Prepared and disseminated a written report of surveillance information at least quarterly during the
last year to the reporting units.
• Received from a higher level written report or bulletin containing information which the district
reported during the last year.
• Provided feedback to the community._______
• No. of health facilities that were visited by the DSO during the last 6 months and observations/
comments/ recommendations made._________________________________________________________
• No. of health personnel in the district that were trained in any surveillance activity during the last
year._____________________________________________________________________________________
No. of districts with:
• Transportation and logistic support (vehicle or POL/allowance).
• Supplies for carrying out data management (computers. Fax, statistical package, software, etc).
• IEC materials (including VCR &TV).
• Human resources (trained epidemiologist, microbiologist, lab techs, etc available in the district).
Pagel 20
6/17/2002
Annexure 6.3
District level indicators for monitoring quality of surveillance and response at the health facility (Performed by the DSO).
Function of surveillance
Indicator: Regularly monitor the No. of reporting units that;
Identify and record suspected
cases
•
Have and maintain a clinical register as per the case definitions.
•
Correctly record information in the register.
Confirm suspected cases
•
Have access to a functioning lab that can reliably process specimens for confirming diagnosis of
selected diseases.
•
Safely collect and properly package specimens for transport to higher level lab.
•
Submit specimens of selected diseases for confirmation in a timely way.
•
Keep up-to-date trends for each selected disease.
•
Have been able to detect an outbreak.
Review and analyse data
Are familiar with the action threshold for each selected disease.
Report data
Response to outbreak
WHO
•
Report number/case-based information for selected diseases.
•
Have a reliable supply of reporting formats.
•
Accurately record case register data on summary report forms.
•
Submitted reports on time during last 3 months.
•
Submitted the required No. of reports during last 3 months.
•
Used local information to conduct community disease prevention and control activity during the last
12 months.
•
Implemented prevention and control measures based on local data for at least one outbreak/ disease.
Page121
6/17/2002
Provide feedback
•
Received a bulletin or report from district about data which the health facility reported to higher level
during the year.
•
Met with community members to discuss investigation results during the last 6 months.
•
Use standard case management protocols for selected diseases.
•
Use a minimum level of standard precautions with all infectious cases.
•
Maintains an emergency stock of drugs for outbreaks.
Supervision
•
Used a supervision checklist for surveillance during at least one supervisory visit in last 6 months.
Training
•
Conducted training for health staff on any aspects of surveillance.
Resources
•
Have reliable transport with fuel.
•
Have access to reliable communications.
•
Have supplies for carrying out outbreak investigations.
•
Have funds for outbreak response.
Maintain readiness for epidemic
response
WHO
Pagel 22
6/17/2002
Annexure 6.4
Process, Performance & Impact Indicators
for monitoring of IDSP at the state level
Process indicators
1. No. of block level institutions strengthened with electronic connectivity every year.
2. No. of District level institutions strengthened with electronic connectivity every year.
3. No. of regional medical colleges strengthened with electronic connectivity every year.
4. Development of training material for PHC/Block/district./state/private sector.
5. No. of labs strengthened PHC/block/district/state.
6. No. of institutions provided with printed formats and registers at sub centre/PHC/Block/district/state/ private sector.
7. IEC material development.
8. No. of PHC's connected with telephone.
9. No. of districts with EIT activity.
10. No. of municipal corporations strengthened.
Performance indicators
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
WHO
No. of village link workers reporting weekly/monthly surveillance data.
No. of sub centres /PHC/Blocks reporting in printed format.
No. of blocks/districts/regional medical colleges submitting monthly computerised analysis.
No. of epidemics reported within 24 hours.
No. of epidemics reported by village link workers/health personnel/private sector/community.
No. of epidemics investigated by district EIT every year.
No. of epidemics investigated by state EIT every year.
No. of selected diseases reported.
No. of diseases confirmed by lab investigation.
No. of PHC's/blocks/regions identifying early warning signals.
Page123
6/17/2002
11.
12.
13.
14.
No. of meetings of technical/administrative committees organised every year state/district/corporation/blocks.
No. of bulletins published every year.
No. of circulars on surveillance issued by state /district/block/PHC every year.
No. of field surveys conducted in a year.
Impact indicators
1. Morbidity and mortality of selected communicable diseases.
2. Morbidity and mortality of other communicable diseases.
3. Morbidity and mortality of non-communicable diseases.
4. Percent population affected by high risk factors.
5. No. of epidemics suspected with the help of weekly/monthly monitoring.
6. Time lag between reporting system sub centre/PHC /block/district/state.
7. Yearly epidemic analysis block/district/state.
8. Time lag between information and action during epidemic sub centre/PHC/block/district/state.
9. Completeness of reporting weekly/ monthly/epidemic.
10. Community awareness about early warning signals, selected diseases and containment measures.
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Annexure 6.5
Key Areas to be monitored at various levels
State
District
Hospital
PHC
SC
Legislation
Mechanism to implement it
Focal point for Surveillance
Is there a budget for
surveillance
Operational manuals
Response manuals
Case management manuals
Case definitions
Is the case definitions being
used
Register for case detection
Training of the staff
%age of MOs trained
%age of PMWs trained
%age of lab technicians
trained
Lab facilities available
Tests done at the Labs
Capacity to collect lab
samples
Lab guidelines for
collection and
transportation
Transport media available
Reporting forms
WHO
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%age of weeks that forms
were not available
Use of software for data
entry
Freq of reporting
Mechanism of reporting
Percentage of reports
received in the past 3
months
Percentage of reports
received on time in the past
3 months
Is the data analysed by
person
Is the data analysed by
time
Is there trend analysis
Is there an action threshold
defined for each disease
Are there denominators
Are denominators used
Use of software for data
analysis
%age of suspected
outbreaks investigated in
the past one year
Avg time lag between
notification and response.
Of those investigated, %age
where the risk factor was
identified
Of those investigated, %age
where the info was used to
improve the system.
Is there a plan for epidemic
preparedness & response
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Availability of a EIT
Vehicle for EIT
Availability of drugs and
supplies at all times of the
year
Availability of a budget
line for epidemic response
Availability of an Epidemic
cell
Any evaluation of the
response
Acceptable CFRs
Feedback
Newsletter
No: of Visits of supervisors
in the past 6 months
Availability of a computer
Availability of internet
facilities
Availability of fax
Availability of phone line
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♦
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FEEDBACK
This section covers
• Necessity for feedback
• Types of feedback
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INTRODUCTION
It is essential that feedback loops be in-built in the system. Invariably data
that originates from the peripheral health facility is compiled and forwarded
to the next higher level without any feedback being given to the originator.
This results in demotivation of the reporting unit and unreliability,
sluggishness/ falsification of data (non-reporting of suspect cases) as they
would not know if the information they provided was utilised or not.
Feedback helps to inform the peripheral staff the value of the work that they
have performed.
USES OF FEEDBACK
If regular feedback in the form of accuracy of formats, corrections if any,
interpretation (if different) and also feedback about similar outbreaks from
other reporting units, is received it would serve to keep the doctors in the
periphery alert to the outbreak potential of particular diseases. Simple
appreciation of the timeliness of reporting would energise the reporting unit
to continue to report suspected cases. It should be emphasised that feedback
is to reinforce health staff efforts to continue to actively participate in the
surveillance system.
•
•
•
•
•
Uses of Feedback______ ___________
Keeps channels 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.
Keeps 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
levels. It also gives them an idea of their performance in comparison to other
colleagues.
Gives them an idea of their performance - Feedback helps the staff at the
lower level identify their strengths and weaknesses.
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.
TYPES OF FEEDBACK
Feedback may be given both formally and / or informally.
The exact modality of giving formal feedback to the reporting units may be
•
•
•
WHO
Newsletters
Monthly review meetings
Reports
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•
Informal feedback
Newsletter:
This may be through regular epidemiological bulletins with tables and graphs
showing trends and progress towards targets and reports on the investigation
and control of outbreaks on the lines of the NPSP newsletter or the Orissa
monthly newsletter. The bulletins usually contain:
•
•
Summary tables showing the number of reported cases and deaths to
date for each of 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 definitions, disease profiles, management
protocol of diseases, latest diagnostic aids available, new strategies, etc.
Monthly review meetings
At the District / Block Monthly meetings, the previous months' data is shared
using information sheets, presentations and handouts. This also helps in peer
review as others in the district are able to share their opinion. Care must
however be taken to concentrate on the positive and not be too harsh on the
negative aspects. Else this tool may be a demotivator.
Reports
Outbreak investigation reports (summary report) must be made available to
all health personnel in the periphery so that they can remain alert to similar
outbreaks from their areas also. Such reports are excellent tools for feedback
and learning.
Informal feedback
This is an useful form especially when one has to point out the mistakes. This
may be in form of oral feedback that points out what should have been done
and how not to repeat the same mistake again.
CONCLUSIONS
Feedback is an important and often neglected aspect of surveillance and
needs to be built up.
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DISEASE-WISE SUMMARIES
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■
ACUTEDIARRHOEALDISEASES
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CHOLERA
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I
TYPHOID
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ACUTEHEPATITIS
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MEASLES
CASE DEFINITION
Clinical case description:
Any person with:
• Fever and
• Maculopapular rash, and
• Cough, coryza or conjunctivitis
Laboratory criteria for diagnosis:
• At least a fourfold increase in antibody titre or
• Isolation of measles virus or
• Presence of measles specific IgM antibodies.
Case classification
Suspect case: A case that meets the clinical case definition.
Probable case: Not applicable
Confirmed case1: A case that meets the clinical case definition and
that is laboratory-confirmed or linked Epidemiologically to a labconfirmed case.
Epidemiology (see Fig 1)
1-Host: Common in children between 9 months to 3 years of age. Newborns
and young infants are protected by maternal antibody transferred through
placenta. Male = Female. Humans are the only known host.
2-Environment: It is a highly contagious disease and often responsible for
epidemics, especially in conditions of overcrowding and poverty, where large
numbers of non-immunized children are in close contact. In temperate and
tropical climates, measles occurs primarily in the late winter and early spring
(November-April).
3-Agent: Paramyxovirus (Morbillivirus)
4-Mode of transmission: human-to-human via airborne droplet spread, direct
contact with nasal or throat secretions, etc.
5-Incubation period: The incubation period is usually about 10 days and
varies from 7 to 18 days. Thus during an epidemic/outbreak immunization of
susceptibles can avert more cases.
1Onlyforoutbreakconfirmationandduringeliminationphase.
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6-Period of infectivity: An infected person can infect others from 4 days prior
to onset of rash to 5 days after appearance of rash. The vaccine virus has not
been shown to be communicable.
7-Infectivity rate: The agent is highly infectious and most susceptibles
exposed to the agent acquire the disease.
8-Signs and symptoms: The first sign of infection is high fever lasting 1-7
days. During this period there may be running nose, cough, red and watery
eyes and also Koplik's spots. After a few days (usually 4th day) a slightly
raised erythematous rash develops
Fig 1 - Epidemiology of measles
Uninfected
(1), (2)
(B)
Agent(3)
f
(A)
(4)
Infected (7)
(5)
Diseased(8)
No disease
(6)
w7/
Death
Recovery
Complications
(9)
(10)
(11)
which spreads over the face and upper neck down to the body, then to the
hands and feet over a period of about three days. It lasts for 5-6 days and
WHO
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fades successively from the same areas. There may also be loss of appetite and
loose stools especially in infants.
9-Case fatality ratio: Deaths are common in developing countries ranging
from 5-30% depending on the nutrition status of the patient and the
effectiveness of the health services.
10-Recovery is usually associated with lifelong immunity.
11-Complications: In developing countries, complication rates can be as high
as 75%. Complications occur particularly in children under 5 years and can be
diarrhoea, pneumonia, malnutrition and Vit. A deficiency, otitis media,
encephalitis (including sub-acute sclerosing pan-encephalitis, SSPE) and
deaths.
Differential Diagnosis: Prickly heat, allergic rash, chickenpox, any other
dermatitis.
Case management:
•
•
•
•
•
•
•
There is no specific anti-viral drug against measles virus.
Patients are managed symptomatically with supportive measures only,
e.g treatment of fever.
Vit. A 2 lakh IU for >lyear olds and 1 lakh IU for infants <1 year,
reduces severity of the disease and prevents further loss of Vit. A.
Feeding of children should continue.
Monitor for complications. Educate the mother about the dangers of
complications and the early warning signs.
Immunise close contacts if they are identified within 72 hours of
exposure.
Treatment of complications should be carried out vigorously.
Prevention: Immunisation with a live attenuated vaccine. 0.5 ml sc for
children above 9 months of age.
Surveillance goal (see Fig 2):
•
Detect outbreaks of fever with rash promptly.
Thresholds
■ A single case of measles in a tribal or remote area
■ Clustering of cases
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Response to an outbreak.
•
•
•
Report suspected case to the next level. Also verify the case diagnosis by a
clinician.
Collect blood samples from five cases for confirming the outbreak. Send
the material to Reference lab (Specific for each state).
Do an epidemiological investigation
o
o
o
o
o
•
Active search for cases of measles - identify all cases by age, sex
and immunization status. Also date of onset of illness and
complications if any. Get the support of the community for this
search.
Enumerate all the children in the area, including their age, sex and
immunization status
Draw the epidemic curve and understand the dynamics of the
outbreak, including the index case, the transmission and direction
of spread and the susceptible population.
Analyse the data by time, place and person.
Calculate the attack rate and the case fatality ratio.
Simultaneously institute control mechanism
o
o
o
o
o
o
o
WHO
(A) Isolation is impractical in the community at large; children with
measles should be kept out of school for at least 4 days after
appearance of the rash. Restriction of the affected children from
moving out of the house till free of the illness should also be
emphasized. Basically do not allow the diseased children to come in
contact with susceptible children.
(B) Immunize all children who do not have the disease. Ring
immunization, starting from outer circle and moving inner.
Immunization of contacts: Live-virus vaccine, if given within 72
hours of exposure, may provide protection. Normally children
between 6 months to 5 years is targeted, but if there is evidence that
older children are affected, then one can increase the upper age
limit to 15 years.
(C) Supportive treatment to all patients - including paracetamol.
(C) Give Vitamin A supplement to ALL children, whether diseased
or not.
(C) Treat any child who has complications
Educate the community about "dos and don'ts" - example is given
below.
Keep the higher authorities informed through daily updates and
then a final report at the end of the outbreak (20 days after last case)
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Post outbreak activities
•
After the outbreak, analyse the information with the staff and understand
the reasons why the outbreak occurred (poor immunization coverage,
resistant population, poor socio-economic groups, tribal pockets, etc).
Sample messages for the community.
o
o
o
o
o
Keep the child at home, do not expose the child to other children
Give normal food to the child with measles
Protect your child from measles by immunization
Vitamin A will protect your child from getting complications
If your child has measles and then develops cough, diarrhoea,
drowsiness or pain in the eyes, immediately take to a doctor.
Conclusions:
Remember
that measles is a killer in our country, especially among the poorer
sections of the community and particularly among the malnourished.
o Prompt and effective action can reduce mortality considerably
o Be alert for complications
o Involve the community at all stages of the outbreak - they are your
best allies.
o
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WHO
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I
Fig 2: Surveillance goal in measles
Case of measles
Detection by community / MPW / Link workers / MOs
Immediate notification to higher authorities
I
Investigation by MO
Outbr^k verified
Management of
outbreak
•
•
•
I
Detection of all
Epidemiologically linked cases
Blood samples collected
from the initial 10 cases.
,
j
I
Send to reference lab
Ring immunization
Vit A supplements
Treat complications
IgM Positive
No
epidemiological
link to Lab confirmed
cases
Epidemiological link to
lab confirmed cases
—I
Suspect case of
measles
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Ig M negative
Confirmed case of measles
6/17/2002
Not a case of measles
DENGUE
Clinical case definition:
An acute febrile illness of 2-7 days duration with 2 or more of the following:
•
headache,
•
arthralgia,
•
retro-orbital pain,
•
rash
•
myalgia.
•
haemorrhagic manifestations
•
leucopenia
Laboratory criteria for diagnosis:
Any one or more of the following:
•
Isolation of the dengue virus from serum, plasma, leukocytes, or
autopsy samples
•
Demonstration of a fourfold or greater change in reciprocal IgG or IgM
antibody titres to one or more dengue virus antigens in paired serum
samples
•
Demonstration of dengue virus antigen in autopsy tissue by
immunohistochemistry or immunofluorescence or in serum samples
by EIA
•
Detection of viral genomic sequences in autopsy tissue, serum or CSF
samples by polymerase chain reaction (PCR)
Case classification
Suspected: A case compatible with the clinical description.
Probable: A case compatible with the clinical description with one or
more of the following:
•
supportive serology (reciprocal haemagglutination
inhibition antibody titre >_1280, comparable IgG El A titre or
positive IgM antibody test in late acute or convalescent
phase serum specimen).
• Epidemiologically linked with a confirmed case of dengue
fever (occurrence at same location and time as other
confirmed cases of dengue fever).
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Confirmed: A case compatible with the clinical description and
laboratory-confirmed.
Dengue Haemorrhagic Fever (DHF)
A probable or confirmed case of dengue
1. And Haemorrhagic tendencies evidenced by one or more of the
following:
•
Positive tourniquet test
•
•
Petechiae, ecchymoses or
purpura
•
Bleeding: mucosa,
gastrointestinal tract, injection
sites or other
Haematemesis or melaena
2. And thrombocytopenia (100,000 platelets or less per mm3)
3. And evidence of plasma leakage due to increased
permeability, manifested by one or more of the following:
•
•
•
vascular
>_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.
hypoproteinaemia)
Dengue Shock Syndrome (DSS)
All the above criteria, plus evidence of circulatory failure manifested by
rapid and weak pulse, and narrow pulse pressure (<_20 mm Hg) or
hypotension for age, cold, clammy skin and altered mental status.
Epidemiology
Agent: The viruses of dengue fever are flaviviruses and include serotypes 1, 2,
3 and 4. The same viruses are responsible for dengue hemorrhagic fever.
Host: Affects all age groups, but children usually have a milder disease than
adults. Recovery from infection with one serotype provides lifelong immunity
but does not provide protection against other serotypes, and instead may
exacerbate subsequent infections
Environment: Outbreaks of dengue are usually reported after rainfall due to
collection of water around peridomestic areas. The ambient temperature
range for dengue transmission is 16 to 40 degrees C.
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Reservoir: The viruses are maintained in a human-Aedes aegypti mosquito
cycle.
Mode of transmission: Dengue is transmitted by the bite of infective
mosquitoes, principally Aedes aegypti.
Vector: Aedes aegypti mosquito is a day-biting species with increased biting
activity for 2 hours after sunrise and several hours before sunset. Both Ae.
aegypti and Ae. albopictus are found in urban settings. The mosquito has
characteristic white stripes on the back and legs and is also known as tiger
mosquito. The mosquito is a domestic breeder and breeds in water containers,
discarded tyres, coconut shells, desert coolers, overhead tanks, etc.
Incubation period: Three to fourteen days, commonly 5-7 days.
Period of communicability: Not directly transmitted from person to person.
Patients are usually infective for mosquitoes from shortly before the onset of
fever to the end of the febrile period, an average of about 6-7 days. The
mosquito becomes infective 8-12 days after the viremic blood meal and
remains so for life.
Basic Facts
Dengue is known to exist in India for over a century and causes significant
morbidity and mortality. The first major outbreak occurred in Calcutta in
1963. Increasingly outbreaks are being reported all over India. During 1996 a
large outbreak was reported from Delhi with 10,252 cases and 423 deaths.
CFR is high in DHF and DSS Case-fatality rates in untreated or mistreated
shock have been as high as 40%-50%; but with good physiologic fluid
replacement therapy, rates should be about 3.5 % but low in dengue fever by
itself.
Clinical signs & symptoms: An acute febrile viral disease characterized by
sudden onset, fever for 3-5 days, intense headache, myalgia, arthralgia, retroorbital pain, anorexia, GI disturbances and rash. Early generalized erythema
occurs in some cases. A generalized maculo-papular rash usually appears
about the time of defervescence, which is difficult to detect in Indian
complexions. Minor bleeding phenomena, such as petechiae, epistaxis or gum
bleeding, may occur at any time during the febrile phase. Dengue fever is a
self limiting disease but in some cases with underlying pathologic changes,
adults may have major bleeding phenomena, such as GI hemorrhage in peptic
ulcer cases or menorrhagia. Recovery may be associated with prolonged
fatigue and depression. Epidemics are explosive, but fatalities in the absence
of dengue hemorrhagic fever are rare.
DHF/DSS recognized principally in children below 15 years (may also occur
in adults) is characterized by abnormal vascular permeability, hypovolemia
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and abnormal blood clotting mechanisms. In patients with severe or fatal
dengue, shock is usually the principal pathophysiologic defect. Coincident
with defervescence, the patient's condition suddenly worsens with marked
weakness, severe restlessness, facial pallor and circumoral cyanosis.
Extremities are cool, skin blotchy, pulse rapid and weak; patients may be
hypotensive with a narrow pulse pressure. Hemorrhagic phenomena are seen
frequently and include scattered petechiae, a positive tourniquet test, easy
bruisability, and less frequently, epistaxis, bleeding at venipuncture sites, a
petechial rash and gum bleeding. GI hemorrhage is an ominous prognostic
sign that usually follows a prolonged period of shock. The liver may be
enlarged, usually 2 or more days after defervescence.
Differential Diagnosis Differential diagnosis includes all epidemiologically
relevant diseases listed under arthropod-borne viral fevers, measles, rubella
and other systemic febrile illnesses, especially those accompanied by rash.
Lab investigation - see details in case definition
Case management
The management of dengue fever is symptomatic:
•
•
•
•
Bed rest during the acute febrile phase
Antipyretics (avoid salicylates/ibuprofen) and tepid water
sponging if temperature above 39 degrees C
Analgesics or mild sedatives if pain severe
Increased fluid intake.
The management of DHF/DSS is similar to DF and includes:
•
•
Oxygen therapy and rapid fluid and electrolyte replacement, by
IV fluids (lactated Ringer's solution at 10-20 ml/kg/hour).
Isotonics, plasma expanders if indicated, etc
Fresh frozen plasma may be indicated in serious cases and
rarely blood transfusion.
Surveillance goal (see Fig 2)
•
•
Detect and respond promptly and appropriately to cases and impending
outbreaks of Dengue Fever, DSS and DHF. Surveillance to include
epidemiological, entomological and lab parameters.
To confirm an outbreak, by collecting paired sera and sending for IgM and
IgG antibodies to dengue virus.
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•
•
•
Immediate number/case-based reporting of cases and deaths when an
outbreak is suspected.
Appropriate management to reduce mortality
Effective control measures to interrupt transmission and reduce new cases
Identification of an outbreak
•
•
•
Any increase in fever cases should be investigated, especially in areas
where dengue is endemic or known to exist.
Report each case of DF/DHF/DSS to local health authorities immediately.
Here the role of the private sector and labs is important as sentinel centers.
Entomological surveillance should be able to detect increasing density of
the vector and predict a potential outbreak.
Thresholds
If a single suspect case is reported:
Confirmation of an outbreak
•
If an outbreak of dengue is suspected, send paired sera to the nearest
reference lab for diagnosis. Blood for serological confirmation should
be carefully collected using universal precautions. The sera should be
separated and stored at 4 degree C and sent to the referral lab by
quickest means preferably in ice (but not frozen). Samples would be
accompanied with the detailed information about the cases. . HI, CF,
IgG and IgM ELISA, and neutralization tests are diagnostic aids. IgM
antibody, indicating current or recent infection, is usually detectable by
day 6-7 after onset of illness.
Investigation of an outbreak
The MO PHC will investigate every dengue outbreak in the same way as any
other epidemic prone disease. The health staff would alert the MO regarding
large number of unexplained fevers in the community especially post
monsoon or after fresh rainfall. S/he should arrange to collect serological
samples from a few suspected cases for confirmation of the outbreak.
Time: Cases of fever in the area would be plotted daily (including deaths) and
any significant peaks in time noted. In outbreaks an epidemic curve would be
visible and would be constantly updated & observed till the curve shows a
significant down trend and the outbreak is controlled.
Place: Each case would be plotted on a spot map of the village regularly and
clustering of cases around particular areas would be looked for. The spot map
would depict all major (rivers and lakes, etc) and minor water collections
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(drains, storage tanks, etc) where mosquito breeding is likely to occur and any
significant increase in cases around these areas would be monitored.
Person: A line list of cases, including age and sex would be maintained at the
peripheral health centre and number based reporting to the district would be
carried out daily/weekly depending on the number of cases. Active search for
more cases would also be carried out around the neighboring houses of each
detected case. Analysis of the age distribution and sex distribution of cases
would be regularly carried out.
Vector surveillance for Aedes aegypti mosquitoes would be carried out in
and around all habitations in the affected area.
Prevention & Control of an outbreak
The MO would:
•
Organize community surveys to determine density of vector mosquitoes,
to identify larval habitats (which for Ae. aegypti is usually in artificial or
natural containers holding water close to or within human habitations,
e.g., in old tyres, flower pots, water storage containers) and to promote
and implement plans for their elimination.
•
Indoor residual spray of dwellings with appropriate insecticide would be
carried out.
•
Prevent access of day-biting mosquitoes to patients by screening or using a
mosquito bednet, preferably insecticide impregnated, for febrile patients,
or by spraying houses with a knockdown adulticide or residual
insecticide.
•
Determine place of residence of patients for 2 weeks before onset of illness
and search for unreported or undiagnosed cases.
•
Search for and destroy Aedes species of mosquitoes in places of human
habitation, and eliminate or apply larvicide to all potential larval habitats
of Ae. aegypti.
•
Ground applications of ultra-low-volume insecticides can effectively
reduce vector populations, but fogging and aerial spraying with
insecticides may help in aborting epidemics when used together with
source reduction.
Health education of the community on
Prevention of breeding of mosquitoes:
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•
•
•
Adopting personal measures for eliminating/destroying mosquito larvae
habitats
Drain water from collections around their dwellings like coolers, buckets,
tyres, flower vases, coconut shells, etc
Cover all stored water containers
Prevent mosquito bites by:
•
•
•
Protecting against day biting mosquitoes by using screening, mosquito
nets, appropriate clothing and repellents.
Wear suitable clothes covering arms and legs during outbreaks to prevent
easy biting access by mosquitoes
Permit indoor spray of their dwellings by the health workers
Encourage the community to identify cases and report to the health staff so
that prompt treatment can prevent DHF/DSS.
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Fig 2. SURVEILLANCE PROCESS IN DENGUE
Case of fever
Detection by community
MPW / Link workers / MOs
Investigation by MO
Outbreak verified
Management of outbreak
Management of Outbreak
Active case search
Entomological surveillance
Clinical Management of
patients
• Health education of the
community
• Anti-mosquito measures
•
•
•
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Blood samples collected from
the initial 10 cases.
Four fold inreease in IgG / IgM
antibodies
I
Confirmed case of DE/ DHF /
DSS
6/17/2002
JAPANESEENCEPHALITIS
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PLAGUE
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