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I
NATIONAL CHILD SURVIVAL
AND SAFE MOTHERHOOD PROGRAMME
CONDUCT DISEASE
SURVEILLANCE
Ministry of Health and Family Welfare
Government of India
New Delhi
1992
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GOALS AND COMPONENTS OF
THE CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME
GOALS
o
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Infant mortality rate reduced from 81 to 75 by 1995 and 50 by 2000.
Child (1-4 years) mortality rate reduced from 41.2 to < 10 by 2000.
Maternal mortality rate reduced from 400 to 200/100,000 by 2000.
Polio eradication by 2000.
Neonatal tetanus elimination by 1995.
Measles - prevention of 95% deaths and 90% cases by 1995.
Diarrhoea - prevention of 70% deaths and 25% cases by 2000.
Acute respiratory infections - prevention of 40% deaths by 2000.
Components of this package would be:
Children
Newborn care at home - warmth and feeding.
Primary immunization by 12 months - 100% coverage
Vitamin A prophylaxis (9 months to 3 years) - 100% coverage
Pneumonia - Correct case management aLhome/health facilitiac
Diarrhoea - Correct case management
<n every village.
Pregnant Women
Immunization against tetanus - 100% ci
Anaemia prophylaxis and oral therapy
Antenatal check-up - at least 3 check-L
Referral of those with complications
Care at birth - promotion of clean deliv
Birth timing and spacing
*
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CONDUCT DISEASE SURVEILLANCE
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ADAPTED FROM WHO MODULE
J
J
CONDUCT DISEASE SURVEILLANCE
Published by :
Ministry of Health & Family Welfare
Government of India
Nirman Bhawan
New Delhi.
First Published
Revised
Revised
Revised
Revised
Revised
Revised
1985
1986
1987
1988
1989
1990
0^6
1992
COMMUNITY HEALTH CEIA
CH/oI
326, V Main, I Block
Koramongala
Bangalore-560034
India
This publication is available in English only
CONTENTS
INTRODUCTION
1
LEARNING OBJECTIVES
2
1.0
2.0
3.0
4.0
PLAN FOR SURVEILLANCE
3
1.1
What are the types of Surveillance?
Exercise A
3
9
1.2
Assess your surveillance system
Exercise B
10
20
COLLECT AND COMPILE DATA
23
2.1
Routine reporting system
Exercise C
23
33
2.2
Sentinel reports
35
ANALYZE DATA
39
3.1
Analyze data from routine reporting sites
Exercise D
40
46
3.2
Reasons for various disease trends
Exercise E
Exercise F
51
54
55
3.3
Analyze data from sentinel reporting sites
57
TAKE ACTION
59
4.1
Identify problems and implement solutions
59
4.2
Submit surveillance report
61
4.3
Provide feed back
Exercise G
Exercise H
62
63
64
5.0
6.0
INVESTIGATE AND CONTROL OUTBREAKS
66
5.1
Diarrhoeal diseases
67
5.2
Poliomyelitis
75
5.3.
Measles
79
ADVERSE EVENTS FOLLOWING IMMUNIZATION
80
6.1
Types of adverse events
80
6.2
Measures to minimize risks
82
6.3
Field investigations and analysis of reports
83
6.4
Make a report
84
6.5
Dealing with the public and media
85
ANNEXURES
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
XIII
a.
List of lame children
b.
List of neo-natal deaths
c.
List of maternal deaths
Calculate vaccine efficacy
Annual incidence rate of poliomyelitis
Annual neo-natal tetanus mortality rate
Monthly sentinel surveillance reports
a.
Vaccine preventable diseases
b.
Diarrhoea/pneumonia
c.
Maternal deaths
Analysis of annual data from sentinel surveillance
a.
Vaccine preventable diseases
b.
Diarrhoea/pneumonia
c.
Maternal deaths
Mother-infant immunization card
Mother and child care record with instructionsMonthly PHC report
Monthly district report
Definitions of terms
Form-12 - Clinical observation of lame children
Form-13 - Investigation of neonatal deaths
I
CONDUCT DISEASE SURVEILLANCE
INTRODUCTION
Surveillance is collection of data for action. By collecting information about cases and
analyzing data you can determine what action is needed to reduce number of cases.
Surveillance data are also used to*
see if the fixed day strategy for delivery of child survival and safe motherhood
interventions is being implemented ;
*
evaluate impact of immunization services on the occurrence of vaccine-preventable
diseases in the community;
*
evaluate impact of safe motherhood services on maternal deaths and quality of care
during delivery;
*
establish priorities among vaccine-preventable diseases as well as other diseases
contributing to deaths in children below five years such as diarrhoea and pneumonia;
*
identify specific population groups at higher risk of illness and death from vaccinepreventable diseases, diarrhoea and pneumonia to ensure that immunization activities
as well as other services and resources can be used efficiently;
*
observe disease trends and identity causes of maternal deaths as well as deaths in
children below five years. This is necessary to plan immunization services, safe
motherhood and child survival programmes;
*
identify, investigate and control outbreaks or epidemics.
Information on diseases and deaths related to child survival and safe motherhood
programme is collected from three main sources in our country i.e. from Mother-Infant
immunization card, health worker’s mother and child care record and monthly reports from
Primary Health Centre as well as hospitals. Apart from disease surveillance, other
information which are crucial for implementation of Child Survival and Safe Motherhood
programme include those related to the implementation of the fixed day strategy, coverage
with immunization, Vitamin A and anaemia prophylaxis and select ante-natal services, supply
of vaccines as well as Vitamin A concentrated solution and Iron and folic acid tablets,
maintenance of equipment, transport, cold chain equipment, occurrence of untoward
reactions following immunization.
1
Action should be taken at the level at which data is collected. This is especially true for
health centres, since it is at this level that most health services are provided. If medical
officers of health centres wait for receiving feedback from district or state before taking any
action, it may be too late.
LEARNING OBJECTIVES
You will acquire and practice skills which will enable you to conduct surveillance
activities for various vaccine preventable diseases, diarrhoea, pneumonia and
investigate neonatal and maternal deaths as well as cases of acute poliomyelitis.
You will also be able to line-list cases of poliomyelitis as well as neonatal and maternal
deaths.
You will, in this module, learn to collect, analyze and present data in the form of
charts, graphs and maps and take action including giving feed-back on the basis of
your findings.
You will also learn procedures you will have to undertake in the event of outbreaks of
diseases you aim to prevent through various interventions of the child survival and safe
motherhood programme.
2
1.0
PLAN FOR SURVEILLANCE
Collect and
compile
data
2.0
Plan
for
surveillance
1.0
Analyze
Data
Take
Action
3.0
4.0
In this section, you will learn about different types of surveillance systems as well as
various activities you will have to undertake regularly. You will also learn how to
assess whether your surveillance system is organized well so that you may collect
information that is timely, complete and accurate.
1.1
WHAT ARE THE TYPES OF SURVEILLANCE?
There are two major types of surveillance systems that will be described in this
chapter:
Routine reporting
Sentinel reporting
In addition, there are other kinds of surveillance activities:
Case/outbreak investigations
Special studies - morbidity/mortality surveys
1.1.1
Routine reporting
This is the simplest and most widely practised method of collecting
information. It includes both active and passive surveillance. All cases
attending out patients’ department (OPD) are recorded in a register. You
may keep a tally sheet as shown in Fig 4 on page 23. This will be particularly
useful if there is heavy attendance in your OPD and a large number of cases
are seen. The health staff collect information during their field work about
the number of cases of diseases which have to be reported for the purpose of
this programme. The health workers will report occurrence of diseases and
deaths in their sub-centre area. This information will normally be collected
by the workers through a system of informants in every village and urban unit.
The health workers during their home visits will include in their ’priority
houses’ the list of houses where various events such as vital events - births,
deaths as well as diseases have occurred. Normally, such information is noted
3
in the daily dairy of the Health worker and a consolidated report sent to the
Medical officer in-charge of the Primary Health Centre. However, when any
disease or deaths are occuring more often than usual, the worker will send a
report immediately and at weekly intervals. This system of collection of
information on diseases and deaths is known as community based
surveillance. The list of diseases to be reported is given in Figure 3 on page
10. Health staff may also investigate ev^ry case of neonatal death. At the
end of every month, they analyze this information and send it to the district
manager.
In certain circumstances cases may have to be reported
immediately, for example, suspected cases of cholera or acute poliomyelitis.
Usually, the health centres form the basic units in routine reporting.
In this module you will learn about reporting of cases of various diseases. If
you are a district manage r/he al th officer, you will also collect data on deaths
due to various vaccine preventable diseases including neonatal tetanus,
diarrhoea and pneumonia in addition to maternal deaths from hospitals in
your district.
SUGGESTED REGISTER FORMAT FOR RECORDING CASES AT OPD
Serial No.
1
Annual
3
4
5
Father's/ Address
Name of
2
Monthly the chi Id/ Husband's
name
mother
6
7
Date of Sex
birth/
age in
years
8
9
D i agnos i s
Date
of
onset
10
11
Immuni Result/
zation Outcome
status
Fig. 1 : A sample register format for use in the out-patients department
4
Routine reports may give an incomplete picture of the total number of cases
of disease actually occurring in an area. Some of the reasons for incomplete
reporting are:
*
Not all cases come for treatment. Many children with mild or
moderate degree of the disease may not seek treatment. Others may
go to private practitioners. The reported number of cases depend
largely on the extent to which the health facilities are utilized by the
population. In areas where health facilities are frequently used, the
reported number of cases may be higher than in other areas which
actually may have just as many or more cases.
♦
Some diseases, such as neonatal tetanus, are more commonly dealt
with at home and therefore may be less likely to be seen at the health
centre. Some children may die soon after symptoms appear much
before being taken to a health facility e.g. neonatal tetanus, cholera.
*
Not all health facilities may report regularly and some may have
incomplete reports. Thus, there may be missing or lost data. Even
when reporting is fairly regular and complete, there may be
inconsistencies if health workers in the system follow different
procedures and use different case definitions and guidelines.
*
Not all cases seen and diagnosed by health centre staff are reported.
Also, some health workers may not recognize certain diseases and
hence they are not reported.
1.1.2
Sentinel reporting
In SENTINEL REPORTING only a small number of reporting units
are selected to participate e.g. District hospitals, Paediatric and
Obstetrics departments of medical colleges, etc..
*
These health facilities report the number of cases of disease
that occur for a specified time period.
♦
They may also be asked to report additional information such
as the age and immunization status of each case.
When we want to collect data on deaths, we use hospitals as sentinel
sites, since hospitals are likely to have deaths occurring there.
However, using this source alone might give an artificially high case
fatality rate because usually the most severe cases are hospitalized.
Sentinel sites are chosen because they are likely to see cases of a
certain disease in a certain age group, and their staff are trained to
report regularly and accurately. Since their number is smaller and
5
carefully chosen,it is easier to maintain quality and regularity of reports.
A sentinel surveillance system is developed to obtain more reliable and
extensive disease information than is available from the routine
reporting centres.
A hospital, health centre, laboratory or a
rehabilitation centre which attends to a relatively large number of cases
of the disease can be considered as a sentinel centre. A sentinel centre
may provide you with information on one or more diseases.
There should be a close liaison between the sentinel centres and the
local health office. Follow up action on the reports, when indicated,
should be immediate. The sentinel centres provide you useful
information and also serve as effective "watch-dogs or sentinels" for
you. You will get an early warning if things go wrong in your area.
Since sentinel reporting provides data on parts of the population only
whose representativeness is not known, incidence rates for the entire
area served cannot be automatically extrapolated from sentinel data.
However, if the size and the estimated growth rate of the populations
served by sentinel facilities are known, disease incidence rates for at
least the sentinel populations can be calculated. More important than
estimates of disease, changes can be monitored over time. Such data
can also provide important information on age groups at risk and
immunization status of cases.
Community based sentinel surveillance
Select random cluster sample villages/urban wards.
Visit periodically once in a month and undertake a complete
survey in 3-5 days.
Conduct quick house to house survey to find new cases and
deaths
Support with minimum laboratory investigations necessary
Analyze data locally and provide feed-back on illness, main
causes and modification needed for service delivery
Advocate interventions which community can undertake to
prevent future infection
Provide treatment
Make a follow-up visit
Observe change in practice/behaviour.
6
1.13
Case/outbreak investigations
CASE/OUTBREAK INVESTIGATIONS are attempts to identify why
case(s) of disease occurred. The purpose of these investigations are to:
*
♦
♦
♦
confirm diagnosis;
determine why the outbreak occurred;
initiate the most appropriate control measures;
identify where and to whom to apply these measures;
prevent similar outbreaks in the future.
In general, ’’case investigation” is investigation of a single case and an
"outbreak investigation” is investigation of many cases. However, when
the occurrence of a particular disease is either very low, or is expected
to be very low due to high levels of immunization/protection, even one
case can be considered an "outbreak” e.g. poliomyelitis..
As a medical officer of a health centre or a district, you should arrange
for investigation of every case of neonatal deaths as soon as possible.
Similarly, cases of poliomyelitis should also be investigated immediately.
Further, if many cases of gastroenteritis occur within a short period or
a typical case of cholera is reported, you must investigate immediately.
The role of a health centre or district supervisor in most outbreak
investigations is to analyze surveillance data, initiate control measures
and notify higher officials of disease trends that might indicate an
outbreak of a disease.
1.1.4
Special studies
SPECIAL STUDIES are conducted by trained health staff, investigators
or epidemiologists. They are used to
*
♦
measure the number of cases of disease in an area and
to evaluate reliability of routine or sentinel reporting.
For example, a morbidity and mortality survey may be a better method
for diseases that tend not to be seen at health facilities for geographical
or cultural reasons (such as neonatal tetanus). In special studies, the
sample size, methodology, questionnaires and forms are designed to
avoid bias and misinterpretation of data.
7
Community-based, house-to-house surveys may be necessary in some
cases. However, these surveys are expensive and require specially
trained personnel. For this reason, the decision to conduct one is
usually made at the national or state level. However, health centre and
district level managers may be asked to participate in these surveys e.g.
sample surveys conducted on Poliomyelitis and Tetanus in 1981-82 and
the National EPI Review in 1989.
Various surveillance methods are complementary and meet different
health service needs. Data best suited to be collected by different
methods are shown in Figure 2.
DATA COLLECTED
SURVEILLANCE METHOD
Routine reporting system
11 loess
Sentinel reporting system
11Iness
Deaths
Age
Immunization status
Community based sentinel
surveiI lance
11Iness
Practices - causing
modifying
Local analysis & feed back
Advocating community promotion
for intervention
T reatment
Followup
Case/outbreak investigation
11Iness
Deaths
Age
Sex
Immunization status
Name and address
Extent of outbreak
Clinical symptoms
Special studies
11Iness
Deaths
Socio-economic data
Risk factors
Figure 2 : Data collected by different surveillance methods
8
EXERCISE A
The purpose of this exercise is to review information that has been presented so far. Several
questions about disease surveillance are listed below. Answer each question by referring to
the text on Pages 3-8, if necessary. Write your answer in the space provided below each
question.
1.
What information on cases of disease does a health centre medical officer include in
his Monthly Report to the district health officer?
2.
List four reasons for incomplete reporting in routine reporting sites.
3.
What additional information, other than the number of cases of disease, does a
sentinel site report?
4.
What are the major purposes of a case/outbreak investigation?
5.
In what way are health centre and district health officers involved in an outbreak
investigation?
6.
When would a special study be conducted? Give one example.
See the facilitator when you are
ready to discuss your answers
9
1.2
ASSESS YOUR SURVEILLANCE SYSTEM
1.2.1
What should be reported?
Given below is the extract A on surveillance from the monthly report for a
PHC or district.
A.
SURVEILLANCE
Number Reported
For the Month
Disease
Cases
Deaths
Cumulative since April
Cases
Deaths
Diphtheria
Pertussi s
Neonatal Tetanus
Tetanu . (others)
Poliomyelitis (Acute)
Measles
Tuberculosi s
Pneumoni a
Under 5 years
Acute Diarrhoea
Dysentery
Maternal Deaths
(Reported)
: Before delivery
: During delivery
: Within 6 weeks of delivery
Figure 3 : Extract on Surveillance from Monthly Report
The information collected should be only as much as will be used.
*
Routine reporting sites should report the total number of cases of each
disease only and
*
Sentinel sites should report in addition, the age and immunization
status.
Please note that while surveillance for cases and deaths due to tuberculosis,
pneumonia, acute diarrhoea and dysentery is for children under 5 years, you
will report all cases and deaths (all ages) due to other vaccine preventable
diseases included in this form.
10
1.2.2
Which sources of data will be used?
Possible sources of data about cases of disease include out-patient and in
patient registers, individual patient records and records of immunizations
given. Select sources that are most likely to be complete and accurate.
Sources of information include dispensary, subcentre, PHC, hospital, private
practitioners and health workers.
Report all new cases. Avoid duplication of reporting.
Count only those cases which have been diagnosed by a health worker. Do
not count cases which have been reported to the health centre by community
members, unless they were also diagnosed or confirmed by health centre staff.
The following cases should be counted:
♦
All cases seen and diagnosed by health workers at outreach sessions;
♦
Cases which come to the health centre for treatment;
*
Cases seen and treated in medical college hospitals, district and sub
district hospitals,
*
Cases treated at non-government health facilities (for example, mission
hospitals or private physicians);
When you or your supervisory staff visit villages for supervision, be sure to ask
about cases of measles, neonatal tetanus, poliomyelitis, diarrhoea and
pneumonia as they are often left out while reporting.
1.2.3
What information is recorded on the patient register?
Whatever may be the format of register you are using ensure that following
information is recorded : name, complete address, disease, age, sex etc. A
sample format is given in figure 1 (page 4).
1.2.4
Which forms will be used to report data?
You must know which forms are used to report surveillance data. Health
centres and district offices should use the following forms:
♦
*
♦
♦
*
Disease surveillance portion of monthly report;
Individual case investigation forms (e.g. Neonatal deaths, poliomyelitis
and diarrhoea/ cholera);
Disease maps;
Disease charts;
Line lists for poliomyelitis, neonatal and maternal deaths.
11
1.2 5 When will reports be submitted?
Under the Child Survival and Safe Motherhood programme routine
surveillance reports should be submitted every month. This means that health
centres report to the district and the district sends a consolidated report to the
state and centre every month.
Surveillance section of monthly report should be filled even if there are no
cases to report. This is known as "zero reporting". The fact that no cases
were seen is important information!
NOTE: The health centre medical officers are asked to immediately notify the
district of a suspected case of poliomyelitis or cholera so that an investigation
can be conducted. Outbreak reports in case of occurrence of poliomyelitis,
neonatal deaths and diarrhoea should be sent as soon as these outbreaks
occur. These are given in detail in Section 5.0
1.2.6 What do health workers require training for?
As a medical officer, you should train health workers to conduct various
surveillance activities. Health workers should be able to:
*
*
*
♦
understand the purpose of surveillance;
recognize diseases you are to prevent or controlusing standard case
definitions;
know how to use various records/registers in the health system; and
know what actions are subsequently needed.
Recognizing cases of diseases which you will aim to prevent under the
programme is an important surveillance task for a health worker. Since not
all health centres have access to laboratories, it is often necessary to diagnose
cases on the basis of symptoms only. Therefore, all staff members should
know the important symptoms of all diseases under surveillance and be able
to make a fairly accurate diagnosis.
The chart in the next few pages lists the case definitions and the most
common symptoms of the diseases included in the programme. Not all the
cases will have all of the symptoms and there may be others that are not
mentioned here. This chart is a brief review only.
12
A.
THE VACCINE PREVENTABLE DISEASES
DISEASE
LAY DEFINITION
(suspected)
STANDARD CASE DEFINITION
(Probable diagnosis)
Measles
History of fever and rash and any
one of the following :
cough
running nose
red eyes
History of a generalized blotchy
rash lasting 3 or more days
History of fever and history of any
one of the following :
cough, running nose, red eyes
Poliomyelitis
History of sudden onset of
weakness and paralysis of the
leg(s), and/or arm(s) and/or trunk
AND history that paralysis was
not present at birth or associated
with serious injury or mental
retardation.
History of fever
History of no progression of
paralysis after the first 3 days
AND
History that acute paralysis was
not present at birth or associated
with serious injury or mental
retardation/other diseases
A case of poliomyelitis is defined
as any patient with acute flaccid
paralysis (including any child less
than 15 years of age diagnosed to
have Guillain Barre syndrome) for
which no other cause can be
identified :
Typical findings on physical
examination :
o acute flaccid paralysis
o no sensory loss
o muscle tenderness
o wasting of the affected muscles
(late findings)
o absent or depressed deep
tendon reflexes
o asymmetrical findings.
Diphtheria
Sore throat, with grey patch or
patches in the throat
Acute pharyngitis, acute
nasopharyngitis, or acute
Laryngitis, with a
pseudomembrane.
Neonatal
Tetanus
History of normal suck and cry
first two days of life AND
History of onset of illness
between 3 and 28 days of life
History of normal suck and cry’ for
the first 2 days of life and
History of onset of illness between
3 and 28 days of age AND
History of inability to suck
followed by stiffness and/or
"convulsions" and often death
a
> rr>
AINU
History^ of inability to suck
followed by stiffness and/or
jerking of muscles.
13
DISEASE
LAY DEFINITION
(suspected)
STANDARD CASE DEFINITION
(Probable diagnosis)
Tetanus
History of injury or ear infection
followed by difficulty in opening of
mouth (or jerking of mouth) or
stiffness of the neck, body.
A person is likely to be suffering
from tetanus when (s)he has :
- a stiff jaw and trouble opening
mouth or while swallowing ;
- painful stiffness of the neck and
abdominal muscles (often other
body muscles also get stiff);
- a clear mind ;
- a wound, often infected or history
of a wound within the past few
weeks. In severe cases, the person
may appear to be smiling (risus
sardonicus) with raised eyebrows.
The back and neck may be arched,
arms may be bent with clenched
fists and legs extended. Noise,
light or slight touch may trigger
sudden, painful tightening of the
muscles (convulsions).
Tuberculosis
An ill child with history of contact
with a suspect or confirmed case of
pulmonary tuberculosis.
An ill child with history of contact
with a suspect or confirmed case of
pulmonary tuberculosis; and a child
who does not return to normal
health after measles or whooping
cough; with loss of weight, cough
and wheeze who does not respond
to antibiotic therapy for acute
respiratory infection OR with
abdominal swelling with a hard
painless mass and free fluid; with
painful firm or soft swelling in any
group of superficial lymph nodes;
with any bone or joint lesion of slow
onset; with signs suggesting
meningitis or disease in the central
nervous system.
Any ill child with one of the
following :
Pertussis
14
*
who does not return to normal
health after measles or
whooping cough; and
*
with loss of weight, cough and
wheeze who does not respond
to antibiotic therapy for acute
respiratory infection.
History or observation of repeated
and violent coughing, with any one
of the following : cough persisting
for two or more weeks, fits of
coughing, cough followed by
vomiting, typical whoop in older
children.
History of severe cough and history
of any one of the following : cough
persistent for two or more weeks,
fits of coughing, cough followed by
vomiting.
Confirmation by laboratory methods1
1.
Measles
Positive serology. Four-fold or greater rise of measles
antibody titres in serum.
2.
Poliomyelitis
Positive virus culture from stool for polio virus. Positive
serology (four-fold or greater rise in scrum polio antibody
titres)
3.
Diphtheria
Positive culture of Coryncbactcrium diphtheria
(demonstration of toxin production recommended, but not
required in typical cases).
4.
Tetanus and Neonatal
tetanus
Nil
5.
Childhood tuberculosis
Microscopic detection or culture of Tubercle bacilli from
secretions
6.
Pertussis
Positive culture or immunofluorescence of nasopharyngeal
secretions for Bordetella pertussis bacteria
i
Laboratory methods or procedures of investigations are listed here for completion of the
confirmation of diagnosis. It is not mandatoiy to do particularly when facilities are not
available.
15
B. OTHER DISEASES/EVENTS FOR SURVEILLANCE
DISEASE
LAY DEFINITION
(suspected)
STANDARD CASE DEFINITION
(Probable diagnosis)
Diarrhoea
(including
dysentery)
Child having watery and frequent
stools is diarrhoea
Stools contain more water than
normal. If stools contain blood or
mucus, it is called dysentery.
Stools containing either blood or
mucus is dysentery.
Pneumonia
A child having cough, cold, difficult
breathing, fast breathing with or
without chest indrawing
Frequent passing of normal stools,
however, is not diarrhoea.
Remember : babies breast-fed
often have softer stools but may
not suffer diarrhoea.
Not severe pneumonia when there
is fast breathing and no chest in
drawing. Fast breathing when
respiratory rate of 60 or more in a
young child of age less than 2
months; 50 per minute or more, if
baby is 2 months to 12 month; 40
per minute or more if 12 months
to 5 years
In addition to fast breathing, if
chest in-drawing is present, there is
severe pneumonia. All pneumonia
in babies upto the age of 2 months
are severe pneumonia.
A child with cough or difficult
breathing who has any of the
danger signs such as :
o not able to drink
o central cyanosis
o convulsions
o abnormally sleepy or difficult to
wake
o stridor/wheezing in calm child
o severe under-nutrition
has got very severe pneumonia.
Anaemia in
Pregnancy
16
Lack of strength, shortness of
breath and pale nails, conjunctiva
and inside of the mouth.
Reduction of red blood cell
volume or haemoglobin
concentration below the values
occurring in healthy pregnant
women i.e. llgm/lOOml
Mild anaemia - 9-11 g/ 100ml
Moderate anaemia - 6-9 g/lOOml
Severe anaemia - <6 gm/100ml
DISEASE
LAY DEFINITION
(suspected)
STANDARD CASE DEFINITION
(Probable diagnosis)
Maternal
Death
Deaths in women during pregnancy
or within 42 days of delivery
Death of a woman while pregnant or
within 42 days of termination of
pregnancy, irrespective of the
duration or the site of the pregnancy
from any cause related to or
aggravated by pregnancy or its
management, but not from
accidental (or incidental) causes.
Maternal deaths can further be
broadly be grouped under three
heads depending on •when a
pregnant woman dies :
♦
before delivery - when death
occurs before labour begins
*
during delivery - when death
occurs during labour, child-birth
or birth of placenta
♦
within 6 weeks of delivery when death occurs within 42
days of delivery or termination
of pregnancy.
Confirmation by laboratory methods
1.
Diarrhoea/dysentery
Demonstration of faecal leucocytes and/or RBCs, Amoeba
or Giardia;
Culture of stool showing pathogenic bacteria or virus
2.
Pneumonia
Chest X-ray showing Pneumonia
Lung needle aspiration culture showing causative organism
(not done routinely)
3.
Anaemia
Haemoglobin estimation
Peripheral smear
17
1.2.7
Causes of maternal deaths
A. Direct obstetric deaths
Those resulting from obstetric complications of the pregnant state (pregnancy,
labour and puerperium) from interventions, omissions, incorrect treatment and
from a chain of events resulting from any of the above. 75% of maternal deaths
are due to direct obstetric causes.
B. Indirect obstetric deaths
Those resulting from previously existing disease or disease that developed during
pregnancy and which was not due to pregnancy, but which was aggravated by
physiological effects of pregnancy. 25% of maternal deaths are caused by indirect
causes.
We will briefly describe here the direct obstetric deaths you will aim to prevent
through the child survival and safe motherhood programme.
1. Prolonged labour - is said to occur when true labour (i.e. second stage of
labour) has persisted for more than 24 hours. Prolonged labour may be due
to malpresentations such as breech, brow, shoulder presentation (transverse
lie) or prolapsed arm.
2. Obstructed labour - Failure of progress of labour in the presence of strong
uterine/contractions.
*
Obstruction caused by malposition of fetus at onset of labour
*
Obstruction by bony pelvis - contracted pelvis, fetopelvic disproportion
(CPD), unusually large fetus causing disproportion, hydrocephalic fetus
causing disproportion, fetal abnormality causing disproportion such as
conjoined twins, myelomeningocoel, tumour, etc.
Obstruction by deep transverse arrest, shoulder dystocia, locked twins.
3. Toxaemia of pregnancy
♦
18
A condition characterized by high blood pressure, increased weight gain,
swelling of legs and fingers with or without headache seen more commonly
during first pregnancy after the 30th week (third trimester) - rarely occurs
before the 24th week.
*
Toxaemia will be suspected by a health worker if there is increased blood
pressure (>140/90 mm) or if there is a weight gain of more than 5 kg in
one month.
♦
Eclampsia is the severe form of toxaemia of pregnancy, and is
characterized by convulsions and severe headache.
4. Bleeding
a) Antepartum haemorrhage (APH) is the bleeding per vagina after 28 weeks
of pregnancy. Usually, it is due to placenta praevia and less commonly due
to toxaemia of pregnancy.
b) Post partum haemorrhage (PPH) is the excessive bleeding (more than 500
ml. of blood against the normal of 200 ml.) from the genital tract which
occurs during the third stage of labour or within 24 hours after the
placenta has been expelled.
5. Puerperal sepsis
Infection of the genital tract within 14 days of child birth, characterized by :
*
♦
*
♦
*
♦
soft uterus not decreasing steadily in size
foul smelling lochia or red lochia continuing even after 10 days
lower abdominal pain and tenderness
headache
vomitting
pallor or flushed face
6. Septic abortion
Infection of the genital tract following abortions, characterized by :
*
*
*
♦
lower abdominal pain and/or tenderness
fever and foul smelling discharge per vagina
minimal vaginal bleeding
history of attempt to terminate pregnancy
19
EXERCISE B
In this exercise, you will compare your surveillance activities with those described in
this module. The purpose of the exercise is to see if there are ways you could
improve your surveillance system.
1. Answer the following questions about your surveillance activities
♦
Is your health facility part of a routine reporting system?
YES/NO
*
Is your health facility part of a sentinel reporting system?
YES/NO
*
Are you responsible for conducting case investigations?
YES/NO
If yes, for which diseases and under what circumstances?
*
Are you responsible for conducting outbreak investigation?
YES/NO
If yes, for which diseases and under what circumstances?
2. Which of the target diseases do you report?
Do you use the standard case definitions, or list of
symptoms for each of the six diseases?
YES/NO
3. List five sources of data on
Source
1.
2.
3.
4.
5.
Do you receive reports of maternal deaths?
Complete Accurate
YES/NO YES/NO
YES/NO YES/NO
YES/NO YES/NO
YES/NO YES/NO
YES/NO YES/NO
YES/NO
Do you "double count" cases that visit twice for the same episode
of illness or that are referred to a hospital?
YES/NO
20
Do you count cases that:
*
♦
*
*
were not diagnosed by a health worker?
come to the health centre for treatment?
are treated at non-government health facilities?
are seen at outreach sessions?
YES/NO
YES/NO
YES/NO
YES/NO
Can you think of any way to improve the sources of data so that the information
you collect will be more complete and accurate and will provide information on
as many cases as possible?
4. Look at a copy of the surveillance report you use 1to regularly report cases of
disease. Then answer these questions about your form:
*
*
*
Is it important to know the sex-wise incidence of diseases and death in the
programme?
YES/NO
Why ?_
Is neonatal tetanus reported separately?
YES/NO
Is death due to tetanus in the postpartum period included
under maternal deaths?
YES/NO
5. Answer these questions about submitting monthly surveillance reports:
♦
*
Do you submit reports even if no cases reported?
YES/NO
What are the obstacles, if any, that prevent you from submitting reports on
a regular and timely basis? How could these obstacles be overcome?
0'^ z
CH 101 WZ
21
community health cell
32b, V Mo in, I Bioclc
Koranung H
Bangalore-66;)034
India
/
6. Are all your staff well trained in surveillance activities?
*
Do they understand why surveillance is important?
YES/NO
♦
Do they know how to use the patient register?
YES/NO
♦
Can they diagnose diseases, using standard case definitions?
YES/NO
♦
In what other areas could you strengthen the skills of your staff?
See the facilitator when you are
ready to discuss your answers
22
YES/NO
2.0
COLLECT AND COMPILE DATA
Plan
for
surveillance
1.0
Collect and
compile
data
2.0
Analyze
Data
Take
Action
3.0
4.0
Data collection is more than merely counting the number of cases of disease. If data
collection is systematic and thorough, it will facilitate analysis of data and alert you on
various problems. When collecting surveillance data it is important to :
*
*
*
*
meet deadlines for reporting
ensure all cases of disease which are seen are actually reported (completeness)
submit reports even when no cases are seen (zero reporting)
provide prompt feedback.
Health centre and district health officers collect and compile data in a similar way. For
example, both tally cases, total them at the end of the month and prepare disease charts.
The difference is that health centre medical officers collect information about cases that
occur in their health area. A district health officer collects information about cases that
occur in all health centres in the district.
District health officers are also responsible for making sure that surveillance information
collected at the health centre is reliable, accurate, complete and submitted on time. If
not, the district health officer will discuss with the health centre staff to identify why
there are certain specific problems in reporting and how they can be rectified.
2.1
ROUTINE REPORTING SYSTEM
2.1.1
Tally cases on a daily basis and total them every month
To "tally” cases of disease, place a mark on the appropriate column in the tally
form (Fig. 4 ) for every case that is diagnosed or reported. Each tally mark 7’
represents one case of the disease. After four tally marks cross it to make a block
of five cases. In a health centre, cases should be tallied every day, immediately
after the cases are recorded in the patient register. In a district office, cases are
tallied at the end of every month when all the health centres have submitted their
surveillance reports.
23
Look at Fig. 4 for an illustration of tally marks, showing, for example, that two
cases of polio, eleven cases of measles, and one case of neonatal tetanus were
diagnosed and tallied on the report.
On the last day of each reporting period, health centre medical officer should
total the number of cases of each disease tallied during that reporting period.
Record the total in the Monthly report. To this number will have to be added the
number of cases and deaths reported by the health workers on the basis of
information collected by them through the community based surveillance strategy
described earlier. Care should however be taken to avoid duplication of entries
by cross-checking the names and addresses of patients reported by the health
centre and by the health workers. This can best be done at the time of the
sectoral meeting in which the health workers and supervisors meet before the
PHC meeting.
District health officers should also total the number of cases of disease in the
district, after they have received the health centre reports. Like health centre
medical officers, they can record the total in the Monthly surveillance report.
Number Reported (as on 31.12.91)
D i sease
For the Month
Cases
Deaths
Cumulative since April
Cases
D i phther i a
Pertussis
///
14
Neonatal Tetanus
I
5
Tetanus (others)
///
9
Poliomyelitis (Acute)
//
6
Measles
AW AW /
190
Tuberculosis
Pneumonia
Under 5 years
Acute Diarrhoea
Dysentery
Maternal Deaths
(Reported)
: Before delivery
: During delivery
: Within 6 weeks of delivery
Figure 4 : Tallymarking of monthly surveillance report
24
Deaths
2.1.2
Investigate all cases of neonatal tetanus
As a Medical Officer you should use a case investigation form to investigate all
cases of neonatal deaths. The purpose of investigating neonatal deaths is to
identify why the case occurred so that future cases can be prevented.
When investigating a neonatal death, ask the mother of the neonate who died if
she is willing to answer some questions about her infant. Explain that the
information she provides will help you prevent future deaths.
With the case investigation form given on the facing page and ask questions listed
on the form and carefully record her responses. The questions are on :
♦
♦
*
*
*
♦
*
The immunization status of the mother.
Whether the mother received antenatal care.
The venue of birth of the baby.
Whether a trained attendant was present during delivery.
How the cord was cut and treated.
Whether the infant sucked normally at birth, then later developed problems
with sucking, convulsions and stiffness.
Whether the infant was treated in a hospital for the illness.
District health officers should monitor and ensure that neonatal deaths are
investigated promptly and correctly and help with the investigations himself or
provide additional training if health workers are uncertain of the procedures to
follow.
2.13
Make sure poliomyelitis cases are investigated
You must undertake special activities when notified of a case of suspected polio.
These activities are briefly summarized below. Refer to section 5.2 outbreak/case
investigation for details.
You have the responsibility for investigating polio cases. Do the following
immediately :
1. collect information using a case investigation form.
2. establish a provisional diagnosis.
3. collect and send laboratory specimen according to programme specifications.
4. enter data on the line list of lame children (see Annexure I a)
25
5. arrange for follow-up of case.
6. initiate community control activities after discussion with district officials.
7. include the case of polio in your regular monthly surveillance report.
8. report all activities to district and state officials.
2.1.4
Investigate all maternal deaths
In your monthly report, under the section A on surveillance, you are collecting
information on maternal deaths occuring in your area. A majority of these deaths
may be taking place at homes and in villages and some in the PHCs or other
institutions. Whenever you learn about a maternal death in your area you should
ensure that the death is investigated and the circumstances leading to the death
are determined. The form shown under Annexure Ic should be filled by the
health supervisor and checked by you or the medical officer of the PHC for
deaths occuring in your area. In addition, the sentinel surveillance centres will fill
in every month the report on maternal deaths (Annexure Vc) as well as analyse
the deaths taking place every year on the form Annexure Vic. As a manager of
the child survival and safe motherhood programme, you will try and determine
the causes of maternal mortality and also determine whether they are occuring
before, during or after child-birth or abortion.
26
Form No. 13
National Child Survival & Safe Motherhood Programme
Investigation of Neonatal Deaths
To be completed by the Medical Officer on all infants who died within the 1st month of life (a separate form for each neonatal death).
1.
General Information
1.
2
3.
4.
5.
II.
State/U.T
District
Town (Mohalla)/PHC (Villaagc)/Ward
Physician's name
Date of investigation
Backgroand Information on Neonatal Death
Name of Child
2
Sex
3.
4.
Father’s Name
5.
6.
7.
8.
111.
IV.
Address of child
Date of birth of child
Person interviewed by the Investigator
Relationship of person interviewed to child
Date of death of child
Mother’s Immunization History
1.
Does the mother know about vaccination with TT?
YES
2
No of doses received during this pregnancy?
10]
3.
4.
Date of last dose of TT
Card entry verified
YES
PJ
NO
[2]
[3]
NO
Infants Care since Birth (please circle appropriate answer)
2
3.
4.
5.
Where was the child delivered?
Who delivered the child ?
Hospital/Health Centre/Home/In the Fields/Other (please specify)-----------------------------------Doctor/DTV/ANXI/rr.TBAAJntr.Dai/Family members/Other (please specify)-----------------------------
How was the cord cut?
Sterile /unsterile (unboiled) Instrument
How was the cord dressing done? (use code) + (a=oil, b=cowdung. c=gentian violet, d=antibiotic, e=none and f=other)
When the child became ill, who treated the child? (use code) + + <a=govt. health centre, b=reg physician (allopathic/ayurvcdic/homeopathic),
c=unregistered physician and d=no treatment received)
6.
V.
Was the infant able to suck the milk after birth?
Did the infant stop sucking milk when illness began?
Did the infant have a fever?
Did the infant have convulsions?
Was the infant noted to be stiff?
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
NO
Other Information on Mother
1.
2
3.
VII.
within 2 hrs / 2-4 hrs / 4-8 hrs / 8-24 hrs / 24-48 hrs / > 48 hrs.
Symptoms preceeding infant’s death (pl<lease circle appropriate answer)
1.
2
3.
4.
5.
VI.
When was the child initiated on breast-milk?
Is the mother alive?
If dead, date of death
Symptoms precceding death
Medical Officer’s Diagnosis
1.
2
Cause of Neonatal Death
Cause of Mother’s Death
Date of Reporting:
Investigator's Name:
27
2.1.5
Prepare a disease map
In the health centre, a' disease map can be used to monitor the geographic
locations of cases of disease. It can help you learn whether cases are clustered in
one particular area or whether they are widespread. For example, by looking at
the map in Figure 5, you will notice that there are a large number of measles
cases in village G.
Use the map to monitor locations of cases of all diseases or of only some of them
such as measles, neonatal tetanus and poliomyelitis. In order to monitor the
locations of cases of diseases, follow the steps below. Every day, after you
diagnose and tally a case of disease:
1. Place a pin or draw a dot on the map to indicate the village where the case
of a particular disease occurred.
2. If you are monitoring locations of cases of more than one disease, use
coloured pins or dots, with each colour representing a different disease. If the
number of cases of a disease reported in your area is usually very large, you
may use a pin or dot to represent more than one case for example for every
five or ten cases. Remember not to place the pin for fractions or less than five
in that case.
If a case diagnosed and treated at the PHC belongs to a village outside its
geographic jurisdiction do not place a pin for that case. Notify the PHC or
district from where the particular patient was treated in your PHC.
3. At the end of each reporting period, record in a notebook the number of
cases that occurred at each village during the previous reporting period.
4. After you have recorded the number of cases of the target diseases in each
village, remove all the pins or dots from the map.
By just one look at the map you will be able to tell exactly where the target
diseases are occurring and how serious the situation is in each village, e.g. if the
map shows 11 cases of measles were reported in each of the 2 villages, one with
a population of 5,000 and the other with a population of 800, you could easily
interpret that the smaller village has a serious problem compared to the larger
village.
District health officers do not usually prepare disease maps because health
centres only report the address of cases under special surveillance. However, they
can map or plot cases by health centre or health facility. District health officers
should, however, monitor that health centres are preparing and using disease
maps.
28
o
0° 0
o°
|0
0
©♦
oo 0
a
D
♦
o
one case of polio
one case of measles
one case of neonatal tetanus
maternal deaths
Major Highway
Population data
All weather road
Village A 5,000
Village B 2,500
Village C 600
Village D 600
Village E 700
Village F 500
Village G 800
Village H 5,000
Foot Path
o
Village
Health Centre
5 Km.
Total Population 15,700
Figure 5 : Mapping of cases in a health centre area
29
2.1.6
Prepare disease charts or graphs
Disease charts and graphs are used to present surveillance data in a way that makes
the data easier to comprehend. They allow you to compare the number of cases
occurring in each reporting period to the number that have occurred in the past.
Plot cases of polio and neonatal tetanus, measles, diarrhoea on a disease chart (see
Figure 6) or a disease graph (see Figure 7).
Number of measles cases per month
Health centre "A” 1990
50
N
u
m
b
e
r
40
30
o
f
c
a
s
e
8
20
10
0
1
Jan
Feb Mar Apr May Jun
Jul
ir“
Aug Sep Oct Nov Dec
Figure 6 : A sample disease chart
To prepare a disease bar chart, perform the following steps:
1. Draw a blank chart, using the one in Figure 6 as a model. Note that the vertical
lines should be placed on either side of the name of months. On the left axis,
called "Number of cases", draw a line for each case or for a group of cases (for
example, for every 5 cases).
The numbers on the left axis should be based on the average number of cases
reported over previous years.
2. Write a title On the chart, making sure to identify the disease that is the subject
of the chart, the reporting period, the year and the health area.
3. On the last day of each reporting period, identify the number of cases of the
disease which were diagnosed at the health centre during the reporting period.
This information is obtained from the monthly surveillance report.
30
4. In the space for the reporting period on the chart, draw a bar representing the
number of cases diagnosed. Then shade in the boxes that represent all cases that
were reported.
Most health centres make disease charts for a 12-month period. The simple disease
bar chart below shows the number of measles cases reported per month at Health
centre A in 1990. The chart is filled in for January through May. Note that 7 cases
of measles were reported in January and 45 cases were reported in April.
Most district officers make disease charts or graphs that show disease trends over a
period of several years (See Fig. 7).
1 20
1OO
80
eo
<o
20
o
1987
1988
1989
1990
1991
Figure 7 : Disease trends over five years plotted on a graph
When you have completed preparing the disease bar chart or graph for various
diseases, display them in the health centre and district office. Displaying charts is very
helpful :
*
Charts help educate both health workers and members of the community about
the diseases that affect them. For example, use the charts to start a discussion on
how the health centre is able to improve the health status of the community.
♦
When a district health officer distributes copies of the district charts to health
centre medical officers, they can compare disease trends in their area to disease
trends in the district.
31
*
You will also be able to use deaths and provide valuable feedback to your health
workers and show them that you care about their work.
2.1.6
District health officers receive surveillance reports
Timeliness
District health officers should keep a chart on the wall to record dates of submission
of monthly reports by the health centres. By maintaining this chart, you can quickly
review which health centres and hospitals are reporting promptly. A sample chart is
given in Figure 8. A report received late has no value as beyond graphical
representation and academic discussion, no control action or feedback can be
initiated.
Reports should be submitted to the district within the first week of every month.
Remember : Health centres should submit reports even if no cases were seen. If
reports are late or missing or they are incomplete or late contact the health centre.
Determine the reasons for incomplete or delayed reporting and discuss how you can
help the health centre medical officers improve reporting.
DATES SURVEILLANCE REPORTS RECEIVED
District :
REPORTING
BASTAR
Year :
?91
Date of receipt of the monthly report of
UNITS
Health centre A
Jan
Feb
Mar
Apr
5/2
6/3
4/4
3/5
Health centre B
13/3
Health centre C
9/3
Health centre D
14/2
8/3
Health centre E
6/2
6/3
Health centre F
Hospital A
9/2
7/3
May
6/6
4/4
Jun
Jul
Aug
Sep
Oct
Nov
Dec
3/8
6/9
4/10
6/11
5/12
4/1
5/7
10/9
13/12
8/5
7/6
15 '5
8/6
9/7
11/4
10/5
5/6
6/7
7/8
10/9
9/5
9/5
20/9
20/9
20/9
16/4
8/5
9/7
6/8
11/9 12/10 13/11 12/12
14/6
8/10
14/9
9/11
13/11
15/10
9/11
4/1
8/1
6/12
7/1
27/12 27/12
Figure 8. Receipt of monthly surveillance reports
32
5/12
7/1
EXERCISE C
In this exercise you will total the number of cases on a monthly surveillance report and plot
on a disease chart the cases of measles that were reported over a period of one year. In a
later exercise you will analyze this information. Follow the steps below:
1. On page 24 is a Monthly surveillance k port for a health centre that has cases of disease
tallied on it for the month of December 1991.
2. The health centre supervisor of the health centre did not plot cases of measles on a bar
chart, so you will do it for him. Use the data from the Monthly report on page 24, plus
the following information about the number of cases in each month of the year, to make
the bar chart. Use the workspace given below to draw the chart.
The number of cases of measles for the first eleven months of the year are as follows:
January
February
March
April
May
June
July
August
September
October
November
December
25
32
28
17
12
11
9
10
9
12
14
(Refer to Figure 4 on page 24)
Year:
Health centre:
60
55
50
45
40
35
30
25
20
15
10
5
0
I
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sept
Oct
Nov
Dec
33
If you have brought information on the number of cases of disease in your area, draw
chart for one of the diseases here :
Health centre:
Year:
60
55
50
45
40
35
30
25
20
15
10
5
0
Jan
Feb
Mar
Apr
May
June
July
Aug
See the facilitator when you are
ready to discuss your answers
34
Sept
Oct
Nov
Dec
2.2
SENTINEL REPORTS
In most respects, sentinel sites are similar to routine reporting sites. Both collect
information about cases, investigate cases of selected diseases and deaths and
prepare disease maps and charts/graphs.
However, sentinel sites collect and report more information aoout each case.
They include the immunization status, age and sex of each case, in addition to the
total number of cases of each disease. Therefore, sentinel sites use a different
reporting form.
2.2.1
Sentinel surveillance for vaccine preventable diseases
Figure 9 is a Monthly Surveillance Report format used by sentinel surveillance
sites. The same general rule on using the form applies — both health centre and
district supervisors can use the same form, and they should use the form to tally
and total cases of disease. To complete the Monthly sentinel surveillance report,
follow the following steps:
1. Identify the age and sex of the case and the corresponding column on the
form. The age categories are: "less than 6 months of age", 6-11 months, 12-23
months, 2-5 years of age", and more than 5 years of age".
2. Determine the immunization status of the case:
"Not immunized" means that the case had not received the immunization that
should have given protection from the disease.
"Immunized’’ means 1 dose each of Measles and BCG vaccine and 3 doses
each of DPT and OPV vaccines received with the last dose given at least 15
days before the onset of disease.
"Not known" means that the immunization card is not available and that the
child’s mother or guardian cannot remember whether the child was
immunized for the disease or not.
NOTE: When determining the immunization status of a case of neonatal
death, you must consider the mother’s immunization status. Refer to the
Tetanus toxoid immunization dates entered in the mother’s card to determine
if the child was protected from neonatal tetanus.
3. Special attention will have to be paid to "timeliness" of immunization doses.
For example, if a child has been given measles either before the child was
eligible for the dose say at 6 months or well beyond the recommended age say
at 14 months, the child can still suffer from measles. This should be indicated
as a foootnote in the.sentinel surveillance report.
4. Tally each case in the appropriate column on the form.
35
5. At the end of each month, total the number of cases in the "Total cases"
column.
NOTE: If sentinel sites are considered part of the routine reporting system, the
total number of cases of disease reported by sentinel sites should be included in
the district total.
Sentinel Centre
District
State
Month
Disease**
Year
Cases
Deaths
Description
M
F
M
F
Immunization status
Immu
nized
Not
immu
nized
Un
known
Total
less than 6
months
6-11 months
12-23 months
(<2 years)
2-5 years
> 5 years
Total
*
Immunized children should have received :
1 dose of of Measles and BCG and 3 doses of DPT and OPV vaccines
(last dose received at least 15 days before the onset of the disease).
Note: Do not include a case of poliomyelitis, if history of onset is 3 months or
more. All cases of brochopneumonia or severe diarrhoea who give a
history of measles or pertussis one month prior to illness should be
included under measles or pertussis.
♦*
Use this formal for each one of the six vaccine preventable diseases - Diphtheria, pertussis,
tetanus, poliomyelitis, measles and tuberculosis; one form each for one vaccine preventable
disease.
Figure 9 : Monthly sentinel surveillance report - vaccine preventable diseases
36
2.2.2
Sentinel surveillance for diarrhoea and pneumonia
Figure 10 is a monthly surveillance report format used by sentinel surveillance site
for reporting cases and deaths of diarrhoea and pneumonia. While the information
on diarrhoea is collected by age groups similar to that followed for vaccine
preventable diseases the age groups for pneumonia is i) <2 months, ii) 2 to 12
months, iii) 1 to 5 years and iv) >5 years.
Sentinel Centre
District
State
Month
Disease**
Year
Diarrhoea
Cases
Deaths
Description
F
Not
given
Deaths
Vitamin A Prophylaxis
Full
M
F
M
T
Vitamin A Prophylaxis
Partial
Measles
Immu
nization
o
t
a
1
less than 6
months
6 - 11 m
12 - 23 m
2-5 yrs.
> 5 yrs.
Total
Disease**
Pneumonia
Cases
Description
Full
M
F
M
F
Partial
Not
given
Measles
Immu
nization
T
o
t
a
1
< 2 months
2 - 12 m
1-5 yrs.
> 5 yrs.
Total
Date :
Signature
Figure 10 : Monthly sentinel surveillance report - diarrhoea and pneumonia
37
In addition to including information on the age and sex of children with diarrhoea
and pneumonia, you will also determine the measles immunization status and
whether the child has received the appropriate number of vitamin A megadoses
for that age as per schedule of the Child survival and safe motherhood
programme.
2.23
Sentinel surveillance for causes of maternal mortality
Every health centre will report maternal deaths as part of the monthly reports.
In addition, line listing will be done for of all maternal deaths occurring in a PHC
area and the district as discussed under 2.1.4.
In addition, the sentinel surveillance centres will prepare an analytical report once
a year in April on all maternal deaths that have taken place during one year
(from April to March). A specimen copy of the format is given below. As a
medical officer of the sentinel surveillance site you will report the number of
maternal deaths by the six complications you will attempt to care for in the first
level referral centre.
ANALYSIS OF ANNUAL DATA FROM SENTINEL SURVEILLANCE Maternal Deaths
1.
Sentinel Centre
2.
District
3.
State
4.
Year of Reporting
5.
Total no. of deliveries in the year
SI.
No.
1.
Maternal deaths
Tetanus
Causes
Number
Total
Unimmunized moihers
Immunized
2.
Bleeding
Antepartum
Post-partum
3.
Sepsis
Post-Abortion
Post-delivery
4.
Obstructed Labour
Rupture Uterus
Not ruptured
5.
Toxaemia of
Pregnancy
With convulsions
Without convulsions
6.
Anaemia associated
Severe <6 gm/100 ml
Moderate 6-10 gms/lOOml of Hb
Date :
38
Signature
3.0
ANALYZE DATA
Plan
for
surveillance
1.0
Collect and
compile
data
2.0
Analyze
Data
Take
Action
3.0
4.0
Data obtained from routine and sentinel surveillance systems should be analyzed at
every level of the health system. Analysis at a health centre is important so that
problems are identified at the level where action can be taken quickly. When
analyzing surveillance data, it is important to look for:
*
*
*
trends in disease occurrence
clustering of cases in certain areas/periods of time and
changes in age groups
Start analyzing data by asking yourself "Why did the case(s) occur?" By doing this,
you will take the next step i.e. identify the specific action that you must take. You
cannot find solutions to problems unless you know the causes of the problem.
Both health centre and district health officers follow the same procedures when
analyzing data from routine reporting. You identify disease trends and identify causes
of the trends and review neonatal death and poliomyelitis case investigation forms.
District health officers perform additional analysis with data from sentinel sites.
Different methods of data collection give various types of information. The following
information can be obtained by analyzing routine and sentinel surveillance data:
ROUTINE REPORTING Disease trends by time and area
SENTINEL REPORTING Disease trends by time in selected areas (to serve as
advance warning and indicators of the effectiveness of
services)
Age distribution of cases
Sex distribution of cases
Immunization status of cases
39
3.1
ANALYZE DATA FROM ROUTINE REPORTING SITES
There are two key steps in analyzing data from routine reporting sites:
First, identify disease trends by looking at the total number of cases and
deaths that occurred and compare with the number reported in previous
months and previous years. Are the numbers higher, lower or about the same?
What are the most probable reasons for it?
Next, review the following forms :
I
Line lists for (i) neonatal deaths, (ii) acute poliomyelitis i.e. list of lame
children and (iii) maternal deaths ;
II
Case investigation forms for (i) neonatal deaths, (ii) acute poliomyelitis
and (3) diarhoea/cholera deaths (during epidemics)
You will have to ensure that every maternal death, neonatal death and case
of poliomyelitis reported in the monthly PHC report as well as the report of
the health workers (based on their community based surveillance information)
is investigated in detail and the relevant case investigation forms / line lists are
completed. During outbreaks of gastroenteritis, your workers may have to fill
in diarrhoea/cholera investigation forms as well (see section 5.0)
3.1.1
Identify disease trends and their causes
The term "disease trend" refers to whether or not there are changes in the
number of reported cases of disease over time. Unexpected increases can be
a sign of failure. Decreases can signal either success or reporting failure.
Seasonal trends in vaccine preventable diseases suggest that there is a problem
with immunization coverage and/or vaccine quality.
In routine and sentinel reporting systems, there are five major factors which
influence the number of reported cases of a disease:
*
*
*
*
*
Completeness and timeliness of reporting
Seasonal variation
Epidemic pattern
Immunization coverage
Age at immunization
These factors are described in detail in the following pages.
40
Completeness of reporting
Changes in the number of reported cases can be caused by real changes in the
incidence of disease or by changes in the way that cases are reported. Two
major reasons for changes in reporting are:
1
,?sr^'
2-
a.
Changes in the women’s awareness and willingness to make use
of the ante-natal, intra-natal and post-natal care offered by the
health centre;
b.
Changes in parents’ attitudes in the use of the health centre
when they have a child with a reportable disease and
c.
Number of units reporting cases can either increase or decrease.
This is closely linked to timeliness. In a district if only certain
health centres report in time, the district report will be
incomplete.
Changes -in the skill and interest of health, worker in gagnoSing,
recording and reporting the cases they see.
For example, when you take steps to increase the utilization of health services
by the community, more patients may be encouraged to come to the health
centre and you may at the same time increase the interest and skills of your
health workers. Therefore an increase in the number of reported cases may
be a sign of improvement in the services, rather than a sign of increased
disease in the community!
However, if neither of the above conditions have changed since the previous
reporting period, you can be more confident that comparing the reported
cases with those of past periods will tell you the actual trends in the diseases.
Seasonal variation
Some diseases occur in seasonal patterns. This means that there is a season
in which more cases occur than at other times of the year. The seasonal
variation for some diseases (for example, pertussis, polio, measles) are more
noticeable than those for other diseases (such as tuberculosis, tetanus). When
immunization coverage increases, the seasonal variation is less obvious.
The season in which most cases of any disease occur is different in different
geographic areas. Also, not all diseases peak during the same season.
Therefore, you must use your disease charts to learn when the seasonal peaks
of each disease occur in your area.
41
Number of cases of measles per month 1991
50
40
30 -
20 -
10 -
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov Dec
Figure 11 : Seasonal variation of measles
Figure 11
above shows the seasonal variation of measles. Notice the increased
number of cases in February, March, April and May.
When analyzing surveillance data, think about how seasonal variations may explain
the increased or decreased number of cases. Ask: Is the increased or decreased
number of cases likely due to seasonal variation?
Epidemic pattern
An "epidemic" is defined as the occurrence in a community or region of illnesses
similar in nature clearly in excess of the usual incidence.
Some diseases naturally occur in epidemic and non-epidemic years. That is, an
epidemic year will occur, followed by 1, 2, 3, or more years with relatively few cases
of the disease, followed by another epidemic year. When immunization coverage
increases, the epidemic pattern change and the time interval between epidemics
increase.
When disease incidence reach low levels due to effective immunization activities, no
clear epidemic pattern may exist. Even one case may justify careful investigation and
possible control measures. This is especially true for polio, when, after a break of
several years, a case may be introduced, necessitating immediate action.
42
Figure 12 : Epidemic pattern and seasonal variation
The epidemic pattern varies among different areas and every disease manifests a
different pattern. Epidemics of some diseases are more frequent than others. You
must therefore, use disease charts and graphs to learn about epidemic patterns of
diseases in your area. Figure 12 above shows the epidemic pattern and the seasonal
variation of measles. Note the difference between the two types of disease trends.
When analyzing surveillance data, consider the influence of epidemic paterns by
asking: How does this year’s pattern compare with previous years? Can the increase
(or decrease) be explained by the epidemic pattern?
NOTE: An unchanged epidemic pattern for vaccine preventable diseases, especialy
measles and pertussis, means that the immunization activities need improvement.
Immunization coverage
The purpose of immunization is to reduce the number of cases of vaccine
preventable diseases. Therefore, if immunization coverage increases and vaccines of
high quality are used, number of cases will decrease. Similarly, if coverage decreases,
you can expect more cases of the disease. An example is found in the history of
tetanus in District D as shown in Figure 13 in page 44. Note how quickly the number
of cases decreased as immunization coverage increased.
43
l
80
12
70
10
fa2
Xi
N
NON-NEONATAL TE’ANUS
60
A (H
!|
8
50
O
•H U-l
a
o o
O -H
O 4->
- aj
O r-l
E -P
6
IMMUNIZATION COVERAGE
OF PREGNANT WOMEN
WITH 2 DOSES OF TT
4
■
o
(D O
4-> O
(0 M O
O
/
/
/
/
40
in
30
tn <u
20
U-l
a
O
dP
2
NLONAIAL IL I ANUS
10
■I
0
70
72
74
76
78
80
82
84
86
88
90
0
Figure 13 : Tetanus in District D
If all children in the target population are immunized with a vaccine of good quality,
there will be very few cases of disease. Yet, even with 100% coverage, you will see
some cases of disease. This is because no vaccine is 100% effective, and because
unimmunized people may move from other areas into your area.
• However, any case in an immunized child must be investigated thoroughly. First
confirm the diagnosis in such cases and confirm the history of immunization at least
2 weeks prior to the illness. If more than 10% of all cases were in children who were
immunized then the vaccine used was not potent. This is an emergency for your
programme.
Age at vaccination
Vaccines must be given at the right age in order to be effective. All efforts must be
made to complete the full course of immunization as early as possible but definitely
before the first birthday. Measles vaccine is not administered before 9 months of age.
It is important to administer vaccines before the child has been exposed to the risk
of infection i.e. every child should be immunized against measles before it attains the
age of one year. If vaccines are used up for children who are already immune
through natural infection, it is a waste. Such an effort will not reduce the load of
susceptibles within a community.
44
S'
Timeliness
The national immunization schedule indicates the ideal time schedule for every
antigen. It is advocated that all children need to be fully immunized by age one. It
is important to immunize a child with any dose of vaccine / antigen as soon as the
child becomes eligible for the same. Among the important reasons for less than
expected impact is delay in timely immunization. Therefore, to get maximum
epidemiological impact of reduction of various vaccine preventable diseases timely
immunization by age is absolutely essential. You will, while analyzing the
surveillance reports, have to specifically ask your health workers whether this is being
done.
When analyzing surveillance data, check the immunization reports and ask: Are
immunization reports correct and are the calculated coverage levels accurate?
*
*
*
If coverage is going up, is the number of reported cases going down?
If coverage is going down, is the number of reported cases going up?
Are immunized people getting the disease from which they should be
protected?
45
EXERCISE D
This exercise is to understand the various ways in which reported data is interpreted.
A wrong interpretation must be avoided. To avoid misinterpretation more details of
the process of collection of data and the related factors are to be provided.
1.
5 hospitals in Koraput district reported deaths due to diarrhoea inthe year
1991. The total number of deaths were 240. From the records of previous 4
years the number of deaths due to diarrhoea were 190 (1990), 165 (1989), 135
(1988) and 100 (1987) respectively. Now plot these figures on a graph paper
and comment on the graph.
Are the number of deaths due to diarrhoea increasing or decreasing in the
district: (Please circle the correct answer)
Increasing / De creasing / Not sure, want more details
2.
Rayagada hospital has sent without fail the reports on deaths due to diarrhoea
to district headquarters at Koraput from 1987 onwards. The annual figures are
100, 110, 120, 130 and 140 for 1987, 1988, 1989, 1990 and 1991 respectively.
Now plot these figures on a graph paper and answer the following question:
Are the number of deaths due to diarrhoea increasing or decreasing in
Rayagada area? (Please circle the correct answer)
Increasing / Decreasing / Not sure, want more details
Once you are ready please inform the course facilitator. Those who have
ticked "Not sure, want more details" deserve to be congratulated. Others may
ask "why?" Now read:
Misinterpretation of data
Several factors can influence the reporting of number of cases. You will have to
carefully review the possible reasons for ’increase’, ’decrease’ or ’no change’ in
number of cases reported by your centre.
Analysis of your data should be .thorough. Unless it is carefully analysed, mere
plotting a graph of the total number of cases reported may not provide the true
picture. In 1991 there were 5 hospitals reporting in Koraput district: Rayagada (A),
Gunupur (B), Koraput (C), Umarkot (D) and Kodinga (E). If only a summary of
total cases is plotted, it appears that the number of deaths is increasing. Figure 14 on
the facing page illustrates this point.
46
r 1
Koraput district - total diarrhoeal deaths by year
250
200 -
150 -
100
50
O—
1987
1989
1988
1990
1991
Figure 14 : Diarrhoeal deaths in Koraput district
Although earlier we felt that the diarrhoeal deaths in Koraput have been increasing
every year, you will notice from the table below that the number of reporting units
have also been increasing through the years. The increase thus is pronounced due to
increase in number of reporting units.
Increased Reporting sites
Hospital
Hospital A
1987
1988
1989
1990
1991
100
110
120
130
140
25
30
25
30
15
20
20
15
20
Hospital B
Hospital C
Hospital D
30
Hospital E
Total Cases
100
135
165
190
240
47
Increasing completeness of reports
One method of overcoming incompleteness of reporting from multiple sites is to
choose what is known as a sentinel site - an institution that consistently and
completely reports all cases of the diseases under the programme. At first glance,
hospital A in the previous example would seem to fit that criteria. But, once again,
it is important to look beneath the surface of yearly compilation of reports. For
example, it is possible that the hospital has not completely reported for every month
of the year. The table below illustrates this point very well.
Months
January
1987
1988
5
February
10
March
25
1989
1990
1991
15
10
10
10
15
15
15
15
April
25
20
May
30
30
June
30
July
10
August
September
15
20
15
15
10
5
15
20
15
October
10
10
20
10
20
20
10
10
November
10
December
25
15
Total Deaths
100
110
120
15
5
130
140
Further, when we analyse the information given in the table abovee and calculate the
average monthly diarrhoeal deaths in Hospital A, you will note that the death rate
has been actually coming down. The table on the facing page illustrates the decrease
which becomes obvious after analysis.
48
Average diarrhoeal deaths at Hospital A
Year reported
1987
1988
1989
1990
1991
Total Number of diarrhoea
deaths
100
110
120
130
140
No. of months reporting
done in the year
5
6
7
9
12
Average monthly deaths due
to diarrhoea
20
18.3
17.1
14.4
11.7
Increasing number of non-residents
Now consider the situation of a sentinel hospital that consistently and completely
reports all deaths due to diarrhoea. In an area with improved standards of living and
transportation increasing number of persons residing outside the normal catchment
area of the hospital have access to the referral hospital. The number of deaths due
to diarrhoea may be higher due to the increasing number of non-residents. If the
yearly summary of total cases is plotted, the graph will show an increase in number
of deaths. However, when the deaths among residents and non-residents is analysed
and plotted separately the picture becomes clearer.
Number of diarrhoeal deaths in a sentinel hospital
160
140 120 ~
100 80 -
60 40 20 -
0
Residents
Non-residents
Total cases
1987
1988
1989
1990
1991
90
10
100
90
20
110
95
25
120
95
35
130
100
40
140
Figure 15 : Deaths in a sentinel hospital amongst residents and non-residents
49
Population size in catchment area
Another reason for an apparent increase in the number of deaths can be the
changing population size of the community. This is particularly important, if migration
of people into or out of area or part of the area is considerable. The best way in such
cases is to convert the absolute number of cases into rates. Rates take the changing
population size over time into account. The following data and graph illustrate this
point. Now finally, it is possible to understand the true impact of the programme
interventions.
Increased population in catchment area
Year reported
1987
1988
1989
1990
1991
Resident cases
90
90
95
95
100
Catchment Population
10000
12000
14000
16000
18000
9
7.50
6.79
5.94
5.56
Rate in residents (per 1000)
Figure 16 : Diarrhoea rate in resident population
The above discussion on deaths due to diarrhoea demonstrates the concept of
epidemiological surveillance, the methods commonly used, the changing needs of
surveillance during different stages of programme development and some of the
problems in interpretation of data.
Remember Surveillance requires thoughtful and thorough analysis. Simple
addition of number of cases reported by various institutions in the area does
not give a true picture of the disease trends in the community.
50
3.2
REASONS FOR VARIOUS DISEASE TRENDS
✓
Determine whether the disease incidence in an area is increasing or decreasing
by reviewing your disease charts or graphs. Compare the number of cases
reported in a particular month with the number of cases in previous months.
Select one of the two sets of guidelines below to identify causes of the disease
trend.
3.2.1
If disease trends are increasing:
1.
Check surveillance reports for counting errors.
2.
Check for increase in the number of reports received. If more health
facilities are reporting, or if facilities are reporting more regularly, the
increase in reported cases may be due to more thorough reporting
rather than to more cases.
3.
Check to see if the increase is expected, according to the seasonal
variation.
4.
Check to see if the increase is likely and according to the epidemic
pattern.
Check to see if the increase can be explained by any new situation,
such as migration of susceptibles into your health area e.g. during mela
or festival; breakdown of water supply etc.
6.
Compare present service coverage levels with previous levels. If
coverage is decreasing, you may see an increase in the number of
cases.
It is important to investigate poor downward trend in the disease
incidence inspite of improved services.
7.
Check for changes in staff or procedures which could cause changes in
diagnoses, timeliness or completeness of reports. The number of cases
that are reported may increase if, for example, more qualified
personnel have been assigned to collect data or if certain facilities have
begun to have more contact with communities they serve.
Visit locations reporting larger number of cases. Health centre medical
officers can see this on the disease map.
8.
Check that health workers are diagnosing cases correctly using lay or
standard case definitions.
.
chioi
community he*lth cell
326. V rin | .uck
Koramong
Bangaiore-56vU34
India
51
9.
Determine the immunization status, sex and age of cases from the
health centre register.
10
Calculate the percentage of all cases in immunized children, using the
formula:
No. of cases in
immunized children
x 100 =
All Cases (immunized
plus unimmunized)
11
Percent cases in
immunized children
A general rule is that if more than 10% of all cases were in children
who were immunized, you may have a problem with vaccine efficacy.*
Check the immunization services for any problems that might be
responsible for an increase in the number of cases. Some of them
could be:
a)
b)
c)
d)
12.
cold chain failure leading to poor vaccine quality
incorrect immunization schedule followed by workers
over-reporting of immunization coverage
incorrect reconstitution/handling of vaccines
Whether there is availability of safe drinking water in adequate
amounts.
If your analysis suggests there is an actual increase in disease, warn
your supervisor that an outbreak may be occurring. Explain what you
think may be the reason for the increase.
* Note:
52
As immunization coverage increases, higher proportion of cases
occur in immunized children (could be more than 10%). For
example, in an area with 100% coverage for measles vaccine all
cases (100%) of measles above 9 months of age will occur in
children who are already immunized. This could be either due
to poor vaccine quality or biological/immunological variation of
some children. For further details on vaccine efficacy see
Annexure II.
3.2.2
If disease trends are decreasing:
1.
Check surveillance reports for counting errors.
2.
Check for decrease in the number of reports received. If fewer
facilities are reporting, or if facilities are reporting less regularly,
the decrease in reported cases may be due to less thorough
reporting rather than fewer cases.
3.
Check to see if the decrease is expected, according to the
seasonal variation.
4.
Check to see if the decrease is likely and according to the
epidemic pattern.
5.
Check to see if the decrease can be explained by any new
situation, such as children moving out of your health area or
increased immunization coverage etc.
6.
Compare the coverage levels with previous coverage levels. If
coverage is increasing, you may see a decrease in the number
of cases.
7.
Check for changes in staff or procedures which could cause
changes in diagnoses or completeness of reports. The number
of cases that are reported may decrease if, for example, health
centre personnel have been given additional duties which
conflict with data collection.
Investigate if there is a sudden decrease in numbers.
Visit locations that report smaller number of cases as part of
routine supervision. This is very important especially when a
NIL report is coming from an area which has low immunization
coverage.
8.
Review records and look for additional, unreported cases.
If the decreasing trend cannot be explained by any of these reasons,
your area has an actual decrease in the number of cases.
Congratulations!
53
EXERCISE E
In Exercise C, you plotted the cases of measles for a health centre. In this exercise,
you will use that information to:
1)
Determine whether the disease trend for measles at the health centre is
increasing or decreasing, and
2)
Identify the reasons for the trend.
To do this, read the results below of an inquiry conducted by the health centre
medical officer. Think about reasons for the disease trend, following the steps just
described in the preceding pages. Then record the answer to the question, "What are
the possible explanations for the increased/decreased number of cases, compared to
last month?"
The results of the inquiiy at the health centre are as follows:
The health centre medical officer checked the patient register to make sure that all cases
were recorded accurately and found no problems.
A review of immunization records showed that fewer children have received measles
immunization every month for the past six months.
He noted that an increase in measles cases occurred last year in December, January,
Febmary and March. However, the increase this year h greater than the increase noted
last year.
He also observed that a health worker immunized a 5-month-old child with DPT 3 and
measles at the same time. When he asked the health worker why she gave measles
vaccine to children who were too young the worker replied that it was because so many
children do not return at the age of 9 months for measles alone.
Finally, he checked health centre records to get the immunization status of all cases and
found that 12% of all cases were in immunized children.
54
EXERCISE F
In this exercise you will practice filling a neonatal death investigation form. Follow
the instructions below:
1.
Review the neonatal death investigation form provided on page 56.
2.
Decide if this is a case of neonatal tetanus and if the case could have been
prevented. Give at least 5 ways on how it could have been prevented.
3.
Identify 5 steps you will take in your PHC/District to prevent similar deaths
from occurring.
See the facilitator when you are
ready to discuss your answers
55
Form No. 13
National Child Survival Sc Safe Motherhood Programme
Investigation of Neonatal Deaths
To be completed by the Medical Officer on all infants who died within the 1st month of life (a separate form for each neonatal death).
I.
General Information
1.
2
3.
4.
5.
Stalc/U.T
District__
Town (Mohalla)/I’l IC (Villaagc)/Ward
Physician’s name____________ .
II.
Background Information on Neonatal Death
1.
2
Name of Child
f? k,CLY\
Pfri Jta cL______
Date of investigation
3.
4.
Sex
Father’s Name
Address of child
5.
Date of birth of child
6.
7.
8.
Person interviewed by the Investigator
Relationship of person interviewed to child
Date of death of child
- ] /- *7^
III.
Mother’s Immunization History
2
Docs the mother know about vaccination with 'IT?
No of doses received during this pregnancy?
3.
4.
Date of last dose of TT
Card entry verified
IV.
Infants Care since Birth (please circle appropriate answer)
10^/
IQ//
<
,
/A
NO,
(W) 11]
12]
13]
-—
YES
6.
I lospital/l Icalth
lomy/ln the Ficlds/Othcr (please specify)
Where was the child delivered?
Doctor/IJ IV/ANM/rr.’l'BAXhilnDaijrarnily members/Other (please specify)
Who delivered the child ?
Sterile XInsterilc\unboiled) Instrument
How was the cord cut?
How was the cord dressing done? (use code) + (a=oil, =cowdungSc=gcntian violet, d=antibiotic^t^nn5fic and f=other)
When the child became ill, who treated the child? (use codcj + + (a=govt. health centre, b=rcg physiejan (allopathic/ayurvedic/homcopathic),
c=unregistered physician andlds iojjratmcnl received)
within 2 hrs / 2-4 hrs / 4-8 hrs / 8-24 hrs p4-48 hrs* > 48 hrs.
When was the child initiated on breast-milk?
V.
Symptoms preccedlng Infant’s death (please circle appropriate answer)
i
2
Did the infant stop sucking milk when illness began?
2
3.
4.
5.
4.
5.
Did the infant have a fever?
Did the infant have convulsions?
Was the infant noted to be stiff?
VI.
Other Information on Mother
1.
2
Is the mother alive?
3.
3.
VII.
Medical Officer's Diagnosis
1.
Cause of Neonatal Death
2
Cause of Mother’s Death
Date of Reporting:
YES
NO
NO
NO
If dead, date of death
Symptoms precccding death
56
NO
NO
Was the infant able to suck the milk after birth?
Q|
Investigator’s Name:
3.3
ANALYZE DATA FROM SENTINEL REPORTING SITES
The district health officer uses data from sentinel sites to: .
*
Compare data from the routine reporting sites with data from sentinel
sites in the same area to determine how well the routine reporting
system is working.
♦
Determine whether there is a shift in the age groups affected by a
disease.
*
Calculate vaccine efficacy (see Annexure II).
In addition, data from sentinel surveillance will allow you to obtain and
analyze data on cases and deaths in different age groups as well as relate
them to the protection levels i.e. by immunization and vitamin A prophylaxis.
3.3.1
Compare data from routine reporting data from sentinel reporting
Since sentinel data are more elaborate and likely to be complete when
compared with than those from routine reports, you can use them to learn
about problems with the routine reporting system.
FOR EXAMPLE:
Sentinel site B reports a sharp increase in measles cases and the routine
reporting sites report only a slight increase. The district supervisor visits the
routine reporting sites and comes to the conclusion that several sites are not
In this situation, the district supervisor learns
reporting every diagnosed case. 1_.
two things:
First, that there is probably a significant increase in the number of cases of
measles; and
Second, that health centre medical officers are having difficulties with
surveillance activities and may need additional training or increased
supervision.
NOTE: If you do not have a sentinel site in your district, one of the options
you have is to use data from routine reporting sites which report reliabily and
in time.
57
3.3.2
Determine whether there is a shift in the age groups affected by a disease
As immunization coverage increases, you will see an increasing number of cases
occurring in older children. This is because vaccines are never 100% effective, and
the number of people who were immunized but not protected (due to vaccine failure)
will gradually accumulate over time. Thus, there will be an increased number of cases
in older individuals.
Since sentinel reports contain information about the number of cases in both children
below and above 5 years of age, you can use this data to determine whether there is
a shift in the age group affected by a disease. This can be done by comparing the
number of cases in the relevant age group at a particular period with the number of
cases in the same age group at an earlier period.
3.3.3
Calculate vaccine efficacy
Vaccine efficacy provides information on the ability of a vaccine to prevent disease
when used in routine immunization services. District health officers may calculate
vaccine efficacy at the end of the year, using sentinel data, when evaluating the
immunization services.
The procedure and formulae for calculating vaccine efficacy is given in Annexure-II.
3.3.4
Retrospective analysis of data from sentinel centres
In the Annexures Va to c are given the formats for carrying out retrospective analysis
of information from sentinel sites. These are :
Va
Vb
Vc
Cases of vaccine preventable diseases
Cases of diarrhoeal diseases and pneumonia and
Maternal deaths and their causes
Every attempt should be made to analyse the complete information for the year on
these formats and obtain additional information related to sub-groups of age and
relate the incidence of diseases to the protection status of children. Further, analysis
of the complications in pregnancy or labour which have resulted in maternal deaths
will help you to identify the training needs set priorities in terms of infrastructural
development and resource mobilization for your hospitals.
58
4.0
TAKE ACTION
Plan
for
surveillance
1.0
Collect and
compile
data
2.0
Analyze
Data
Take
Action
3.0
4.0
Surveillance is "data collection for action". Purpose of any action is to solve problems
in programme implementation and reduce the number of cases of disease. Action
may be necessary even if immunization or other services are working well.
Congratulate your staff for a job well done and look for ways to improve services to
reach the programme goals.
Identifying corrective action is a responsibility of health functionaries at every level.
However, it is more important for prompt action at the level of health centre as it
is at this level that child survival and safe motherhood services are delivered.
4.1
IDENTIFY PROBLEMS AND IMPLEMENT SOLUTIONS
When you analyzed surveillance data, you identified problems and answered the
question, "Why did deaths or case(s) occur?" In this section, you will identify solutions
by answering the question, "What can I do to prevent deaths or cases from occurring
for the same reason in the future?" Solutions must address the cause of the
problem(s).
When identifying problems, health centre staff should:
*
*
identify possible solutions, and
take immediate action.
They should act as quickly as possible - sooner the solutions are sought and
implemented, fewer the morbidity and mortality.
When identifying problems by reviewing surveillance reports of health centres, district
health officers should:
*
*
identify solutions for problems that are area specific and
take action.
When reviewing reports from health centres, as a district health officer you should
ask: Is the analysis of problems by medical officer of health centre and the
recommendations made reasonable? Do they address the causes of the problems?
59
PROBLEMS IN REPORTING - CAUSES AND SOLUTIONS
Report
An increase in the
number of measles
cases among
immunized children
from a health centre
Possible causes
Refrigerator is too warm and the temperature
is not recorded on a daily basis
Proposed action
Assign responsibility for maintenance of
refrigerator and supervise the temperature
records being maintained
Health workers give measles immunization to
children before the recommended age
Provide new vaccines
Train health workers to use the immunization
schedule
Number of reported
cases of polio is
increasing
Number of reported
cases increuses
shnrply
Cold chain failures occur
Repair the cold chain
Improved reporting of cases
(Congratulate health workers for improved
reporting
Decreased immunization coverage
Increase immunization coverage
Refugees enter the area
Immunize the children of the refugees
New outreach by health workers results in more
cases seen
If increased number of cases reflects better
surveillance, congratulate health workers
Increase immunization activities to reduce the
impact of the epidemic pattern
Health workers do more follow-up on drop-outs
and see more cases
An increase is expected according to the
epidemic pattern
Gear your system for better disease control
measures
If polio outbreak, immediately notify your
supervisor
Possible outbreak is occurring
Cases of neonatal
tetanus occur in
babies born to :
a) Unimmunlzed
mothers
b) immunized
mothers
Mothers receive antenatal care but are not
immunized with Tetanus Toxoid
Mothers are visiting the health centre for
reasons other than immunization and arc not
immunized
Ensure 5 cleans for delivery
Train health workers to immunize women
when they come for antenatal care and for
other reasons, and to immunize all women of
child bearing age
Support and encourage health workers
Vaccine exposed to room temperature for too
Reported cases of
measles and
pertussis are
decreasing
long
Ensure quality of vaccine by following cold
chain requirements
Fewer surveillance reports are received
Investigate to find out the decrease is due to
less reporting or a real decrease in disease
Immunization coverage increases, therefore
there arc fewer cases
If appropriate, congratulate health workers.
If the analysis seems appropriate, provide the health centres with the needed
resources and support to implement the solutions. If you have additional ideas on
what the problems are and how they can be solved, mention them to the health
centre medical officer.
If the analysis does not seem appropriate, contact the health centre medical officer
and discuss why you have a different analysis. Listen carefully to the explanation of
the health centre medical officer (s)he may be right!
60
Every health centre and district will identify various solutions, depending on the
policies, available resources and the creativity of the health staff. To assist you, the
chart on the previous page outlines some solutions for common problems, and causes.
4.2
SUBMIT SURVEILLANCE REPORT
After analysis of surveillance data and taking action, send a report to your supervisor.
The heatlh centre medical officer will submit a report to the district health officer
and the district health officer to the regional or national level.
The Monthly surveillance report from health centres to the district officer should be
sent within the first week of the month, and this report shall include:
*
*
♦
the number of cases of each disease;
an analysis of why the trend is in a particular way;
a summary of action taken or that recommended (such as an outbreak
investigation)
In addition, health centre medical officer should submit a copy of all completed
neonatal tetanus death investigation forms to the district office.
Remember! As an efficient
strategy for polio eradication,
you should report every case of
polio immediately. Do not wait
until the end of the month.
61
4.3
PROVIDE FEEDBACK
Information must be shared promptly with all health functionaries involved in the
surveillance system, regardless of what the analysis shows. However, feedback, often
remains a neglected activity. Feedback shows that information reported is used and
appreciated. Thus, feedback will improve accuracy, timeliness and completeness of
reports and raise the morale of your staff.
Feedback includes:
*
comments on timeliness, completeness and accuracy of reports
*
information on the total number of cases of each disease in the district
*
comparisons of data from different geographical areas
*
information on the effectiveness of services
*
suggestions for improving reporting
*
information that will be helpful in solving problems
*
information on action taken
*
words of encouragement for a good job done or to do better
Methods of providing feedback include:
62
♦
supervisory visits to health centres
*
monthly or quarterly newsletters
*
periodic meetings
*
telephone calls
*
letters
*
discuss with functionaries visiting your office for administrative issues
*
any other time you meet the concerned functionaries
EXERCISE G
Vaccine preventable diseases are widespread in the unimmunized communities. It has
been estimated by WHO that 80% of children will suffer pertussis, 90% measles if
unimmunjzed.
Sample surveys conducted in 1981 and 1982 in India revealed the annual incidence
of poliomyelitis and neonatal tetanus mortality as indicated in Annexures III & IV.
Your PHC has a population of 30,000. Birth rate is 30/1000 and IMR is 100/1000 live
births. The reported coverage in your area is 60% for 2 doses of tetanus toxoid to
pregnant women, 70% of infants with 3 doses of OPV, and 65% with measles. Herd
immunity is not taken in account.
Now answer the questions below:
1.
How many cases of neonatal tetanus, polio, whooping cough and measles
would you expect in your area if there was no immunization programme?
2.
How many cases of the above diseases would you expect assuming that the
coverage given above is correct?
63
EXERCISE II
Answer the following questions in the space provided. Then share your answers with
others in a group discussion. (Some of these questions are for health centre medical
officers. If you are district health officer and the question does not apply to you,
describe what health centres in your area should do.)
1.
Do you prepare disease maps? If yes, for which diseases? If not, what are the
reasons for not preparing them?
2.
Do you prepare disease charts? If yes, for which diseases and over what
period of time? If not, what are the reasons for not preparing them?
3.
Do you investigate all cases of neonatal deaths that are reported to your
health centre? If not, why?
If you do investigate every case, do you collect complete information on every
case that is listed in section 2.1.2 of this module? If not, what is not collected?
and why?
What will you do to prevent cases of neonatal tetanus in your area?
64
4.
Do you identify disease trends for diarrhoea, pneumonia and vaccine
preventable diseases every month? If not, why?
5.
Do you investigate maternal deaths? What are the two most common causes
of maternal deaths in your area during the last one year?
6.
Do you use surveillance data to identify action you will take? If yes, give two
examples. If not, why?
See the facilitator when you are
ready to discuss your answers
65
5.0
INVESTIGATE AND CONTROL OUTBREAKS
The primary purpose of investigating an outbreak of diarrhoeal disease is to limit its
spread to other areas and to prevent such occurrences in future. To control the
epidemic the interventions must be selective, effective and at optimum cost.
What is the difference between a case investigation and an outbreak investigation?
An outbreak investigation is the compilation of many case investigations along with
additional analysis done with larger numbers of cases. In general, the process of
investigation is similar. (Note: In case of poliomyelitis even the occurrence of a single
case is to be treated as an outbreak)
Outbreaks do not generate "new" diseases but, by altering the environment may
increase transmission of diseases which already exist in the region through:
66
*
foecal contamination of water due to disruption of pre-existing utilities,
especially sewage systems.
*
disruption of normal ways of life and consequent disruption of personal
hygiene
*
increases in population density (overcrowding) with poor hygiene and
sanitation - a major risk in already densely-populated areas and in temporary
camp settlements
*
population movements - migrants bringing new diseases into an area or
themselves being exposed to diseases to which they have no natural resistance
*
the disruption of pre-existing control programme
*
the creation of environments unusually favourable to transmission of disease
such as rains, floods etc.
5.1
DIARRHOEAL DISEASES
Epidemiological features and criteria for diagnosis
It is necessary to know the standard case definition and epidemiological features of
diarrhoeal diseases before investigating an outbreak.
5.1.1
What constitutes an outbreak
Identification of the existence of a possible outbreak:
When you compare the number of cases with those that occurred in the previous
month or in the same month of the previous years, you can detect outbreak. An
outbreak or epidemic of diarrhoeal disease occurs when the number of cases are
clearly in excess of expected numbers. Care must be taken that they are not due to
completeness of reporting and variation in the number of reporting sites, geographical
size of the catchment area, size of the population etc.
Outbreaks can be predicted for certain seasons, religious festivals, melas etc. Even
relatively small increase of incidence in diarrhoea cases in different PHCs in a district
may indicate an outbreak in a district. It is obvious that sensitivity, reliability and
timeliness of reports and alertness of the local staff are very important in early
identification of an outbreak.
Criteria for number of cases which constitute an outbreak:
States and districts should establish criteria on the number of cases which constitute
an epidemic based on their local situations. For example:
♦
*
a 25% increase in the number of cases reported as compared to the
corresponding period (month or quarter) of the previous year.
a 25% increase in the number of cases reported as compared to the average
of cases over the last four years.
The sentinel reporting centres and medical officers in the out-patient clinics should
be encouraged to be vigilant and report at the earliest without even waiting for the
end of the month.
5.1.2
Confirmation of diagnosis
First reports of outbreaks may often come from the general public, lay press, or
peripheral health workers. It is based primarily on history. The diagnosis should be
confirmed by a medical officer based on history and clinical investigations and if
possible with laboratory support.
67
5.1.3
Laboratory tests
Stool microscopy may show blood - RBCs and pus cells. Amoebic cysts and
occasionally trophozoites with engulfed RBCs may also be seen. A hanging drop
preparation may demonstrate darting motility of Vibrio cholera.
Stool culture and sensitivity tests will identify the particular bacteria with its sensitivity
to different antibiotics.
5.1.4
Process of investigation
Once an outbreak is confirmed formal investigation should follow. Manpower, time
and financial resources for the investigation must be agreed upon by you and your
supervisors at district/state level.
Field investigation:
Identify and record the number of diarrhoea cases. Active surveillance is necessary
to obtain accurate and complete information. This may include house visits, visits or
telephone calls to the medical facilities and ’’line-listing” must continue till the
outbreak is over.
Line-listing is listing of all cases that meet the criteria of a standard case definition
with the relevant data in a standardized manner.
With the assistance of clinicians and laboratory support, sufficient number of stool
specimen should be examined to identify and characterize the causative organism and
monitor its antibiotic susceptibility pattern.
If a cholera epidemic is suspected appropriate fresh transport media must be
provided to all health facilities to collect stool specimen for investigation, eg.
Venkataraman-Ramakrishnan (VR) medium and alkaline peptone water. If no
medium is available a sterile cotton rectal swab should be soaked in the liquid stool,
placed in a sterile plastic bag, tightly sealed and sent to the testing laboratory
immediately.
Once the presence of Cholera has been bacteriologically confirmed, it is not
necessary to culture stools of all cases or contacts.
5.1.5
Descriptive epidemiology
The purpose of epidemiological studies must be to define the extent of the outbreak
and identify modes of transmission so that effective and specific control measures can
be applied.
68
REPORTING FORMATS IN USE DURING OUTBREAKS
List of cases of diarrhoea
SI.
No.
*
Name
Sex
Age
Diagnosis
Address
Remarks/
outcome
Date of
onset
Mention date of death in case of death as outcome of the illness.
Weekly distribution of cases and deaths
SI.No.
No. of deatlis
No. of cases
Week ending
Total
Age and sex distribution of cases
SI.
No.
Age Group
1.
2.
3.
4.
5.
6.
0-11 months
12-23
months
24 - 59 rnohths
5 - 9 years
10-14 years
15 years and above
No.
Male
Percentage
No.
Female
Percentage
No.
Total
Percentage
69
A detailed description of outbreak in terms of time, place and person has to be
prepared.
a)
Cases by time
During an outbreak the onset of illness in the cases should be plotted on a graph by
days or weeks. This type of graph is commonly referred to as an epidemic curve. The
epidemic curve will show peaks of disease separated by troughs during incubation
period and may even suggest patterns or modes of transmission.
It is also useful to present previous year’s information or possibly an average of
previous years, for comparison on a line graph. Such graphs help to demonstrate the
magnitude of the outbreak, and the spread of the disease as well as whether control
measures are succeeding.
b)
Cases by place
A map of the area or even a rough sketch showing the location of reported cases will
indicate the geographical distribution of cases. In some situations, serial spot maps
by week may provide insight into the pattern of spread of the disease over time.
c)
Cases by person
Cases should be described in terms of age and sex.
d)
Cases by breast-feeding status
Diarrhoea cases or deaths among young children below two years can be described
with reference to breastfeeding status (exclusive, partial or none at all).
e)
Cases by source of water supply
Diarrhoea cases among different families who have got different sources of water
supply will be epidemiologically important to know. Open water source like river,
pond, shallow open wells are dangerous during an epidemic. Deep protected wells
and tube wells are safe. Protected chlorinated running water supply will be the safest.
5.1.6
Determining who is at risk of disease
Descriptive epidemiology will help defining population groups at high risk of disease
in terms of age groups, geographical location, source of water, breast-feeding status,
etc.
70
It is appropriate to determine attack rates rather than absolute numbers because
rates take into account variation in the population size of different age groups or
similar factors, e.g. :
If there are 120 cases of diarrhoea among 6000 children below 5 years of age the
attack rate is :
120/6000
0.020 i.e. 20 cases per 1000 children below 5 years of age
5.1.7
Control measures for diarrhoeal disease outbreak
a)
Early case-finding and establishment of diagnosis. In a large outbreak it is
necessary to rule out cholera and dysenteries which will require anti-microbial
treatment in addition to rehydration measures.
b)
Establishment of treatment centres :
C)
*
*
Oral rehydration therapy
Intravenous therapy
*
*
Promotion of home available fluids as soon as diarrhoea starts;
Early recognition of dehydration and seeking ORS packets;
Propagating use of ORS in the community; and ensuring availability of
ORS packets in every village.
♦
d)
Preventive measures :
*
*
*
*
*
*
*
e)
Promote breast-feeding
Improve weaning practices
Measles immunization
Use of plenty of clean water
Promote handwashing
Proper stool disposal
Use of latrines
Role of Cholera vaccination
In the event of an outbreak of cholera, mass cholera vaccination has no role
in controlling or preventing the disease occurrence. The protection levels are
either too low or the time taken for antigenic response in the few who may
be protected will be too long to be adopted as a strategy in public health.
Please note that cholera vaccination has already been discontinued as a
mandatory practice for travel, melas etc. including Khumbh mela.
71
b
6
f)
Chemoprophylaxis
Mass Chemoprophylaxis has no role in an outbreak. However, it is given for
household contacts and for close community living together. During Cholera
epidemic tetracycline, doxycycline or furazolidone prophylaxis may be used.
5.1.8 Write-up and report results
The following is a suggested format for writing up the results of an outbreak
investigation :
a)
General Information:
State
District
Town/PHC
Ward/Village
Population
b)
Background Information:
Person reporting the outbreak
:
Date of report
:
Date investigations started
:
Person(s) investigating the outbreak:
c)
Details of Investigation:
Describe how the cases were found [may include: (a) house-to-house searches
in the affected area; (b) visiting blocks adjacent to the affected households;
(c) conducting record reviews at local hospitals; (d) requesting health workers
to report similar cases in their areas, etc.]:
72
d)
Descriptive Epidemiology:
*
*
♦
♦
e)
Cases by time, place and person (attach summary tables and relevant
graphs and maps).
Age-specific attack rates, mortality rates and complication rates.
Source of water for consumption, occurrence of festivals, melas etc. in
the community.
High-risk age-groups and geographical areas.
Description of control measures taken:
Depending on the disease, all or some of the following may be applicable:
No. of households visited :
No. of children examined :
No. of cases treated
:
No. of contacts of cases treated (if applicable)
No. of children hospitalized:
No. of ORS packets supplied :
No. of wells chlorinated
:
No. of villages with ORS
packets available
:
0
Description of Measures for follow-up visits:
g)
Brief description of problems encountered (during outbreak investigations and
control):
73
h)
Factors which, in your opinion, contributed to the outbreak (may include:
contamination of public water supply, seasonal recurrence, local festival,
common nursery/school, etc.):
D
Conclusions and recommendations:
Date
74
*
For future outbreak investigations and control:
♦
For improvement in water supply, sewerage, excreta disposal etc. to
minimize recurrence of outbreaks:
(Name and designation)
5.2
POLIO MYELITIS
5.2.1
Is an outbreak occurring?
An outbreak is occurring if the number of reported cases is in excess of what would
be expected for time (season), place (district), or age-group. In areas where
immunization coverage is more than 80%, even a single case should be treated as an
outbreak.
5.2.2
When should a case/outbreak investigation be initiated?
Every case of suspected polio in your area must be investigated. However, isolation
and type identification of viruses from such outbreaks and their comparison with
previously endemic cases of poliomyelitis will help.
5.2.3
How should case/outbreak investigation be carried out?
Conduct investigation of each case:
*
confirm diagnosis using standard case definition.
*
collect clinical and demographic information.
♦
collect information on immunization status and source of immunization.
*
collect laboratory specimens.
*
enter data on line-listing forms.
♦
use the case investigation form for each suspected case (Form No. 12)
*
arrange for follow-up to determine clinical outcome and to collect
convalescent serum specimen.
In an outbreak, conduct these additional activities:
*
assess/review immunization status of the community.
*
make time graph showing cases by day or week of onset.
*
map geographic distribution of cases.
*
summarize information on cases - age, sex, immunization status.
*
Calculate vaccine efficacy (Annexure II).
75
Guidelines for timing of ease investigation of poliomyelitis
Days
Onset of paralysis. Clinical investigation. Faeces and serum samples.
Faeces and/or serum samples (if not obtained earlier).
7 =
(laboratory evaluation of first samples)
21
Second serum sample.
35
(laboratory evaluation of second samples)
60 ----
Second clinical investigation and final diagnosis.
90 ZZ
5.2.5
What laboratory investigations should be done?
Conduct laboratory investigation for representative endemic cases and for
representative cases during outbreaks. The objectives of the laboratory investigation
are to :
*
*
*
♦
Confirm that the paralysis is due to poliovirus
Identify the type (1,2, or 3)
Identify whether the poliovirus is of wild or vaccine strain in origin.
Determine intratypic characterization.
5.2.6
How will you respond to outbreaks?
I
If the district coverage for polio vaccine is 80 % or above
You will don containment immunization for units of 20()()-3()()() children in urban
areas within 5 km in low density rural areas. This means that you will give one dose
of OPV to all children below 3 years regardless of immunization status. Two such
77
rounds of containment immunization 1 month apart will have to be conducted. The
first round has to be completed within 1 week of onset of paralysis. There is no use
in containment immunization if investigations reveal that more than one month has
already elapsed from the onset of paralysis of last case. Also, the containment
immunization activities will have to be carried out as a part of the fixed day schedule.
In addition, mopping up operations will also have to be carried out These too will
be done in the specified area as a part of the fixed day strategy. They will be done
in the blocks or PHC areas where poliomyelitis cases were reported m the previous
year The mop-up rounds will be done in areas with relatively high coverage Two
such mop-up rounds at one month interval will have to be conducted and all children
less than 3 years will have to be given the OPV regardless of their immumza ion
status.
No records of children immunized through such containment immunization or mopup rounds need to be maintained. Only tally-marking of the doses given will have to
be done.
II
If the district coverage for polio vaccine is less than 80 %
You will have to increase routine immunization efforts to increase coverage levels
and organize special immunization activities such as catch-up rounds in blocks / areas
where service delivery is weak or coverage levels are very low.
Please note that the best way to ensure complete immunization of all «nfanJs ,n the
area is to plan for immunization sessions in every village every mont an a ere
to the fixed day strategy for delivery of services. As a programme manager you wi
have to monitor the adherence of your workers to the fixed day plans and support
PHCs and their staff to carry out the programme as scheduled.
78
5.3
MEASLES
When you learn about measles outbreaks in any part of your PHC or district, you
must remember that you will have to investigate such outbreaks primarily to identify
the deficiencies in the implementation of the immunization programme. Hu
containment immunization rounds will control an outbreak of measles. Specia steps
(such as training, re-inforcing the area with drugs etc.) will have to be undertaken o
ensure good case management at home level and to educate mothers about
complications that may arise e.g. pneumonia and diarrhoea. Health workers an
medical practitioners of your area should be conscious of the post-measles
complications which are the major causes of mortality. You should also ensure that
the community based surveillance for various diseases of the programme is
functioning properly.
1
i)
79
6.0
ADVERSE EVENTS FOLLOWING IMMUNIZATION
Adverse medical events do follow immunization occasionally. Such reactions are
known and are difficult to avoid. It is important to make the communities understand,
however, that the risk bf these adverse reactions is small compared to the morbidity
and mortality due to the vaccine preventable diseases.
Some of these unfortunate events are due to the intrinsic characteristics of vaccines.
Some can be traced to the avoidable programme problems such as poor handling or
administrative technique. Some occur just coincidentally due to other causes.
It is important to detect these adverse effects early enough to prevent recurrence. If
allowed to continue, they will seriously undermine the credibility of immunization
services and any other activities of the health functionaries in the community.
6.1 TYPES OF ADVERSE EVENTS
6.1.1. Vaccine-induced adverse events
Most of the commonly occurring adverse events are mild reactions and of short
duration. Fever, rash and mild lymphadenopathy are systemic reactions in addition
to the local reactions like redness, tenderness and pain at the injection site.
BCG vaccine gives rise to suppurative lymphadenitis in 1-2% of immunized children
under 1 year of age. Extremely rare, but two serious complications following BCG
immunization, are disseminated tuberculosis and osteitis.
Moderately severe events such as generalized seizures may occur following measles
or DPT immunization. DPT immunization also gives rise to collapse ’(hypotonic
hyporesponsive episodes). Recovery appears generally to be complete. Rarely measles
vaccine associated encephalitis occurs and could possibly result in permanent
disabilities.
A serious event is the acute encephalopathy or other neurological illness with
sequelae following administration of Pertussis components of DPT. (Under such
circumstances, subsequently needed doses of DPT are replaced with a dose of DT).
One should also remember that in the case of poliomyelitis outbreak in an area, any
injection including OPT vaccine can precipitate an attack of paralytic poliomyelitis.
However, one needs to be aware and rule out traumatic neuritis which may lead to
spontaneous recovery in months depending on the seriousness of nerve injury.
Other complications are allergic reactions to the antigens themselves or other
albumin, antibiotics or preservatives.
components such as egg
<
80
i
6.1.2. Adverse effects due to programme errors
The most common manifestation is DPT-associated site abscess. They may be
bacterial or sterile in nature.
Bacterial abscesses are due to contamination or incorrect management of sterilizing
equipment, reuse of syringes and needles and/or inadequate field training and
monitoring.
Sterile abscesses are a rare consequence of vaccines containing aluminium salts,
particularly DPT. Although sterile abscesses normally may be seen once in 100,000
injections, inadequate shaking of the vaccine before use, subcutaneous injection and
use of vaccine that has been frozen can increase the rate.
The vast majority of abscesses in the field are bacterial abscesses. Abscesses require
prompt attention from health workers for adequate medical care. It is an "indicator"
of poor programme implementation.
Sudden onset of severe watery diarrhoea, vomiting and fever within a few hours of
measles vaccine administration which often lead to death has been reported. This
condition is called Toxic shock syndrome caused by bacteria Staphylococcus aureus
a contaminant in the measles vaccine when it is reused from opened vials the next
day.
When vaccines are stored along with other drugs in the same refrigerators, use of
dangerous drugs in place of vaccines or diluents to reconstitute vaccines take place.
BCG should not be given to a child with natural tuberculosis or immuno-suppression
or AIDS virus. Similarly DPT should not be given to a child who had seizures
following first dose.
6.1.3
Coincidental events
Vaccines are usually administered to children at an age when infections are common.
Some adverse events reported may be coincidental only, the primary cause of the
adverse event being unrelated to vaccine administration. Investigation is necessary to
establish the caused relationship. It is important that children of the same age-group
in the area who did not receive vaccines are also examined.
The state health authorities may be advised to have a standing committee of an
epidemiologist, a paediatrician and a microbiologist on call to ensure prompt and
thorough investigation of severe adverse events.
BCG vaccine should be used within three hours of reconstitution
Measles vaccine should be used within four hours of reconstitution
81
6.2
MEASURES TO MINIMIZE RISKS
The following measures will help minimize risks of adverse events following
vaccination :
♦
Procedures for sterilization of syringes and needles should be scrupulously
followed and monitored. Wherever feasible steam sterilization should be given
preference over boiling.
♦
A single, sterile syringe and a single, sterile needle should be used for every
injection.
*
Measles vaccine should be used within 4 hours of reconstitution.
*
Diluent for measles vaccine should be kept separate from other potentially
harmful injectable drugs.
*
Training programmes for all categories of personnel should receive the highest
priority to ensure high quality of services.
*
Reporting of abscesses by health workers in their areas should be made
compulsory.
*
Field monitoring of services should be regular and any deficiencies should be
noted and corrected in a timely manner.
82
6.3
FIELD INVESTIGATIONS AND ANALYSIS OF REPORTS
The basic principles of field investigations of outbreaks can be adopted for investigation of
adverse events. The first principle is to examine as many cases as possible to confirm
diagnosis. All children immunized during the particular session should be followed up and
relevant details entered in the line list of cases with adverse reactions. It is important that
children not immunized of the same age-group in the locality are also examined to rule out
coincidence.
An analysis of data should be made, by time, place and person in the same manner as in any
epidemiological investigation. The details of children vaccinated may be summarized as
shown in the table given here.
Number of children immunized, with reactions and number of deaths
Date of Immunization :
Vaccine
Number
immunized
No. with
reaction
Date(s) of
reaction
Number
died
Date(s)
of death
Operational aspects of the programme need to be carefully reviewed with special reference
to procedures followed for the collection, storage and issue of vaccines; methods adopted
for sterilization of syringes and needles (including the total quantities of syringes and needles
available for a session) and frequency and quality of routine field monitoring.
Where the adverse events are unexpected and not easily explainable, it is important that the
signs and symptoms of each case are carefully noted. The timeliness and completeness of
investigations is of prime importance. Check for use of reconstituted vaccine of
BCG/Measles being transferred from session to session and used beyond the recommended
hours.
Vaccine samples should be sent for testing to the national control laboratory. The samples
should be packed properly in ice and sent by a courier. The forwarding note should clearly
state the circumstances under which the sample(s) are sent. It is important that the used vial
with the remaining vaccine is sent for testing along with unused vials of the same lot/batch.
A report on the suggested format given on page 84 on severe adverse events should be sent
immediately to the concerned state and central officers so that a decision regarding possible
holding or recall of the concerned batch of vaccine can be taken pending laboratory
investigations.
83
6.4
MAKE A REPORT
A report should be prepared giving details on the investigations conducted. This
report should start with general information regarding the place where the event
occurred. The name of the state, district and PHC/ward should be clearly stated. The
following points should be covered in such a report:
6.4.1
Cases
How and when were the first symptoms observed and who reported the event?
Who conducted the investigations and when were they begun?
How were the investigations conducted?
Number of children immunized and the type of reactions observed. The line list and
summary tables should be attached to the report.
Whether any children of the same age-group in the area, who were not immunized,
had similar symptoms.
6.4.2
Clinical aspects
*
*
*
Detailed clinical picture
Treatment given
Outcome
Diagnosis by clinicians and observations, if any made by them.
6.4.3
Operational aspects
♦
How are immunization services generally provided in the area? Procedure followed
on the day of the event?
When and from where the vaccines were received? How were the vaccines stored and
transported?
How many syringes and needles are available and procedures followed for
sterilization of the equipment?
Who administered the vaccines and what was the training they received?
Have similar reactions been observed in the past and were they reported?
6.4.4
Laboratory investigations
Samples sent for testing and the names of laboratories. The testing of the vaccine can
take 2-4 months depending on the vaccine and the tests.
6.4.5
Suggestions and recommendations
What was the likely cause of the adverse event?
Measures recommended to minimize risks in future.
Date:
84
Name and designation
6.5
DEALING WITH THE PUBLIC AND THE MEDIA
Panic of people must be avoided. Accurate information must be provided in a timely
manner to the news media regarding the numbers affected and the remedial
measures taken.
There is often hue and cry when adverse events occur following immunization since
it is perceived that the health worker has performed an act that has injured or killed
an otherwise healthy child. It is important that the community’s concerns are dealt
with in a professional but sympathetic manner.
The press and other media can be made use of in soliciting cooperation of public for
immunization. The government procedures for dealing with press should be followed
and nominated government spokespersons must provide information.
85
REMEMBER THIS ABOUT SURVEILLANCE !
PLAN for surveillance
The two major types of surveillance are
*
♦
Routine reporting (including community based surveillance)
Sentinel reporting
Other surveillance activities are
*
*
Case/outbreak investigation
Special studies
COLLECT and compile data
To make sure your data is complete and accurate:
*
♦
*
*
*
♦
Tally cases every day
Prepare disease maps and charts
Line list and investigate all cases of neonatal deaths
Line list and investigate cases of poliomyelitis
Line list all maternal deaths
Total the number of cases at the end of every month.
Collect only as much information as will be used.
ANALYZE data
Identify disease trends and their causes
*
♦
*
*
:
Completeness of reporting
Seasonal variation
Epidemic pattern
Immunization coverage
Analyze neonatal death, poliomyelitis case investigation forms and review information
obtained from sentinel surveillance centres.
TAKE action and give FEEDBACK
Identify the causes of problems and their solutions, where information is collected.
Implement solutions immediately.
Submit surveillance reports
Provide feedback.
86
ANNEXURE-I a
LIST OF LAME CHILDREN UNDER 5 YEARS
PHC/DISTRICTS
Sl.No.
Month of Report
Name of the child
Address
Age^Z
Date of Birth
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Probable Polio:
o History of febrile illness
o History of abrupt onset of weakness or paralysis
o No progression of paralysis after the first three days
o Paralysis not associated with trauma
o Paralysis not present from birth or associated with mental retardation
* Number of OPV doses prior to illness. Check immunization cards or register, if available.
Sex
Date/Month/Year
of onset of
lameness
Immunization
status*
ANNEXURE-I b
LIST OF NEONATAL DEATHS
Month of Report
PHC/DISTRICTS
Sl.No.
Name of the
child
Address
Age/
Date of
Birth
Sex
Date of Death
Immunization
status*
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Probable NNT :
o Infant was able to suck after birth
o Stopped sucking after few days
o Convulsions
o Stiffness
o Fever
*
*♦
Immunization status of mother in number of TT doses. Check immunization registers if available
These columns will be fined in after the neonatal deaths are investigated using Form 13.
Delivered by
Diagnosis
♦♦
♦*
ANNEXURE-I c
LIST OF MATERNAL DEATHS
Month of Report
PHC/DISTRICTS
1
Sl.No.
1.
Name
2.
Name of Husband/Father
3.
Address
4.
Date of Death
5.
Tetanus Immunization - 0/1/2 doses
6.
Date of Delivery or Abortion
2
3
Qualified medical person
(QMP)
7.
Delivered or aborted by
Trained TEA (TTBA)
Untrained person (UP)
8.
Abortion spontaneous (SA)
9.
Diagnosis
10. Complications
Note : Items 1 and 4 will be filled in immediately on receipt of information and other items win be filled in after investigating the maternal death with
the help of health workers and supervisors.
ANNEXURE-II
CALCULATE VACCINE EFFICACY
The term "vaccine efficacy" refers to the ability of a vaccine to prevent disease when used in routine
immunization services. Formulas for calculating vaccine efficacy follow:
Calculate the efficacy of a single-dose vaccicne:
In the example described below, the efficacy of measles vaccine is calculated, but the same process can boosed
to calculate the efficacy of other single-dose vaccines.
The efficacy of measles vaccine is calculated because under ideal conditions this vaccine has a high efficacy
(around 90%) and is therefore an excellent indicator of the effectiveness of the immunization services.
Experience has shown that:
♦
Immunization services with a measles vaccine efficacy of 90% are protecting children as effectively as
possible against measles.
* A vaccine efficacy of 80-90% means that your vaccine is not as effective as it could be, but that there is not
a major problem.
♦
A vaccine efficacy of less than 80% means that there is a problem with the vaccine. This could be due to
problems with the cold chain, the injection technique, or the age at which health workers are immunizing
the children, and you should take action to correct it.
To calculate vaccine efficacy, you will need to obtain the following information from health records:
* the size of your study population (which is children 12-23 months of age since these children were under one
year of age in the previous year)
♦
the coverage with measles vaccine in children 12-23 months of age
♦
the number of cases of measles in immunized children 12-23 months of age
* the number of cases of measles in unimmunized children 12-23 months of age
Calculate vaccine efficacy for measles vaccine (or another single-dose vaccine) by following the steps below:
a.
Identify the size of the study population (that is, children 12-23 months of age). This is equal to
approximately .3% of the total population.
Total population
in the area served
b.
x.O3
= The size of the
study population
Calculate the number of children in the study population who are immunized by multiplying the level of
coverage with measles vaccine by the study population. (See the module, Evaluate Service Coverage, for
details on how to calculate coverage).
Number of immunized
children 12-23 months of age
Study population Immunization coverage
12-23 months of age ok population 12-23 =
months of age
c.
Calculate the number of children in the study population who arc unimmunized by subtracting the
number who are immunized from the total study population.
Study population Number of immunized
12-23 months of agochiidrcn 12-23 months
of age
d.
=
Number of unimmunized
children in study population
iiBi1 ■
Calculate the attack rate in the immunized population by dividing the number of cases occurring in
immunized children 12-23 months of age by the total number of immunized children in the study
population.
To find the number of immunized cases, total the number of cases in immunized children 12-23 months
of age reported in the patient register over the preceding, twclvc-month period.
e.
Calculate the attack rate in the unimmunized children by dividing the number of unimmunized cased 1223 months of age by the number of unimmnized children in the study population.
Number of cases in immunized
children 12-23 months of age
Attack rate in immunized children
______
Number of immunized children
12-23 months of age
_ ___________________ _
To find the number unimmunized cases, total the number of cases in unimmunized children 12-23 months
of age reported in the patient register for the preceding twelvc-month period.
Number of cases in unimmunized
children 12-23 months of age
Attack rate in unimmunized children
Number of unimmunized children
12-23 months of age
f. Calculate vaccine efficacy by using the following formula:
AR
= attack rate
AR in unimmunized - AR in immunized
x
100
=
Vaccine efficacy
AR in unimmunized
Calculate the vaccine efficacy of a multi-dose vaccine:
For public health routine, the important vaccine efficacy calculation to make is that of a full course of
immunizations. This calculation compares those who arc fully immunizd (according to the recommended
national immunization schedule) to the unimmunized (that is, those children who have received no
immunizations at all). One example would be to compare children who have received a full course of OPV
compared to those that have received no OPV at all. For this purpose, the same formula described earlier in
this section can be used.
Guidelines for calculating vaccine efficacy by dose for multi-dose vaccine can be obtained from the WHO
country or regional office oFfrom WHO headquarters in Geneva, Switzerland.
Below is an example of how to calculate the efficacy of measles vaccine, given the following information:
: 45000
Population of health area
Measles immunization coverage in
36%
children 12-23 months of age
Number of measles cases in immunized
children 12-23 months of age
: 128
Number of measles cases in unimmunized
children 12-23 months of age
: 842
a.
45,000
Total population
x
b.
1,350
Study population
12-23 months of
age
x
c.
0.03
•I
1350
Study population
12-23 months of age
0.036
Measles coverage
486
No. of immunized
children
12-23 months of age
1,350
Study population
12-23 months of
age
486
No. of immunized
children
12-23 months of age
864
No. of unimmunized
children
12-23 months of age
d.
128
No. of cases in
immunized
children
12-23 months of
age
486
No. of immunized
children
12-23 months of age
0.026
Attack rate in
immunized children
12-23 months of age
e.
842
No. of cases in
unimmunized
children
12-23 months of
age
486
No. of unimmunized
children
12-23 months of age
0.97
Attack rate in
unimmunized children
12-23 months of age
( 0.097
Attack rate in
unimmunized
children
0.026 /)
100
Attack
rate in
immunized
f.
0.097
Attack
rate in
unimmu.
children
=
x
100
0
73%
VACCINE
EFFICACY
OPTIONAL EXERCISE
In this exercise you will calculate the efficacy of measles vaccine at a sentinel site. Follow the guidelines on
previous payyand record your answers on the worksheet provided below:
Information about health centre Hoshiarpur
: 30,000
Population of district
Measles immunization coverage in
children 12-23 months of age
: 53%
Number of measles cases immunized
children 12-23 months of age
: 85
Number of measles cases in unimmunized
children 12-23 months of age
: 420
x
a.
Study population
12-23 months of age
Total population
x
b.
Study population
12-23 months of
age
Measles coverage
No. of immunized
children
12-23 months of age
Study population
12-23 months of
age
No. of immunized
children
12-23 months of age
No. of unimmunized
children
12-23 months of age
No. of cases in
immunized
children
12-23 months of
age
No. of immunized
children
12-23 months of age
Attack rale in
immunized-children
12-23 months of age
No. of cases in
unimmunized
children
12-23 months of
age
No. of unimmunized
children
12-23 months of age
Attack rale in
unimmunized children
12-23 months of age
c.
d.
e.
f.
Attack rate in
unimmunized
children
) Attack
100
rate in
Attack
unimmu.
rate in
children
immunized
x
ioo
VACCINE
EFFICACY
Vaccine Efficacy
Optional Exercise
(Continued)
What does this vaccine efficacy calculation tell you about the immunization services?
What would you do if you calculated this vaccine efficacy in your own health centre?
Write your answer in the space below:
ANNEXURE-III
ANNUAL INCIDENCE RATE OF POLIOMYELITIS
PER 1000 CHILDREN 0 TO 4 YEARS (Based on sample surveys 1981-1982)
State/UT
Incidence Rate per 1000
children
Rural
Urban
Andhra Pradesh
1.7
1.4
Gujarat
2.5
2.2
Haryana, Punjab
3.1
1.7
Karnataka, Goa
1.2
1.2
Madhya Pradesh (Bhopal
& Jabalpur Divisions)
1.9
1.7
Maharashtra
1.4
1.3
Orissa
0.8
0.7
Rajasthan (Jaipur
Division)
3.1
2.5
Tamil Nadu &
Pondicherry
1.9
2.1
Uttar Pradesh
(Allahabad Division)
2.3
1.6
West Bengal
0.8
1.0
Chandigarh
1.6
Delhi
ALL INDIA
1.7
1.6
ANNEXURE-IV
ANNUAL NEONATAL TETANUS MORTALITY RATE
PER 1000 LIVE BIRTHS (Based on sample surveys 1981-1982)
State/UT
Incidence Rate per 1000
children
Rural
Urban
Andhra Pradesh
6.8
2.7
Bihar
11.3
5.3
Gujarat and
D & N Haveli
5.8
1.9
Chandigarh
8.4
3.1
Karnataka & Goa
5.1
1.6
Kerala
2.0
1.9
M.P. (Bhopal &
Jabalpur)
20.4
1.4
Maharashtra
4.1
4.9
Orissa
8.6
2.0
Rajasthan (Jaipur
Division)
13.5
3.4
Tamil Nadu &
Pondicherry
4.9
UP (Allahabad)
66.7
15.3
West Bengal
11.9
0.5
Haryana, Punjab
1.0
Delhi
ALL INDIA
13.3
3.2
ANNEXURE-V a
MONTHLY SENTINEL SURVEILLANCE REPORTS
Vaccine preventable diseases
Sentinel Centre
District
State
Month
Disease**
Year
Cases
Deaths
Description
M
F
M
F
Immunization status
Immu
nized*
Not
immu
nized
Un
known
Tot
al
Less than 6
months
6-11 months
12-23 months
(<2 years)
2-5 years
> 5 years
Total
♦
Note :
Immunized children should have received :
1 dose of of Measles and BCG and 3 doses of DPT and OPV (last
dose should have been received at least 15 days before the onset of the
disease.)
Do not include a case of poliomyelitis, if history of onset is 3 months
or more. All cases of brochopneumonia or severe diarrhoea who give
a history of measles or pertussis one month prior to illness should be
included under measles or pertussis.
** Use this format for each one of the six vaccine preventable diseases Diphtheria, pertussis, tetanus, poliomyelitis, measles and tuberculosis; one
form each for one disease.
ANNEXURE-V b
MONTHLY SENTINEL SURVEILLANCE REPORTS
Diarrhoea/Pneumonia
Sentinel Centre
District
State
Month
Disease**
Diarrhoea
Cases
Year
Deaths
Vitamin A Prophylaxis
Description
Full
M
F
M
Partial
Not given
F
Measles
Immu
nization
T
o
t
a
1
Measles
Immu
nization
T
o
t
a
1
Less than
6 months
6-11 m
12-23 m
2-5 yrs.
> 5 yrs.
Total
Disease**
Pneumonia
Cases
Vitamin A Prophylaxis
Deaths
Description
Full
M
F
M
F
Partial
Not given
Less than
2 months
3 - 12 m
1 - 5 yrs.
> 5 yrs.
Total
Date :
Signature
ANNEXURE-V c
MONTHLY SENTINEL SURVEILLANCE REPORTS Maternal Deaths
1.
Sentinel Centre
2.
District
3.
State
4.
Month and year of reporting :
5.
Total number of deliveries
in the month
SI.
No.
1.
Maternal deaths
Tetanus
Causes
Number
Total
Unimmunized mothers
Immunized
2.
Bleeding
Ante-partum
Post-partum
3.
Sepsis
Post Abortion
Post delivery
4.
Obstructed Labour
Rupture Uterus
Not ruptured
5.
Toxaemia of Pregnancy
With convulsions
Without convulsions
6.
Anaemia associated
Severe <6 gm/100 ml
Moderate 6-10 gms/lOOml
of Hb
Date :
Signature
ANNEXURE-VI^
ANALYSIS OF ANNUAL DATA FROM SENTINEL SURVEILLANCE Vaccine preventable diseases
Sentinel Centre
District
State
Year
Disease**
Total Paediatric attendance
Cases
Deaths
Description
M
F
M
F
Vaccination status
Immu
nized*
Not
immu
nized
Un
known
Total
Upto 6
months
7-12 months
12-23 months
(<2 years)
2-5 years
+5 years
Total
*
Immunized children should have received :
1 dose of of Measles and BCG and 3 doses of DPT and OPV (last dose should
have been received at least 15 days prior to the onset).
----Note: Do not include a case of poliomyelitis, if
history of" onset: is 3 months or more. All
cases of brochopneumonia or severe diarrhoea who give a history of measles or
prior to illness should be included under measles or pertussis.
pertussis one month
i
**
Use this format for each one of the six vaccine preventable diseases - Diphtheria, pertussis, tetanus,
poliomyelitis, measles and tuberculosis; one form each for one disease.
ANNEXURE-VIb
ANALYSIS OF ANNUAL DATA FROM SENTINEL SURVEILLANCE Diarrhoea and Pneumonia
Sentinel Centre
District
State
Year
Diarrhoea
Disease**
Total paediatric attendance in the year :
Cases
Deaths
Vitamin A Prophylaxis
Description
F
Not
given
Deaths
Vitamin A Prophylaxis
Full
M
F
M
Partial
Measles
Immu
nization
T
o
t
a
1
Upto 6
months
7-12 m
1-2 yrs.
2-5 yrs.
> 5 yrs.
Total
Disease**
Pneumonia
Cases
Description
Full
M
F
M
F
Partial
Not
given
Measles
Immu
nization
T
o
t
a
1
< 2 months
2 - 12 m
1-5 yrs.
> 5 yrs.
Total
Date :
Signature
ANNEXURE-VI c
ANALYSIS OF ANNUAL DATA FROM SENTINEL SURVEILLANCE Maternal Deaths
1.
Sentinel Centre
2.
District
3.
State
4.
Year of reporting
5.
Total number of deliveries
in the year
SI.
No.
1.
Maternal deaths
Tetanus
Causes
Number
Unimmunized mothers
Immunized
2.
Bleeding
Ante-partum
Post-partum
3.
Sepsis
Post Abortion
Post delivery
4.
Obstructed Labour
Rupture Uterus
Not ruptured
5.
6.
Toxaemia of
Pregnancy
With convulsions
Anaemia associated
Severe <6 gm/100 ml
Without convulsions
Moderate 6-10
gms/lOOml of Hb
Date :
Signature
Total
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INSTRUCTIONS FOR FILLING SUB-CENTRE MOTHER AND CHILD CARE RECORD
1.
This register has been developed for you to record all MCH activities of the sub-centre
area.
2.
Separaters are provided to separate the records of each village.
3.
On the separaters fill in the details of the village.
4.
Binding of the register is such that it will help you to insert extra leaves whenever
required.
5.
On the top of every page enter the year. For example enter 1992-93 for cases to be
registered during 1st April 1992 to 31st March 1993.
6.
Col.2
During the field visit you should identify all pregnant women and register them in this
column after giving a Serial No.
7.
The same Serial No. should also be entered in the MCH Card. Please remember to
indicate the year of registration in the card for example a case listed at S.No.2 in 199293 should be written on the card as 2/92-93.
8.
Col.5
The number of pregnancies the woman had including the present one should be
entered.
9.
Col. 10, 14 & 18
While examining the pregnant women look for certain danger signs which may require
your personal continuous supervision and/or referral. These danger signs are:a.
b.
c.
d.
e.
f.
gh.
i.
Anaemia
B.P. above 140 mm Hg.
Abnormal weight gain (>5 kg/month)
First pregnancy with age less than 20 and more than 30 years
More than 4 pregnancies
Bleeding during pregnancy (APH)
Ceasarian operation during previous pregnancy
Abnormal/lack of movements
Convulsions
Please enter appropriate code from the above list.
10. Col. 19
Please choose the appropriate code from the following:
A At home
B At sub-centre
C Other institution including private hospitals
11. Col. 20
Please enter appropriate code from the following on the basis of delivery conducted by:
A
B
C
D
Doctor
ANM/LHV/Nurse
Trained Dai
Untrained Dai and/or others (relations etc)
12. Col. 12
Choose the appropriate code from the following and enter in this column.
A
B
C
D
Mother and child healthy
Mother died
Child died
Dead child born
13. Col. 23
Please enter:
A
B
C
D
If the child was healthy upto 7 days;
If the child was healthy upto 28 days;
If the child died within 7 days, and
If it died after 7 days but before 28 days
14. You are aware that the primary vaccination i.e. one dose of BCG, three doses of DPT
and OPV each, one dose of measles and the first dose of Vitamin A should be given
before the completion of the first year of the child. Hence at Col.36 fill in the code as.
* if primary immunization was completed before the first year of the child;
* if primary immunization was not completed before the first year of the child.
MOTHER AND CHILD CARE RECORD
MOTHER’S RECORD
SI.
No.
1
Name of
pregnant
woman
2*
Age
3
Husband* Order Expected
Date of
of
name &
Address pregnane! delivery
' 5 I
9—
4
TT-1
date
7
ANC-1
IFA
Qty
8
WL
Kg.
9
□anger
Code *
10
TT-2/8
Date
11
ANC-2
IFA
Qty.
12
Wt
Kg
13
Danger
Code *
14
Date
15
ANC-3
IFA
Qty,
10
Wt
Kg
17
Danger
Code ‘
18
Place
al
delivery
19
Delivery
attended
by
20
Dollvcty
outcome
21
MOTHER AND CHILD CARE RECORD
REGISTRATION YEAR 199
CHILD’S RECORD
Weight
at
birth
Child wns
healthy upto
7 ot 28 days
23
22
I
Nomo
of the
child
24
Date
of
Birth
25
Sex
28
Date
of
BCG
27
Dates of OPV Doses
1st
28
2nd
29
3rd
30
Dates of DPT Doses
2nd
1st
31
32
3rd
33
Date of
Measles
dose
34
1 st dose
Immun. “
Status
1st year
35
36
Date of
vn. a
Date of
OPV-B
dose
37
Date of
DPT-B
doso
2nd dose
38
39
Dates of Vit A doses
3rd dose 4th dose
40
41
Sth dose
42
ANNEXURE-IX
MONTHLY PHC REPORT
Reporting Date:
District
P.H.C.
Year
Month
State
II) Pregnant Women
Yearly Target I) Infants
b) Actually Held
Number of Sessions a) Planned
A. SURVEILLANCE
Number Reported
Di sease
For the Month
Cases
Cummulative Since April
Cases
Deaths
Deaths
Diphtheria
Pertussis
Neonatal Tetanus
Tetanus (others)
Poliomyelitis (Acute)
Measles
Under
five
years
Tuberculosis
Pneumonia
Acute Diarrhoea
Dysentry
-i
Maternal Deaths (Repoorted) : Before Delivery
During Delivery
Within 6 weeks of delivery
B. PERFORMANCE
Dose No.of
Beneficiaries Cummulative since April
1
2
B
T T
PREGNANT
WOMEN
Initiated Completed Initiated
I FA
TABLETS
Completed
(Prophylactic)
(Theraputic)
Under 1Yr Over 1Yr
BCG
1
0 P V
1
2
3
DPT
1
2
3
MEASLES
Vi tamin A
OPV Booster
DPT Booster
1
CHILDREN
Vitamin A
1
1
1
1
2
3
4
5
Under 1 Yr
Over
1 Yr
C H 1 L D R EN
DT (5 Years)
1
2
B
TT (10 Years)
1
B
TT (16 Years)
1
2
ANTE-NATAL CARE
During the month
Cases
Cuoimjlative since April
Registered
Institutional Deliveries
Complicated Cases referred
Domi ci 11iary
deliveries conducted
by
HW(F)/LHV
Trained Dais
Others
Condition of newborn
at birth
Weight below 2,000 gm.
Weight 2,000-2,500 gm.
Weight 2,500 and above
Weight not taken
Still born
Abortion
C. SUPPLY POSITION
Opening
Balance
Vaccine/Drugs
Received during Consumed during Balance at the
end of month
the month
the month
DPT
OPV
BCG
MEASLES
TT
DT
Syringes 2 ml
Syringes 1 ml
Needles 20 G
Needles 23 G
Needles 26 G
Immunization Cards
D.
_________ ___________ _
STATUS OF EQUIPMENT (inlciiidng deep freezers, ILRs, voltage stabilizers, vaccine
carriers, cold boxes, weighing machines, BP instruments, vehicles etc.)
Machine
Number
Equipment/
Make
*
Whether
working
If not, date
of breakdown
Date of
Intimation
Remarks*
Please mention in this column:
a)
If machine is beyond repair
KnoaUdnon
b)
If the machine has been attended to by the mechanic within a week of breakdown.
E. UNTOWARD REACTIONS
1.
2.
3.
Date:
Reported deaths associated with immunization
Number of absessess
Other complications
Signature of Medical Officer
To:
The District M.C.H. Officer
ANNEXURE-X
MONTHLY DISTRICT REPORT
Reporting Date:
No. of PHCs
District
State
Month
Yearly Target
I) Infants
Number of Sessions
a) Planned
Year
II) Pregnant Women
b) Actually Held
A. SURVEILLANCE
Number Reported
Disease
For the Month
Cases
Deaths
Commutative Since April
Cases
Deaths
Diphtheria
Pertussis
Neonatal Tetanus
Tetanus (others)
Poliomyelitis (Acute)
Measles
Under
five
years
Tuberculosis
Pneumonia
Acute Diarrhoea
Dysentry
Maternal Deaths (Repoorted) : Before Delivery
During Delivery
Within 6 weeks of delivery
B. PERFORMANCE
Dose No.of Beneficiaries Commutative since April
1
2
B
T T
PREGNANT
WOMEN
I FA
TABLETS
Initiated Completed Initiated
Completed
Under 1Yr Over 1 Yr Under 1 Yr
Over 1 Yr
(Prophylactic)
(Theraputic)
BCG
1
0 P V
1
2
3
DPT
1
2
3
MEASLES
Vitamin A
OPV Booster
DPT Booster
1
1
1
1
Vitamin A
2
3
4
5
CHILDREN
1
DT (5 Years)
1
2
B
C H I L D R EN
TT (10 Years)
1
B
TT (16 Years)
1
2
ANTE-NATAL CARE
During the month
Cases
Cummulative since April
Registered
Institutional Deliveries
Complicated Cases referred
Domi cilliary
deliveries conducted
by
HW(F)/LHV
Trained Dais
Others
Condition of newborn
at birth
Weight below 2,000 gm.
Weight 2,000-2,500 gm.
Weight 2,500 and above
Weight not taken
Still born
Abortion
C. SUPPLY POSITION
Opening
Balance
Vaccine/Drugs
Received during Consumed during Balance at the
end of month
the month
the month
DPT
OPV
BCG
MEASLES
TT
DT
Syringes 2 ml
Syringes 1 ml
Needles 20 G
Needles 23 G
Needles 26 G
Immunization Cards
D. STATUS OF COLD CHAIN EQUIPMENT
Equipment
ILR/DEEP FREEZER
Total
Supplied
Total not
working
No. attended to No. not working for No.Beyond
within 1 week more than 1 mgnth* Repai r
ILR 300 Litre
Deep freezer 300 Litre
ILR 140 litre
Deep freezer 140 litre
* Excluding those beyond repair.
Please attach details of beyond repair equipment as:
Machine No.
Location
UNTOUARD REACTIONS
E.
1.
2.
3.
Date:
To:
1.
2.
Reported deaths associated with immunization
Number of absessess
Other complications
District MCH Officer
Monitoring and Evaluation Unit
Child Survival & Safe Motherhood Programme Division
Ministry of Health & Family Welfare, Nirman Bhavan
New Delhi 110011
State MCH Officer
Date of installation
Out of order since
ANNEXURE-XI
DEFINITION OF TERMS
Attack rate
The percentage of individuals in a defined group who get a disease
over a defined time period.
Case fatality rate
A percentage of the number of persons diagnosed as having a
specific disease who die as a result of that illness.
Disease surveillance
The collection of information about the umber of cases of given
diseases, and the use of that information to evaluate the
effectiveness of the preventive immunization activities, and action
taken to correct any problems which hinder disease-reduction
objectives from being met.
Disease trend
The pattern formed by increases and decreases in thp number of
reported cases of disease over time.
Epidemic
The occurrence of a disease in a pattern in which more cases of a
disease than usually occur in a specified period of time. Synonym:
outbreak.
Epidemic pattern
The occurrence of a disease in a pattern in which more cases occur
during certain months each year or with years’ interval.
Immunization
coverage
The proportion of individuals in the target population who are
immunized.
Coverage
survey
A special study designed to measure the percentage of individuals
in a given age group who are immunized.
Incidence
The number of new cases of disease in a defined population during
a specified period of time.
Outbreak
The occurrence in a community or region of more cases of a disease
than usually occur in a specified period of time. Synonym: epidemic.
Outbreak
investigation
Studies conducted for the purpose of collecting data about an
outbreak with the goal of controlling the disease outbreak and
preventing similar outbreaks in the future.
Routine reporting site A health facility that is designated to submit information on the
number of cases of certain diseases that occur in the area.
Seasonal variation
The occurrence of a disease in a pattern where more cases occur in
one (or more) season(s) of the year.
Sentinel reporting site A health facility that regularly and1 completely submits information
on the number of cases of certain diseases that occur in the area
and also may include additional information such as the age and
immunization status of each cease.
Signs of disease
The evidence of disease found in a case by the examiner.
Special surveys
Studies that answer questions that cannot be answered by data
obtained in the routine and sentinel reporting system.
Symptoms of disease The sensation of disease felt by the patient.
Vaccine efficacy
The ability of a vaccine to prevent disease when used in routine
immunization services.
FORM NO. 12
CLINICAL OBSERVATION OF LAME CHILDREN
(To be completed by the Medical Officer for all lame children between 0 and 5 years of age
(a separate form for every lame child).
General Information
I.
1.
2.
3.
4.
5.
State/U.T.
District
Town (Mohalla)/PHC(Village)
Cluster No.
Line List No.
IL Background Information on Lame Child
1.
3.
5.
7.
8.
2. Sex
Name of Child
4. Head of Household
Father’s Name
6. Address of Child
Date of Birth of Child
Person Interviewed
Relationship of person interviewed to child
III. History of illness resulting in Lameness of the child
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Date of onset of lameness
Address of child at a. Village
onset of lameness: b. District
c. Outside district surveyed YES/NO
Number of doses of polio vaccine received by child proceeding onset of lameness:
(a) one, (b) two, (c) three, (d) more, (e) none.
Medical care during illness resulting in lameness (circle correct answer):
a) Registered physician (Allopathic/Ayurvedic/Homeopathic)
b) Health Centre
c) Un-registered physician
d) Other (please specify)
Did the child have fever at the time of the onset of lameness?
Was the onset of the lameness acute?
Did the lameness progress (increase) after onset?
For how many days did it progress?
Number:
Any history of injury (including injections) prior to the illness?
Mental retardation associated with lameness?
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
IV. Physical Examination of child (Circle correct answer)
1.
2.
YES/NO
Paralysis of lower limb present
Affected limb:
Right
Upper
Lower
Left
3.
4.
5.
6.
Type of paralysis present
Flaccid
Spastic
Sensation in affected limbs
Normal
Impaired
Muscle atrophy (wasting) in affected limb
Gait-Normal/impaired/requires assistance - Unable to evaluate
Evaluation of Lameness (Circle appropriate answer)
V.
1.
Lameness not present 2. Lameness present
a) Does not require mechanical aid to walk
b) Requires mechanical aid to walk
c) Unable to walk
VI. Physician’s Diagnosis on Cause of Lameness
1.
2.
3.
4.
Poliomeylitis
Trauma (please specify)
Congenital deformity (Please specify)
Other (please specify)
Date of Investigation
Investigator’s Name:
Form No. 13
National Child Survival & Safe Motherhood Programme
Investigation of Neonatal Deaths
all infants who died within the 1st month of life (a separate form for each neonatal death).
To be completed by the Medical Officer on
I. General Information
1. State/U.T
______ ____________ ______
2 District
3. Town (Mohalla)/PHC (Villaagc)/Ward
4. Physician’s name
5. Date of invcstigation
__
II. Background Information on Neonatal Death
1. Name of Child
___________________ —
2 Sex
_
3. Father’s Name
_________
__________
4. Address of child
___________________
5. Date of birth of child ____________ _____
6. Person interviewed by the Investigator
7. Relationship of person interviewed to child
8. Dale of death of child
III.
Mother’s Immunization History
1. Does the mother know about vaccination with TF?
10]
2 No of doses received during this pregnancy?
3. Date of last dose of TF
4. Card entry verified
IV.
______________ _
YES
YES
11]
NO
|2|
|3]
NO
Infants Care since Birth (please circle appropriate answer)
WJ?
Hospiial/I lealth Ccntre/Homc/ln the Fields/Other (please specify)—--------- -- ----------------------1. Where was the child delivered?
Doctor/LHV/ANM/Fr.TBA/Untr.Dai/Family mcmbers/Other (please specify)
specify).----------------------------------------- 1—
Sterile /unsterile (unboiled) Instrument
3. 1 low was the cord cut?
(use code) + (a=oil. b=cowdung, c=genlian violet, d=antibiotic, e=none and f=other)
4. How was the cord dressing done? (use code) + (a=oil. b
treked the child? (use code) ++ (»=govl. heslth centre, b=reg physician (allopalhlc/ayutvedtc/homeopalhic),
5. When the child became ill, who t---------------c=umiregistcred physician and d=no treatment received)
6. When was the child initiated on breast milk?
within 2 hrs / 2-4 hrs / 4-8 hrs / 8-24 hrs / 24-48 hr. I > 48 hrs.
2 Who delivered the child ?
V. Symptoms preceedlng Infant’s death (please circle appropriate answer)
YES
YES
1. Was the infant able to suck the milk after birth?
2 Did the infant stop sucking milk when illness began?
YES
3. Did the infant have a fever?
YES
YES
4. Did the infant have convulsions?
5. Was the infant noted to be stiff?
VI.
NO
Other Information on Mother
1. Is the mother alive?
2 If dead, date of death
3. Symptoms proceeding death
VII.
NO
NO
YES
NO
Medical Officer’s Diagnosis
1. Cause of Neonatal Death
2 Cause of Mother’s Death
Date of Reporting:
Investigator’s Name:
NO
NO
I
Education is empowerement. Every girl and boy must be helped to
complete at least primary education in school. This will facilitate
attainment of good health. In this endeavour all of us can contribute and
make a difference.
You can :
* ask every family you meet during your health work, whether their
children are in primary school;
♦
persuade them to send all their children including girls, to attend and
complete primary school, if they are not in school;
* identify the primary school teachers of the villages covered by you;
♦
facilitate communication between the family and the school teacher
whenever possible;
♦
encourage all functionaries working with you to actively promote
school attendance and completion of primary school; ask them
regularly, what they have done;
♦
include a panel/discussion on primary education whenever you
organize a health exhibition/camp.
Position: 4676 (1 views)