Download I. Syndrome of Fever - National Centre for Disease Control

INTEGRATED
MINISTRY
HE A LTH
OF
DISEASE
H EA LT H
WORKERS’
A ND
S URVEILLANCE
FAMILY
OPER ATIONS
WELFARE
MANUAL
_______________________________________________________________
1
INDEX
Sl. No
1.0
1.1
1.2
2.0
2.1
2.2
2.3
3.0
4.0
5.0
5.1
6.0
7.0
8.0
I.
II.
III.
IV.
V.
Topic
Abbreviations ………………………………………………………
Introduction …………………………………………………………
What is surveillance? …………………………….........................
Why surveillance? ……………………………….........................
Integrated Disease Surveillance Project
………………………
Syndromes under surveillance ……………………………...........
Types of surveillance under IDSP ……………….........................
Which are the reporting units? ……………………………...........
Data Collection
.…………………………….................................
Flow of Information
..…………………………….........................
Laboratory Confirmation
………………………………...............
Biosafety ……..………………………............................................
Outbreak Response
……………………………..........................
Inter-sectoral Collaboration
..……………………………...........
Conclusion
……………………………..................,......................
Annexure I: Syndromes Under Surveillance
……………........
Syndrome of Fever ………………………………………………….
Syndrome of Cough (with or without fever) ...…………………….
Syndrome of Watery Diarrhoea ...………………………………….
Syndrome of Jaundice ………………………………………………
Syndrome of Unusual Events Causing Death or
Hospitalization
Glossary of terms
Page
number
3
4
4
4
5
5
6
7
7
8
9
10
10
10
10
12
12
16
18
22
25
27
2
ABBREVIATIONS
AFP
ARI
BDO
CDC
CEO
CFR
CHC
DH
DSU
ESI
IDSP
IEC
JE
MO
MP
NGO
OPD
ORI
ORS
ORT
OT
PHC
RRT
RT
SPP
TB
Acute Flaccid Paralysis
Acute Respiratory Infection
Block Development Officer
Centers for Disease Control and Prevention
Chief Education Officer
Case Fatality Ratio
Community Health Center
District Hospital
District Surveillance Unit
Employee State Insurance
Integrated Disease Surveillance Project
Information Education Communication
Japanese Encephalitis
Medical Officer
Malarial Parasite
Non Governmental Organization
Out Patients Department
Outbreak response immunization
Oral Rehydration Salts
Oral Rehydration Therapy
Orthotoludine
Primary Health Center
Rapid Response Team
Radical Treatment
Sentinel Private Practitioner
Tuberculosis
This manual is intended for the use of the most peripheral workers in the health system,
both in the Government and Private sector. It should help them identify cases, alert the
higher authorities and take action within the limits of their capacity.
3
1.0 Introduction
1.1 What is surveillance?
Surveillance is collecting data on disease conditions so that necessary action can be
taken. Action may be in the form of improvement of services when gaps are identified or
outbreak response when an outbreak is detected. The key output of a good surveillance
system is the early detection of outbreaks. The six main steps in surveillance are:
 Detection and notification of health event;
 Collection of data;
 Investigation and confirmation (Epidemiological, clinical, laboratory);
 Analysis and interpretation of data;
 Response – a link to public health program specially actions for prevention and
control; and
 Feed back and dissemination of results.
1.2 Why surveillance?
Surveillance is an important component of public health measures. Surveillance helps
the health services keep a close watch on health events occurring in the community and
detect outbreaks that may be occurring so that corrective action can be taken
immediately. By preventing outbreaks, the credibility of the health services is greatly
improved.
2.0 Integrated Disease Surveillance Project
Integrated Disease Surveillance Project (IDSP) is a decentralized, state based
surveillance programme in the country. It is intended to detect early warning signals of
impending outbreaks and help initiate an effective response in a timely manner. It is also
expected to provide essential data to monitor progress of on-going disease control
programmes and help allocate health resources more efficiently.
All outbreaks cannot be predicted or prevented. However, precautionary measures can
be taken within the existing health infrastructure and service delivery to reduce risks of
outbreaks and to minimize the scale of the outbreak if it occurs. The effectiveness with
which national programs are implemented and monitored, the alertness for identification
of early warning signals and the capacity for initiating recommended specific
interventions in a timely manner are important to achieve the above objectives.
The course of an epidemic is dependent on how early the outbreak is identified and how
effectively specific control measures are applied. The epidemiological impact of the
outbreak control measures can be expected to be significant only if these measures are
applied in time. Scarce resources are often wasted in undertaking such measures after
the outbreak has already peaked and the outcome of such measures in limiting the
spread of the outbreak, and in reducing the number of cases and deaths, is negligible.
When outbreaks occur or when the risk of such outbreaks his high, the co-operation of
other government departments, non-governmental agencies and the community often
becomes necessary. Such help will be more forthcoming if mechanisms for interactions
have been developed before the onset of an outbreak.
The frequency of the occurrence of epidemics is an indication of the inadequacy of the
surveillance system and preparedness to identify and control outbreaks in a timely
manner.
The Integrated Disease Surveillance system will be operational all over the country and
will help the health services to improve the alertness of the health services to potential
outbreaks. The main components in this surveillance system would be: 1) surveillance of
4
diseases; capacity building of health staff at various levels; strengthening of
laboratories; provision of computers at the District Surveillance Unit to enable rapid
transmission of surveillance data; and partnership with private health sector. There are
many surveillance systems currently in the country. Efforts will be made under IDSP to
converge surveillance under various national disease programs in to a single surveillance
system under IDSP.
2.1 Syndromes under Surveillance:
The paramedical health staff will undertake disease surveillance based on broad
categories of clinical presentation. The following clinical syndromes will be under
surveillance in IDSP:
1.
Fever
2.
3.
4.
5.
6.
i. Less than seven days duration without any localizing signs
ii. With Rash
iii. With altered sensorium or convulsions
iv. Bleeding from skin or mucus membrane
v. Fever more than seven days with or without localizing signs
Cough more than three weeks duration
Acute Flaccid Paralysis
Diarrhoea
Jaundice
Unusual Events causing death or hospitalization
These syndromes are intended to pick up all priority diseases listed under regular
surveillance at the level of the community under IDSP.
1. Fever with or without localising signs
Malaria, Typhoid, Japanese
Encephalitis, Dengue, Measles
2. Cough more than 3 weeks
Tuberculosis
3. Acute Flaccid Paralysis
Polio
4. Diarrhoea
Cholera
5. Jaundice
Hepatitis, Leptospirosis
6. Unusual events causing death
or hospitalization
2.2 Types of surveillance under IDSP:
Plague, emerging diseases, Viral
outbreaks
Depending on the level of expertise of the health staff, disease surveillance under
IDSP will be of the following three categories.
Syndromic: Diagnosis made on the basis of history and clinical pattern by paramedical
personnel and/or members of the community.
Presumptive: Diagnosis made on typical history and clinical examination by medical
officers.
Confirmed: Clinical diagnosis confirmed by an appropriate laboratory test.
Syndromic surveillance is defined as the surveillance of diseases based on the presenting
symptom/s (and not the disease attributable to the syndrome). Under IDSP, the Health
Workers, Village Volunteers and Non-formal Practitioners will conduct syndromic
surveillance. The cases identified through the presenting symptoms are classified as
‘suspect cases’ of a certain disease condition. For e.g. a case of fever with rash will be
classified under the syndrome ‘fever with rash’ and not as measles. The medical
5
diagnosis of a condition, based on presenting symptoms and clinical signs will be
conducted only at the level of Medical Officers (such as those at Primary, Community
Health Centers, Dispensaries and Hospitals) or qualified medical practitioners.
Symptoms, signs and syndrome
Symptom is complaint perceived by the patient or identified by the examiner (e.g.
fever, loose motions, headache, vomiting, cough etc.)
Signs are findings on examination of patients e.g. skin rash, yellow discoloration
(jaundice).
Syndrome is group of symptoms and/or signs attributable to particular disease
condition (e.g. fever with skin rash indicative of measles).
6
2.3 Which are the reporting units?
A reporting unit is one that generates the data and feeds it into the surveillance system.
The Health Workers are the most peripheral workers at the subcentres and are the
primary reporting units in the surveillance system. Village volunteers from the
Panchayat, local private practitioners (including practitioners of Indian Systems of
Medicine) and non-formal health providers may be incorporated as reporting units for
syndromic surveillance, after proper training.
Rural
Urban
Reporting units for disease surveillance
Public health sector
Private health sector
Sub-centers, PHCs, CHCs, District
Sentinel Private
Hospitals
practitioners (SPPs) and
Sentinel hospitals.
Urban Hospitals, ESI / Railway / Medical
college hospitals
Sentinel Private nursing
homes, sentinel
hospitals, Medical
colleges, Private and NGO
laboratories
3.0 Data collection
The health workers are the most important personnel for syndromic surveillance. The
reporting units are the sub-centers of PHC and urban health centers. The peripheral
health workers will be provided a register in which they will note down the syndromes
that are under surveillance as and when they come to know of this during their routine
visits to the village and urban wards. The register will contain the verifiable information
which can be counter-checked by the supervisory staff under IDSP at PHC/CHC and
District levels. The health worker would be expected to record the number of these
syndromes seen by her/him each week and report it to the next level on a weekly basis.
Every Monday, this information will be translated into a summary sheet (form S) and
given to the Medical officer in charge of the PHC / Urban Health Center. This will be
immediately forwarded to the District Surveillance Officer. The reports from the Urban
Health Center will be forwarded to the Municipal Health Officer. The Municipal Health
Officer will then forward the reports to the District Surveillance Officer.
4.0 Flow of information:
The health workers (and other peripheral reporting units such as the village volunteer
and non-formal provider) should register all patients seen by them (either at the
Subcentre or during home visits) into their register for syndromic surveillance. On a
weekly basis, this information has to be transferred onto the suspect case reporting
format (Form S). The health worker, village volunteer or other providers will submit form
S to the PHC Medical Officer every Monday. If there are Sentinel Private Practitioners in
his/her area who form a part of the reporting system, the HW should collect the reports
from them and submit it to the PHC (without delay in sending the subcenter report to
the PHC). The MO PHC will retain one copy of the form S and forward the remaining copy
to the District Surveillance Officer immediately on Monday or latest by Tuesday. The data
from the periphery that will be provided to the PHC will be used for action.
Other than patients coming to the subcenter, the HW may also hear about cases in the
community from key informants. The HW must verify these cases before reporting.
7
Weekly Information Flow under IDSP
C.S.U.
Sub-Centres
Programme
Officers
P.H.C.s
C.H.C.s
D.S.U.
Dist.Hosp.
Pvt. Practioners
Nursing Homes
Private Hospitals
Med.Col.
P.H.Lab
S.S.U.
Private Labs.
Other Hospitals:
ESI, Municipal
Rly., Army etc.
Corporate
Hospitals
Transmission of data
Once the data is collated, and entered into the reporting form, then the HW should
ensure that the form S reaches the PHC every Monday. This may be done either
manually or by telephone where possible.
If there are Sentinel Private Practitioners in a subcentre area, it is the responsibility of
the HW to collect the form S from them and forward them to the PHC. However, in the
process of collecting the forms from them, the HW should ensure that his/her forms do
not get delayed in reaching the MO PHC.
Feedback
If the HW has referred patients for further investigation, she should find out from the
Medical Officer at the PHC about the outcome of the referral. If the HW has received
information about cases from key informants, she should share her diagnosis and action
with them.
5.0 Laboratory confirmation
While the HW is expected to see and report cases, he/she is also required to send
specimens of cases presenting certain symptoms to the laboratory for confirmation. The
table below summarizes the types of samples to be sent to the laboratory as part of
routine surveillance activity and as a part of outbreak response.
Table 5.1: Action to be taken by the HW in the field
Syndrome
Only Fever
Action
Blood Smear for all patients
8
Acute Flaccid Paralysis
Loose watery stools with
dehydration in an adult
Fever with rash
Fever with altered
sensorium
Fever with bleeding
Fever more than 7 days
Cough for more than three
weeks
Unusual severe syndromes
Inform PHC MO immediately to arrange for
collection of stool samples
Two samples of stools taken at interval of 24 hours
and transported to the MO PHC in reverse cold
chain
Take sample of stools in a filter paper or in a sterile
bottle and send it by reverse cold chain to the
nearest District Laboratory (within two hours) or
use Cary-Blair medium for transport of the sample
Referred to the MO PHC for specific lab action
5.1 Biosafety measures
The HW must follow precautionary measures while collecting samples from at the
periphery. This must be supervised by the MP PHC or the laboratory technician at the
PHCs.
Collection
1. Blood samples – Use disposable syringe/needles
2. Discard used needles into sharp boxes
3. Decontaminate used syringes by immersing in 10% bleach; autoclaving and then
discarding. Recommended to use autodestruct syringes.
4. In case of spills – wipe the surface with 10% bleach.
Transportation
1. Transportation boxes should be securely fastened. Keep absorbent cotton inside
the carrier.
2. If cold chain is required, ensure that there are ice packs. Loose wet ice should not
be used. Do not re-use the same cold chain box to transport vaccines.
6.0 Outbreak response
The role of the HW is not simply to collect and transmit data. She/he should also be alert
to outbreaks so that they can be detected early and an effective response can be taken.
Thresholds for outbreaks are given in annexure I (page 11). Once a disease condition
has crossed this threshold, the HW must take the appropriate action which is specified in
the annexure I (page 11). In the case of fever or AFP, the HW should also take the
responsibility of collecting the appropriate sample. Preset trigger levels for diseases have
been identified with specific responses for various levels of the health system. The
trigger levels are dependent on the outbreak/epidemic potential, case fatality rate of the
disease and the prevalence of the problem in the community.
7.0 Inter-sectoral coordination
For an effective outbreak response it is important to involve members of the community
and members of non-health departments/sectors. Therefore, the health worker as a part
9
of the outbreak response will inform the Panchayat office and the locally active NGOs
regarding possible outbreaks in the community (if any).
8.0 Conclusion
The HW is the eye and the ear and the most important personal of the Health Services
and plays a very crucial part in the early detection of outbreaks in the community. If the
HW works sincerely on surveillance, many outbreaks in the community can be prevented
which, will improve the credibility of his/her services.
Other than the HW’s own services, he/she should attempt to identify and build rapport
with key informants in each village who will inform him/her of the health events as and
when they occur. These community based informants would improve the alertness of the
surveillance system and should stimulate the health services to identify and respond
immediately to potential outbreaks.
10
Annexure I: Syndromes under surveillance
I. Syndrome of Fever
Diseases under Surveillance: Malaria/ Typhoid / Measles / Japanese Encephalitis (JE)
/ Dengue
I.a Why surveillance for fever?
Fever is the most common presenting symptom among patients at the periphery. The
disease conditions of public health interest are Malaria, Typhoid, Measles, JE and
Dengue. While the last two are not common, the HW needs to keep them under
surveillance so that they are picked up early to identify impending outbreaks.
I.b Syndrome Definition
All new patients with fever should be classified as follows:
a) Fever less than seven days with:





Rash and running nose or conjunctivitis (suspected Measles)
Altered sensorium (suspected JE)
Convulsions (suspected JE)
Bleeding from skin, mucus membrane, vomiting blood or passing fresh
blood through nose or ear or black motion (suspected dengue)
With none of the above (suspected malaria)
b) Fever more than seven days (suspected typhoid)
Trigger –1 : More than two cases with similar symptoms (as mentioned above) in the
village (1000 Population)
Note: While there may be other accompanying symptoms e.g. fever with cough,
fever with muscle pain, a patient is considered to be suffering from fever, if
his/her main symptom is that of fever.
I.c Recording information at reporting unit
Whenever the staff in the reporting unit sees a patient with fever, they should record it
in their register for syndromic surveillance. This includes simple details such as name,
age, sex, address, the syndrome and date of onset. This would include patients who
come to the reporting unit or as seen during their field visits. While entering the
diagnosis for fever, care must be taken to record it as one of the following categories:
 Only fever
 Fever with rash
 Fever with altered consciousness or convulsions
 Fever with bleeding
 Fever more than 7 days
These registers for syndromic surveillance are the source of data from which the
Syndromic Reporting Form (form S) will be filled by the HW on a weekly basis.
I.d Analysis
The HWs should do a preliminary analysis of their data. If the threshold is crossed, then
the HW should immediately take the necessary action.
Thresholds –
 Sudden/gradual increase in the number of cases of fever over the past
three weeks
 Two or more cases of fever with rash in one week
11



Two or more cases of fever with altered consciousness or convulsions
Two or more cases of fever with bleeding
Two or more cases of fever more than seven days
12
I.f Detailed Surveillance Action:
Syndrome
Trigger event (in a village or urban
ward for 1000 population approx)
Recommended Surveillance Actions
Lab action
A) Fever less than 7
days duration
a) Only fever
2 or more cases
1.
2.
3.
4.
b) With rash
2 or more similar cases
None
c) Altered
consciousness or
convulsions
2 or more similar cases
1. Give vitamin A
2. Give paracetamol.
3. Check measles immunisation status of
cases
4. Search for similar cases
5. Refer the case to PHC
6. Inform MO PHC
7. Strengthen routine measles
immunization services, including
Vitamin A
1. Collect slide for MP.
2. Antipyretics
3. Refer the case to CHC/District Hospital
4. Inform MO PHC
5. Vector surveillance
6. IEC for community awareness*
d) Fever with bleeding
2 or more similar cases
1.
2.
3.
4.
5.
6.
Slides for MP
1
Slides for MP
Presumptive / RT for malaria
Inform MO PHC.
IEC for community awareness1
Collect slide for MP.
Paracetamol
Refer the case to CHC/DH
Inform MO PHC
Vector surveillance
IEC for community awareness
Slides for MP
Slides for MP
Regarding mosquito breeding sites, anti-larval measures and personal protection from mosquito bites (such as use of bed-nets)
13
Syndrome
B. Fever more than 7
days
Trigger event (in a village or urban
ward for 1000 population)
2 or more similar
Recommended Surveillance Actions
1.
2.
3.
4.
Collect slide for MP.
Give paracetamol.
Give anti malarial treatment
Inform MO PHC.
Lab action
Slides for MP
Once typhoid fever is confirmed
1. Orthotoludine testing of drinking
water sources to check for residual
chlorine level.
2. Collect water sample and send it to
PHC for H2S testing and to district
labs for MPN count.
3. Check TCL stock.
4. Conduct appropriate chlorination of all
drinking water sources
5. IEC - Train local person about water
Chlorination / Community awareness
about safe water and personal
hygiene.
CONCLUSION
Remember that increasing cases of fever in the community could be the initial signs of an outbreak of malaria or dengue. So be alert to
the trends. The main focus should be to pick up warning signals of outbreaks at an early stage before it spreads.
14
II. Syndrome of Cough (with or without fever)
Diseases under Surveillance: Tuberculosis / Acute Respiratory Infections
II.a Why surveillance of cough?
Cough is a common symptom, especially among children. There are many causes of
cough, ranging from the common upper respiratory tract infection to cancer of the lung.
However, Tuberculosis and Acute Respiratory Infections among children are the major
public health problems. Thus the symptom of cough is divided into two broad categories:
1) Short duration cough (less than three weeks); and, 2) Long duration cough (more than
three weeks). Adults (more than or equal to five years) with cough for more than three
weeks should be suspected to be suffering from TB, while children (less than five years)
with cough less than three weeks should be suspected to be suffering from ARI.
II.b Syndrome definition:
All new patients with cough as the main presenting symptom should be included. These
Patients will be divided into two categories:
a) Short duration cough (Cough less than 3 weeks) - Suspect ARI (common
among children less than five years)
b) Long duration cough (Cough of more than or equal to 3 weeks) - Suspect
Tuberculosis
Note: While there may be other accompanying symptoms e.g. fever and
breathlessness, a patient is considered as one suffering from cough, if his/her
main symptom is that of cough.
II.c Recording at Reporting Unit
Whenever the HW sees a patient with cough during the field visits or at the sub center,
he/she should record it in the register for syndromic surveillance. This should include
simple details such as name, age, sex, address, syndrome and date of onset. While
entering the diagnosis for cough, care must taken to record it as either short duration
cough or long duration cough (as mentioned above)
.
These register for syndromic surveillance is the source of data from which the Syndromic
Reporting Form S is filled by the HW on a weekly basis.
II.d Analysis and action
The HW should do a preliminary analysis of their data. If the threshold is crossed, then
she should take the necessary action.
THRESHOLD
(increase in number of cases during last 3 weeks)
Cough less than 3 weeks duration
Cough more than 3 weeks duration
RESPONSE
Alert the Medical Officer about a potential
outbreak
Refer the patient to the Medical officer
for further investigation.
II.e Conclusion
Remember that increasing cases of cough in the community may be the initial signs of a
measles outbreak or an outbreak of whooping cough. So be alert to trends. Also try and
pick up suspect TB cases as early as possible before they transmit the infection to others.
15
III. Syndrome of Watery Diarrhoea
Diseases under surveillance – Acute Diarrhoeal Diseases, cholera
III.a Why surveillance for Diarrhoea?
Diarrhoea is one of the most common symptoms faced by health workers at the periphery. It has a
high death rate, especially among children. While sporadic cases are not alarming from the public
health point of view, there is a danger of diarrhoea attaining outbreak situation in a short period of
time, especially in areas where sanitation is poor. Thus it is important to keep a strict vigil on the
cases of diarrhoea – to check whether they are increasing in number or whether there are deaths
occurring due to diarrhoea in the community. Deaths due to diarrhoea and dehydration in adults (>
5 years) should alert the health workers about the possibility of cholera and appropriate action
should be taken as given below. Outbreaks of diarrhoea reflect poorly on the effectiveness of the
health services. Preventing diarrhoeal outbreaks will improve the image of the health services and
the health workers in the periphery.
III.b Syndrome Definition
Syndrome of Acute Diarrhoeal Diseases:
Any new case of watery diarrhoea (passage of even one large profuse watery stools in
the past 24 hours) with or without dehydration. The total duration of illness should be
less than 14 days.
Trigger: 1) More than 10 houses with at least one case of diarrhoea each in a village or
urban ward within a week; or 2) Single case of severe dehydration or death in a patient
more than or equal to 5 years with diarrhoea; or 3) A single death due to severe
dehydration following diarrhoea.
III.c Reporting Details
As the main aim of surveillance is to detect potential outbreak situations, and cases of
cholera is one of them, all diarrhea cases would be divided into two categories – diarrhea
with dehydration and diarrhoea without dehydration. They would be further divided into
less than five years of age and equal to or more than five years of age and by sex (male
and female).
Those cases of diarrhoea which last more than seven days should be labeled as chronic
diarrhea (for surveillance purposes).
Whenever the Health Worker sees a patient with diarrhea during field visit or at the
subcenter, they should record it in their register for syndromic surveillance. This should
include simple details such as name, age, sex, address, syndrome and date of onset. This
would include patients who come to the reporting unit or as seen during their field visits.
While entering the diagnosis for diarrhea, care must taken to record it as one of the
following categories.
 Acute diarrhea with dehydration
 Acute diarrhea without dehydration
The register for syndromic surveillance is the source of data from which the Syndromic
Reporting Form S is filled by the HW on a weekly basis.
III.d Analysis
The HWs should do a preliminary analysis of their data. If the threshold is crossed, then
she/he should take the necessary action.
Thresholds –
 A single case of severe dehydration / death in a patient of more than or equal
to 5 years of age
 More than 10 houses with at least one case of diarrhoea each in a village or
urban ward within a week.
16
III.e Response
Depending on the threshold, the HW should take the following action:
THRESHOLD
ACTION/RESPONSE
A single case of diarrhoea with severe Distribute ORS to the cases including
dehydration / death of a patient who is other vulnerable families
more than 5 years old with diarrhea
Refer cases with severe dehydration to
More than 10 houses having at least one the nearest PHC
case of diarrhea each in a village or
urban ward within a week.
Search for more diarrhoea cases in the
community and prepare line listing of
cases
Alert the MO PHC immediately.
(Details of Action/Response – Refer to
III.g)
III.f Conclusion
Remember that diarrhoea can spread very rapidly in a short time. Appearance of
diarrhoea cases should be is a warning signal of a potential outbreak.
III.g Annexure
i) Case management:
Rehydration therapy is the key treatment for diarrhoea. This is in the form of Oral
Rehydration Therapy.
Diarrhoea with dehydration
 75 ml / kg of ORS in the first 4 hours.
 Reassess dehydration
 If same – continue for another 4 hours
 If rehydrated, ORS – 100 ml/kg/day
 If worsened or increased – Refer to PHC/CHC.
17
ii) Epidemiological investigation
o Active search for all new cases in that area.
o Line listing of cases.
o Information to MO PHC / CHC
iii) Collection of lab specimens
o Collect stool specimens and send to PHC for Cholera isolation
o Water samples for bacteriological analysis
iv) Prevention of further cases / deaths
o Provision of safe drinking water by disinfection of drinking water sources
o IEC to promote food and personal hygienic measures
o Distribution of ORS packets to the vulnerable families.
o Refers cases of dehydration to the PHC
o Intimate the local practitioners about the probable outbreak
v) Safe drinking water: In an outbreak of cholera, providing safe drinking water is the
most accepted method of control. This would include:
 Immediate provision of safe drinking water - steps must be taken to provide
properly treated or other wise safe water to the community for all purposes
(drinking and cooking).
 Chlorine tablets may be distributed to all households so that they may
chlorinate their drinking water themselves.
 All water sources in the community should be chlorinated with bleaching
powder. Residual chlorine should be ensured before this water is used.
 Health education of the community to boil drinking water if feasible may be
resorted to.
Provision of safe water is the responsibility of the department of water supply and should
be coordinated by the BDO / CEO / Collector. However, the health department should be
involved in this measure and should advise the water supply department about the areas
to be targeted.
vi) If diarrhoea outbreak occurs:
vi. a) Sanitary disposal of human waste: During an outbreak the community has to be
educated on the need for observing basic sanitary practices. These include
 IEC on food, personal and sanitary hygiene
 Use of sanitary toilets wherever possible
 Avoid defecation near water sources.
 Importance of washing of hands after defecating and before eating must be
emphasised.
vi. b) Food sanitation: Ensure proper hygiene and sanitatary precautions while
preparing and distributing food. Sale of food items must be strictly monitored and food
should not be exposed to houseflies. The food must be freshly prepared and served hot.
Proper washing of hands by food handlers is essential for food safety. Discourage
consumption of cut fruits and raw vegetables like salads without thorough washing with
safe water.
vi. c) Health Education: Health education is the most effective prophylactic measure
and should be mainly directed at early reporting and prompt treatment, importance of
safe water, hygienic food practices and personal hygiene.
vii) Stool Collection:
vii. a) Purpose:
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To confirm cases of cholera. So stools samples should be taken from adult patients who
have diarrhoea and severe dehydration. These should be transported immediately to the
District laboratory for confirmation.
Vii. b) Procedure:
 Collection of specimens before the patient receives antibiotics
 In the event of an outbreak, collect from 5 – 10 patients.
 If stool is available, pour out /scoop specimen with spoon and fill upto the half the
container
 If stool is not available, introduce the swab well into the rectum (2 – 4 cms deep) and
rotate by 90*. Ensure that it is moist and fecally stained.
 Put specimen / swab into the Cary-Blair transport medium which has been previously
cooled for one hour. This specimen then should be sent to the nearest lab as soon as
possible. Vibrio cholera can be isolated from the media if transported and plated within
7 days. While cold chain is not necessary, it would be advisable to store in a
refrigerator and transport under reverse cold conditions.
 If C-B media is not available, then the specimen (or even filter paper soaked in stool)
can be placed in a sterile container and transported under reverse cold chain
conditions (2* – 8* C). Ensure that the sample reaches the lab within 2 hours.
 Put the containers in separate polythene bags to prevent leakage and cross
contamination.
 Label the samples. The label should contain the
o Patient’s name
o Unique ID number
o Specimen type, date, time and place of collection.
o Name/ initials of collector.
Send the samples to the nearest District Lab. In the urban areas, the samples need to be
sent to the nearest designated lab that may be a Private lab
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IV. Syndrome of Jaundice
Diseases Under Surveillance: Acute Viral Hepatitis A, Viral Hepatitis E and
Leptospirosis.
IV.a) Why surveillance for jaundice?
Jaundice is not a common symptom in the village level, but it has the potential for
developing into an outbreak situation. There are many causes of Jaundice of which
Hepatitis A and E virus and Hepatitis B virus and Leptospirosis are the diseases that are of
public health importance and may occur as outbreaks. To differentiate this type of
jaundice from others of lesser public health importance, surveillance will focus only on
jaundice of less than four weeks duration.
IV.b) Syndrome Definition
Clinical Description:
A case



with an acute illness (less than 4 weeks) and with the following symptoms:
jaundice, dark urine,
anorexia, malaise, extreme fatigue and
pain in the right upper abdomen.
Trigger: More than two cases of Jaundice in different houses irrespective of age in a
village/urban ward or approximately 1000 population.
IV.c) Reporting details
Whenever the HW sees a patient with jaundice during the field visits or at the subcenter,
they should record it in their register for syndromic surveillance. This should include
simple details such as name, age, sex, address, syndrome and date of onset. While
entering the diagnosis for jaundice, care must taken to record it as one of the following
categories.
 Jaundice of less than 4 weeks
 Jaundice of more than 4 weeks.
The register for syndromic surveillance is the source of data from which the Syndromic
Reporting Form S is filled by the HW on a weekly basis.
IV.d) Analysis
The HWs should do a preliminary analysis of their data. If the threshold is crossed, then
he/she should take the necessary action.
Thresholds –
 If there are more than 2 cases of jaundice in a village or an urban ward
(approximately 1000 population) within a week.
 A single case of death due to acute jaundice (jaundice of less than 4 weeks)
IV.e) Response
Depending on the threshold, the MPW should take the following action:
Threshold
Response
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More than 2 cases of Jaundice in different
households irrespective of age per
thousand population in a village or ward
Alert Medical Officer,
potential outbreak
PHC
about
a
Active search for more cases in the
community. Line listing of these cases by
name, age, sex, location and symptoms
A single case of death due to acute
jaundice (jaundice of less than 4 weeks)
Active search for pregnant women with
jaundice, who should be referred
immediately to the district level.
NOTE: If an outbreak of Hepatitis A or E occurs, take all action listed under diarrhoea
outbreak.
IV.f Conclusion
Remember that jaundice is an uncommon but important problem in the community. Most
community members prefer to treat jaundice with traditional medicines, so they do not
usually approach the allopathic system for treatment. Thus a single case of jaundice
should alert the MPW about potential cases in the community and she should make efforts
to trace them. While a single case may be of no public health significance, multiple cases
may indicate problems due to contaminated water supply.
IV.g Annexure
i) Safe drinking water: In an outbreak of jaundice, and if Hepatitis A or E is suspected,
providing safe drinking water is the most accepted method of control. This would include:
 Immediate provision of safe drinking water - steps must be taken to provide properly
treated or other wise safe water to the community for all purposes (drinking and
cooking). Chlorine tablets may be distributed to all households so that they may
chlorinate their drinking water themselves.
 All water sources in the community should be chlorinated with bleaching powder.
Residual chlorine should be ensured before this water is used.
 Health education of the community to boil drinking water if feasible may be resorted
to.
Provision of safe water is the responsibility of the dept of water supply and should be coordinated by the BDO / CEO / Collector. However, the health department should be
involved in this measure and should advise the water supply department about the areas
to be targetted.
ii) Sanitary disposal of human waste: During an outbreak the community has to be
educated on the need for observing basic sanitary practices. These include
 Using of sanitary toilets wherever possible
 If they resort to open-air defecating then they must be instructed to ensure that they
are not next to a water source, that they cover the faeces with mud mixed with slaked
lime.
 The importance of washing of hands after defecating must be emphasized.
 Washing of patient’s soiled linen and clothes should be done only after soaking them in
a solution of bleaching powder. Also washing should not be done with 10 m of a water
source.
iii) Food sanitation: Steps should be taken to ensure proper hygiene and sanitation
while preparing and distribution of food. Sale of food items must be strictly monitored and
food should not be exposed to houseflies. The food should be freshly prepared and served
hot. Proper washing of hands by food handlers is essential for food safety. Sale of cut
21
fruits and eating of raw vegetables like salads without thorough washing with safe water
should be discouraged.
iv) Health Education: Health education is the most effective prophylactic measure and
should be mainly directed at early reporting and prompt treatment, importance of safe
water, hygienic food practices and personal hygiene.
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V. Syndrome of Unusual Events Causing Death or Hospitalization
V.a) Why surveillance of unusual syndromes?
While most common illnesses fit into the syndromic approach, the health workers should
be alert for uncommon events in the community also. Today is a period of bioterrorism
and chemical warfare that pose a threat to the health of the community. So any unusual
illness in the community causing either deaths or affecting large populations should be
brought to the notice of higher authorities immediately.
V.b) Syndrome definition
Syndrome Description:
The sudden occurrence of unusual events, in a geographical region, causing death or
hospitalization and which does not conform with the standard case/syndrome definitions
discussed earlier in the manual.
Some





of the symptoms may be:
Convulsions
Alteration in consciousness
Breathing Difficulty / Respiratory distress
Bleeding
Paralysis
Trigger: Two cases of death or hospitalisation due to an unusual symptom/s. Examples
given above.
V.c) Definitions
 Hospitalization and Death are self explanatory and do not require any specific
definition.
 Convulsion is defined for the syndrome as any patient admitted or died following
involuntary muscular spasms with or without loss of consciousness.
 Altered Consciousness is defined as not able to recognize relatives and not to be
aware regarding time or place.
 Breathing Difficulty: When ever patients complain of severe breathlessness
associated with rapid respiration
 Bleeding from skin, mucus membrane, vomiting blood or passing fresh blood or
black motion
 Paralysis: Severe muscle weakness leading to difficulty in using any of the limbs.
V.d) Reporting details
Whenever the HW sees a patient with unusual syndromes during field visit or at the
subcenter, he/she should record it in the register for syndromic surveillance. This should
include simple details such as name, age, sex, address, syndrome and date of onset.
The register for syndromic surveillance is the source of data from which the Syndromic
Reporting Form S is filled by the HW on a weekly basis.
V.e) Analysis
The HW should do a preliminary analysis of their data. If the threshold is crossed, then
he/she should take the necessary action.
Thresholds –
 Two or more similar cases of unusual symptoms
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Care should be taken to ensure as much as possible that it is a health event that is
unusual. Some cases that may be confused as an unusual events are suicide, homicide,
snake bites, unnoticed head injury etc.
V.f) Response
Depending on the threshold, the HW should take the following action:
Threshold
Two cases of death/hospitalization due to
unusual symptoms.
 Convulsions
 Alteration in consciousness
 Breathing Difficulty / Respiratory
 Bleeding
 Paralysis
Action
Refer the patients to the District Hospital
immediately
Inform the MO of the PHC immediately
Active search for similar cases in the
community. If there are such cases, then
line list them according to their age, sex,
location, clinical details and date of onset
of symptoms and refer them to District
Hospital.
V.g) Conclusion
Remember that unusual syndromes are the best way of picking up the presence of new
agents in the community. This is the ultimate test of a surveillance system and all levels
of health workers should be alert to this. This also indicated effective surveillance in a
given area.
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Glossary of terms
Non formal practitioner – This refers to the practitioners who are not medically
qualified but provide health care at the community level, especially in rural areas
Health Worker (M/F) – For consistency and convenience, all peripheral staff of the
health system such as Health Workers, Health Assistant, Health Supervisor, Multi Purpose
Worker, Lady Health Visitor, Auxiliary Nurse Midwife, Anganwadi Workers, Village
Volunteers, Non formal practitioners at the village level etc have been referred to as
Health Worker (HW).
Trigger level – Under IDSP, a warning signal has been set under every disease to
identify a potential outbreak situation, which will serve as a trigger for action. This
warning signal is referred to as the trigger level. For e.g. a single case of measles is a
trigger for a measles outbreak that should set into action, the control measures.
Outbreak/epidemic potential – It is the nature of diseases that are highly
communicable by virtue of their nature of transmission that makes them prone to reach
outbreak situations rapidly.
Key informants – These are members of the community that are knowledgeable about
the community, especially in rural areas, it’s composition, health problems etc and are
capable of providing information to the HW regarding health events in the community.
Key informants could be panchayat members, school teachers or members of local NGOs,
to list a few.
Threshold - Every disease needs a basic number of cases in order to sustain the
transmission to other vulnerables in the population. Also, when a disease reaches this
threshold level, there is a risk of an outbreak of that disease.
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