Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Epidemiology wikipedia , lookup
Race and health wikipedia , lookup
Public health genomics wikipedia , lookup
Epidemiology of measles wikipedia , lookup
Reproductive health wikipedia , lookup
Marburg virus disease wikipedia , lookup
Eradication of infectious diseases wikipedia , lookup
Infection control wikipedia , lookup
International Association of National Public Health Institutes wikipedia , lookup
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: 18 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 19 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 20 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. 22 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 23 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. 24 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. 25