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Transcript
1.0 Introduction 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 programmes 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. 1.1 What is public health surveillance? Surveillance is defined as the ongoing systematic collection, collation, analysis, and interpretation of data and dissemination of information to those who need to know in order that action is taken. A more complete definition of surveillance is ‘The ongoing systematic collection, analysis and interpretation of health data essential to planning, implementation and evaluation of public health practice closely integrated with timely dissemination of these data to those who need to know.’ The final link in the surveillance chain is the application of these data to prevention and control. A surveillance system includes a functional capacity for data collection, analysis and dissemination linked to public health programs (CDC 1988). Surveillance is the backbone of public health programme and provides information so that effective action can be taken in controlling and preventing diseases of public health importance. In some cases action must be immediate – within hours – in order to prevent large scale epidemics and deaths (Cholera, meningitis, food contamination). In others, control and prevention activities are long term response to information about disease such as tuberculosis, HIV and Non Communicable Disease risk factors, for which action may be taken in weeks, months or even years. 1 1.2 What are the Key Elements of Surveillance System? All surveillance systems involve six key elements: • Detection and notification of health event • Investigation and confirmation (epidemiological, clinical, laboratory) • Collection of data • Analysis and interpretation of data • Feed back and dissemination of results • Response – a link to public health program specially actions for prevention and control 1.3 What are the levels where surveillance activities are performed? Activities Periphery District State Detection and notification of cases +++ ++ - Collection and consolidation of data + +++ +++ Analysis and Interpretation + +++ +++ +++ +++ + Feed Back + +++ ++ Dissemination + ++ ++ Action ++ +++ + Investigation and confirmation - Nil + Some Activity ++ Considerable Activity +++ Great Deal of Activity 1.4 Why do we need to do surveillance? Uses of Surveillance: • Recognize cases or cluster of cases to trigger interventions to prevent transmission or reduce morbidity and mortality • Assess the public health impact of health events and determine their trends • Demonstrate the need for public health intervention programs and resources and allocate resources during public health planning • Monitor effectiveness of prevention and control measures • Identify high-risk groups or geographical areas to target interventions and guide analytic studies • Develop hypothesis that lead to analytic studies about risk factors for disease causation, propagation or progression. 2 2.0 Integrated Disease Surveillance Project (IDSP) The IDSP proposes a comprehensive strategy for improving disease surveillance and response through an integrated approach. This approach provides for a rational use of resources for disease control and prevention. In the integrated disease surveillance system: The district level is the focus for integrating surveillance functions. All surveillance activities are coordinated and streamlined. Rather than using scarce resources to maintain vertical activities, resources are combined to collect information from a single focal point at each level. Several activities are combined into one integral activity to take advantage of similar surveillance functions, skills, resources and target populations. The IDSP integrates both public and private sector by involving the private practitioners, private hospitals, private labs, NGOs, etc and also emphasis on community participation. The IDSP integrates communicable and non-communicable diseases. Common to both of them are their purpose in describing the health problem, monitoring trends, estimating the health burden and evaluating programmes for prevention and control. Integration of both rural and urban health systems as rapid urbanization has resulted in the health services not keeping pace with the growing needs of the urban populace. The gaps in receiving health information from the urban areas needs to be bridged urgently. Integration with the medical colleges (both private and public) would also qualitatively improve the disease surveillance especially through better coverage. 2.1 Objectives of the Integrated Disease Surveillance Project The overall general objective of the IDSP is to provide a rational basis for decision-making and implementing public health interventions that are efficacious in responding to priority diseases. Keeping this in mind the main objectives of the IDSP are: • To establish a decentralized district-based system of surveillance for communicable and non-communicable diseases so that timely and effective public health actions can be initiated in response to health challenges in the urban and rural areas • To integrate existing surveillance activities (to the extent possible without having a negative impact on their activities) so as to avoid duplication and facilitate sharing of information across all disease control programmes and other stake holders, so that valid data are available for decision making at district, state and national levels. 3 2.2 Core Conditions under surveillance in IDSP Regular Surveillance∗: Vector Borne Disease : 1. Malaria Water Borne Disease : 2. Acute Diarrhoeal Disease (Cholera) : 3. Typhoid : 4. Jaundice Respiratory Diseases : 5. Tuberculosis : 6. Acute Respiratory Infection Vaccine Preventable Diseases : 7. Measles Diseases under eradication : 8. Polio Other Conditions : 9. Road Traffic Accidents (Linkup with police computers) Other International commitments : 10. Plague, Yellow fever Unusual clinical syndromes : 11. Menigoencephalitis/ Respiratory (Causing death/hospitalization) Distress, Hemorrhagic fevers, other undiagnosed conditions Sentinel Surveillance: Sexually transmitted diseases/Blood borne : 12. HIV, HBV, HCV Other Conditions : 13. Water Quality : 14. Outdoor Air Quality (Large Urban centers) Regular periodic surveys: NCD Risk Factors : 15. Anthropometry, Physical Activity, Blood Pressure, Tobacco, Nutrition State specific diseases: e.g. Dengue, Japanese Encephalitis, Leptospirosis Surveillance for disease conditions is important for public health action: ∗ • The number of core diseases is limited to improve quality of surveillance and to reduce work load on the peripheral health worker. • Diseases and other conditions of regional importance will be under surveillance in addition to the above core list in all states. • The list will be reviewed and modified according to the needs of surveillance at least once in two years. Viral Hepatitis, ARI are also under active consideration at the various levels and may be included subsequently 4 • Does the disease condition have high health impact (morbidity, mortality, disability) (Malaria, NCD risk factors, Road Traffic Accidents (RTA)) • Does it have significant epidemic potential? (Cholera, Measles) • Is it a target of a specific national, regional or international disease control program? (HIV, TB, Polio) • Will the information collected lead to significant public health action? To plan any disease control programme and to identify and control outbreaks, it is important to know the following: o Who get the diseases? o How many get them? o Where do they get them? o When do they get them? o Why do they get them? There are five steps in the surveillance procedure, which must be carried out at each level, starting from the Primary Health Centre (PHC). Each level must have the capacity for analyzing and using surveillance data for early detection, prevention and control of outbreaks. The five recommended steps are: o Collection of data o Compilation of data o Analysis and interpretation o Follow up action o Feedback 2.3 Pre-requisites for effective surveillance Prerequisite for effective surveillance are: o Use of standard case definitions o Ensure regularity of the reports o Action on the reports For developing an effective disease surveillance system, the District Health Officer/PHC Medical Officer must also be clear about: o What information to gather? o How often to compile and analyze the data? o How often and to whom to report? 5 o What proforma or formats to use? o What action to take? The data collected should be uniform, regular and timely. Standard case definitions are important to ensure uniformity in reporting so that all reporting units use the same criteria for reporting cases. It is also important to have a list of all reporting units so that the regularity and timeliness of the reports is checked. If no cases are seen, a nil report should be submitted. All levels in the system must: o Have the standard case definitions? o Have a list of all reporting units? o Monitor receipt of reports in time o Monitor completeness of reports The standard case definition of diseases is given at the end of the manual under Annexure-I 3.0 Types of Surveillance in IDSP: Depending on the level of expertise and specificity, disease surveillance in IDSP will be of following three categories: i. Syndromic – Diagnosis made on the basis of symptoms/clinical pattern by paramedical personnel and members of the community. ii. Presumptive – Diagnosis made on typical history and clinical examination by Medical Officers. iii. Confirmed – Clinical diagnosis confirmed by an appropriate laboratory test. Syndromic Surveillance The paramedical health staff will undertake disease surveillance based on broad categories of presentation. The clinical syndromes under surveillance are: 1. Fever i. Less than seven days duration without any localizing signs ii. with rash iii. with altered sensorium or convulsions iv. bleeding from skin or mucous membrane v. more than seven days with or without localizing signs 2. Cough with or without fever (for less than three weeks or more than or equal to three weeks duration) 3. Acute Flaccid Paralysis 6 4. Diarrhoea 5. Jaundice 6. Unusual events causing death or hospitalization These syndromes are intended to pick up all priority diseases listed under IDSP for surveillance. 3.1 Surveillance by Medical Officers: Though it is ideal to have all diseases under surveillance confirmed by laboratory tests, this is often not feasible. During routine surveillance, the diagnosis made by the Medical Officer is considered presumptive in nature. The validity of presumptive diagnosis of surveillance conditions will be higher than that of the syndromic one undertaken by the health worker. Under IDSP the MOs of PHC, CHC, Medical Colleges and Sentinel Centre will conduct presumptive surveillance routinely. This will be supplemented by confirmation of diseases by laboratory reporting. 3.1.1 Methods of data collection Several methods can be used for collecting data. While routine reporting (passive surveillance) is universalized, other methods are need and area specific. These include: o Sentinel surveillance o Active surveillance (active search for cases) o Vector surveillance o Laboratory surveillance o Sample surveys o Outbreak investigations o Special studies 3.1.2 Routine reporting (institutional based or passive reporting) All the national health programmes require that the cases and deaths recorded in the outpatient or in-patient departments of hospitals, dispensaries, CHC, PHC and other health facilities manned by a medical officer are reported to the local health authority on a monthly basis. In the Integrated Disease Surveillance Program the essential surveillance components will be identified and transfer of information to program officers facilitated so that information for action is available on a weekly basis. At each level in the system, the report is required to be analyzed and appropriate action taken as indicated. The reports should be checked for completeness and regularity as these factors can influence the analysis of the reports. 3.1.3 Sentinel surveillance A sentinel surveillance system is developed to obtain more reliable and extensive disease related information than the one that is available through the routine reporting. A hospital, 7 health center, laboratory or a rehabilitation center which caters to a relatively large number of cases of the disease can be considered as a sentinel center. A sentinel center can provide information on one or more diseases. Since the sentinel centers are carefully selected and because the number of the reporting units is much smaller, it is easier to maintain the quality and regularity of the reports. There should be a close liaison between the sentinel center and the local health authorities. The sentinel from the private sector can help in providing early warning signals, which should trigger action for outbreak investigation. The sentinel center data will not include all cases in the area. However, if one or more sentinel centers have been carefully selected, it will include sufficiently large number of cases for epidemiological analysis. Data from sentinel centers are useful to determine trends in the incidence of the reported disease. The district hospital, infectious diseases hospital, medical college hospital (if located in the district) and other large hospitals and laboratories should be included as sentinel centers and reports from these centers should be analyzed separately. These centers would also be submitting the routine monthly report under the passive surveillance system. 3.1.4 Regularity of reports Monitoring the regularity of surveillance reports is an important function of the surveillance system. A list of all reporting units in the area must be kept. The Chief Medical and Health Officer of the district must identify the reporting units. Besides the PHCs and CHCs, hospitals, large dispensaries and clinics should be included as reporting units. 3.1.5 Frequency of reporting A system of monthly reporting of diseases and programme specific data already exists in the districts. Many epidemic prone communicable diseases have short incubation period. If a review of the data is made only on a monthly basis, it might delay the timely identification of an outbreak in the early phase. Reporting units need to move into weekly reporting of cases of epidemic-prone diseases seen in their institutions, if surveillance has to be action oriented. If pre-determined trigger levels are breached for a disease, it should serve as a warning signal for investigation. The area of residence of the patients should be checked and if these cases are clustered with respect to time and place, an immediate field visit is indicated. An epidemic can be averted by taking appropriate control measures in time. If an outbreak is suspected or identified, the next level should be notified immediately. Some outbreaks may be explosive and become apparent in a short time. This should be investigated immediately. Cases of acute hemorrhagic fever or encephalopathy should be investigated and reported immediately. Daily reports are necessary once an outbreak has been identified so that the situation can be monitored. Neighboring areas would also need to step up surveillance activities to rule out the spread of the outbreak. After the outbreak has subsided, weekly reports should be continued for at least double the maximum incubation period of the disease. 8 Only data that is used should be collected, otherwise it will clutter and overburden the system. All the data collected at PHC or district is not required to be transmitted to the state or central levels unless a special request is received. 3.1.6 Active surveillance However good the routine reporting system, there will still be cases that will not be recorded under this system. Patients with mild or moderate severity may not seek treatment and some may go to private practitioners. It is also possible that patients in severe condition are taken directly to a large hospital in another district for specialized care. Some cases may die within a short period of onset of symptoms without receiving care at a health facility such as cases of neonatal tetanus. Active surveillance or active search for cases is resource intensive. The decision to start active surveillance depends on many factors and ground situations. Active search may be called for under the following circumstances. • During outbreaks, determine the extent of the outbreak and keep mortality rates low by initiating early treatment. Active surveillance is carried out to know the magnitude of the problem which will help in planning logistics for control. In addition, it will give baseline data to evaluate control strategy. It also helps in understanding the genesis of the outbreak. • To check if reports received by rumor registry are true. • As the number of cases of a disease decline to negligible levels, it becomes important to receive information on every single case as quickly as possible so that further transmission is interrupted by initiating outbreak control measures. For example, active surveillance is recommended for Acute Flaccid Paralysis (AFP) • To confirm the absence of even a single case. This is done during the pre-certification phase for disease eradication, as ‘zero’ incidence has to be maintained for a period of three years. During field visits by the supervisors, absence of disease can be confirmed by contacting few key persons such as a school teacher, gram pradhan, anganwadi worker and others. The health personnel, outreach personnel of other government departments, non-governmental organizations, panchayats and the members of the community must be encouraged to report cases. The lay case definition of the disease should be widely circulated for this purpose. The health personnel should not be punished or discouraged in any way from reporting cases as this will lead to suppression of vital information. 3.1.7 Laboratory surveillance Laboratory surveillance plays an important part in confirming diseases since regular summary data can at best be presumptive. The validity of changing trends in suspect cases (syndromes) and presumed cases made by Medical Officers can be confirmed only by laboratory testing. 9 Under IDSP, the laboratory network will report independently all confirmed cases in a prescribed format. This will allow to understand and validate the changes in pattern of syndromes and probable cases seen at the reporting centers. Laboratories also help in diagnosis of cases for case management and this function will be facilitated by quick feed back of laboratory reports on a case based format back to the reporting units. Clinical samples should be collected and transported properly to the identified laboratories for appropriate tests. The samples should be labeled properly and accompanied with requisite epidemiological information. Testing water samples for coliform organisms is a measure to determine the risk of water borne outbreaks. Water quality monitoring is recommended in vulnerable pockets and from sources supplying drinking water to a large population. Checking the chlorination levels of the water is also important, especially during the monsoon and post-monsoon periods. These measures by the health department are precautionary measures in addition to the mandatory requirements of the concerned department. Laboratory surveillance must be stepped up in anticipation or in the event of an outbreak. Serological and other laboratory based surveys are sometimes conducted as research projects to collect baseline prevalence rates or to identify high risk factors, age-groups or population sub-groups. The identification of new agents and changes in the behavior of micro-organisms especially in relation to susceptibility to anti-microbials are also important components of laboratory surveillance. 3.1.7.1 Biosafety a. Collection 1. Blood samples – wearing of gloves, clean surface, venepuncture by disposable syringe and needle. Sterile containers to be used (supplied by the CHC). 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. b. Transportation 1. Transportation boxes should be securely fastened. Keep absorbent cotton inside the carrier. 10 2. If cold chain is required, ensure that there are ice packs. Loose wet ice should not be used. 3. Containers for transportation would be provided by the CHC (tube + Plastic bag + Cotton pad). 4. Care should be taken to see that there is no leakage. 5. In case of suspected unusual pathogens, e.g. plague, anthrax etc; sample collection and transportation should be done with utmost precautions; 6. Post mortem samples maybe transported in reverse cold chain in a sterile container to the designated laboratory (as decided by the S.S.U.). 3.1.8 Sample surveys Surveys give reliable epidemiological information. These are particularly useful to collect baseline data prior to the launch of a large control program, especially if such data are lacking through other sources. In IDSP Non communicable diseases (NCD) risk factors will be collected through regular surveys. Surveys are, however, difficult to conduct and are relatively expensive. The sample size, sampling procedure, methodology, questionnaires and forms must be well designed to avoid bias and misinterpretation of data. These surveys can be conducted after a period of 3 to 5 years cyclically. 3.1.9 Special studies Special studies are sometimes required to study problems that are not addressed through the methods of data collection listed above. Some districts, for example, may have a high prevalence of cases linked to or suspected to be due to environmental pollution; other districts may have problems related to multi-drug resistant micro-organisms. 3.1.10 Outbreak investigations Outbreak investigation is the primary method of confirming emerging infections. Changes in trends observed and suspected outbreaks are confirmed by outbreak investigations. Outbreaks investigations provide a rich source of epidemiological information. The outbreaks should be investigated to ascertain its etiology and understand why they occurred as well as to identify high risk areas and groups. Laboratory help should be utilized in establishing the diagnosis of early cases only. Once the cause of outbreak is confirmed, laboratory support should not be wasted for each and every case. The data collected as a result of outbreak investigations must be utilized for improving programme activities and the surveillance system as well as for filling gaps identified as a result of these investigations. The results should be shared with other district officers and other states so that the experience gained could be effectively used for preventing such outbreaks in these areas. 11 4.0 Reporting Units participating in regular passive surveillance under IDSP: The syndrome of fever will be kept under regular passive surveillance at the periphery by the reporting units in both public and private sector in rural and urban areas of the district. Primarily Passive Surveillance will be undertaken at all reporting units by the Medical Officer. Each reporting unit will be provided a unique identifier so that identity and type of reporting unit can be recognized. Table 4.1 Reporting units for disease surveillance Public health sector Private health sector Rural CHCs, District Hospitals Sentinel Private practitioners (SPPs) and Sentinel hospitals. Urban Urban Hospitals, ESI / Railway / Medical college hospitals Sentinel Private nursing homes, sentinel hospitals, Medical colleges, Private and NGO laboratories 1. Sub-center - Health Worker / ANM reports all patients fulfilling the clinical syndrome from area covered by the sub-centre. 2. PHC / CHC Medical Officers report as probable cases of interest where this cannot be confirmed by laboratory tests at the peripheral reporting units and as confirmed when the laboratory information is available as in case of Blood smear +ve: Malaria and Sputum AFB +ve: Tuberculosis. 3. Sentinel Private Practitioners, District Hospitals, Municipal Hospitals, Medical colleges, Sentinel hospitals, NGOs - Medical Officers report as probable cases of interest. 4. Other Sentinel sites o ANC Sites NACO - HIV/ HBV/HCV surveillance, o Water Board, o Pollution control Board, o District Police Office for Road Traffic Accidents. • Participating Labs will report confirmed cases when they get positive diagnostic tests especially in PHC, CHC, Medical Colleges, District Hospitals and Private Hospitals. 4.1 Role of the various functionaries in routine surveillance The cases that have been detected and recorded need to be compiled and transmitted to the next level on a regular basis. This should be done every Monday from each type of reporting unit. Reports from subcenters, PHC/CHC, Medical Colleges, SPPs, Private Hospitals etc should be sent to the district surveillance unit of each district on Monday of every week. All reporting centers will provide zero reporting if no cases were detected. 12 1. Health worker as and when he/she detects additional cases during routine field visits will add the information to the register for syndromic surveillance and report the cases seen in the week of reporting using form S. This form will be filled in triplicate: one copy will be retained by the Health Worker at the periphery and two copies will be sent to the MO PHC every Monday. 2. The MO of PHC/CHC will report weekly statistics recorded in form P and L on Monday to district surveillance officer by telephone, fax, e-mail or by hand. The MOs will also forward one of the two copies of form S received from each sub-center which fall under that PHC. The other copy of form S will be retained by the MO PHC for follow-up action. 3. The Sentinel Private Practitioner from rural areas will provide regular reports to MO PHC in form S. Weekly reports will reach every Monday to PHC/CHC. If no cases are detected zero reports will be sent by all SPPs. The mode of transmission will be in any of the following methods. 4. • Letter • Fax • Telephone • Direct Courier Medical Colleges, District Hospitals, Railway Hospitals and SPPs from urban areas will report in Form P and Form L (if there are accredited laboratories) to District Surveillance Officer at weekly intervals. Remember to report any unusual clustering of cases or any health event causing deaths in a short span of time. Use telephone, fax, email, special messenger, police wireless – any method to report immediately. If there are no cases in that week / month, do not forget to write ‘zero’ in the relevant row. The designation of the person responsible for data compilation and transmission at each level is identified below: 1. PHC Pharmacist 2. CHC Computer Operator / Pharmacists 3. SPPs MO 4. District Hospital Computer / Pharmacists 5. Medical Colleges Statistical Officer 6. Laboratory MO in charge / Laboratory Technician The quality of the data filled up by the health staff needs to be checked by a senior staff and only then transmitted. For all forms, the original has to be sent to the higher level while a copy to be maintained at the reporting unit from where it originated. 13 Note: • Do not set up a parallel system of disease surveillance but strengthen the existing surveillance system of the state and district. • District is the hub of activities for surveillance and response • Feedback from all levels is important for motivation & sustenance of the surveillance system. 14 4.2 Formats for Reporting: Information by the reporting units will be transmitted to the District Surveillance Officer once a week since most diseases with epidemic potential has a short incubation period. Since IDSP is primarily designed as action oriented program, information on the action taken from the reporting units as well as the frequency of diseases particularly from the public health systems should be conveyed. The formats for various units including the private practitioners and Sentinel hospitals participating in the program have been designed to make it feasible to report diseases with minimum effort and have been simplified to include only the most essential summary data. The action taken will not be included from SPPs since this responsibility rests with the public health system. If no cases are seen ‘0’ will be marked against the corresponding disease and the results submitted to the DSU. Each sentinel site will record selected disease conditions by prior agreement but will send regular weekly report including zero reporting. If there are more than expected number of cases of particular syndrome, the Medical Officer inform DSU and initiate epidemic investigation. 15 16 District Surveillance officer District surveillance Officer Urban dispensary District hospital / Medical colleges / NGO hospitals Corporation Hospital District Surveillance Officer PHC/CHC District Surveillance Officer PHC Sub center, village volunteers, nonformal providers SPPs (both rural and urban) To From FLOW OF INFORMATION MO / Nurse / Pharmacist/ statistical officer MO / Pharmacist MO / pharmacist MO / pharmacist Health Workers/ volunteer Functionary Weekly Weekly Weekly Weekly Weekly Frequency Procedure for reporting by various functionaries at various levels: Summary of Flow of Information From OP / IP register to Form P Laboratory confirmed list will be sent separately in Form L2/L3 From OP / IP register to Form P From OP / IP register to Form S or Form P (S from non-formal providers, P from registered practitioners) From OP / IP register to Form P and Form L1 Daily register Form S Source / Forms The compiled list of all cases will be sent to District surveillance officer preferably by Electronic method so that information is compiled at the DSO without delay. The information is transmitted manually once week on Monday The information is sent to the District Surveillance officer through the MOs of PHCs (from the rural practitioners) or by E-mail, courier or by a specific method from the urban areas. Form P and L1 to be sent from PHC/CHC to District surveillance officer preferably by Electronic method so that information is compiled at the DSO without delay. The reporting unit will retain a copy of the forms. Form S will be filled weekly. A copy to be retained by the peripheral worker, one will be retained at the PHC and the original will be sent to the District Surveillance Officer. Method of transmission 17 To District Surveillance Officer District surveillance Officer District Surveillance Officer All reporting units From Sentinel Private labs Medical College Laboratory District Public Health Laboratory District Public Health Laboratory Officer in charge of District Lab Officer in charge of District Lab Microbiologist I/C Nodal lab technician Nodal lab technician Functionary Laboratory Network at District Level: As early as possible Weekly Weekly Weekly Frequency Case based reports for case management Summary format to be completed at District public health laboratory. Case based reports for Quality assurance tests From the lab registers to Form L3 From Lab register to Form L 2 Source / Forms Through District Computer network so that feed back from DPHL is quickly available for case management at the reporting units District IDSP Computer network so that feed back from DPHL is quickly available for case management at the reporting units Electronic communication, Telephone, Fax, E-mail, IDSP network Any available method of communication may be used. Telephone, fax, c ourier Method of transmission 5.0 Outbreak Response 5.1 Setting for Case Based Active Surveillance Active case based surveillance may be initiated by the MO I/C of the CHC and PHC in response to a suspected epidemic in following situation:1. A community member reports unexptected occurrence of cases 2. The MPW detects unexpected occurence of cases during his/her routine home visit 3. The Mobile team identifies cases during village visits 4. The media reports clustering of cases in a community or area e.g. outbreak of severe illness suggesting Malaria in a village and epidemic investigation is initiated In addition, the Peripheral Health Staff of PHC/CHC will identify syndromes by Active Surveillance during their field visit and report to the MO of PHC/CHC. Other than the reporting units mentioned below, efforts must also be made to identify key informants in each village / ward so that prompt information of any outbreak can be passed onto the health authorities. An outbreak or epidemic is defined as the occurrence in a community of cases of an illness clearly in excess of expected numbers. While an outbreak is usually limited to a small focal area, an epidemic covers large geographic areas and has more than one focal point. There is yet another definition of an outbreak – occurrence of two or more epidemiologically linked cases of a disease of outbreak potential (e.g. measles, cholera, dengue, JE, AFP or plague). 5.2 Detecting an outbreak: There are various ways in which outbreaks can be detected. Some of these are: 5.2.1 Rumor register The rumor register is to be maintained in each public health facility. Source of information from the community should be verified to identify outbreaks. It is an important source of information and should not be neglected. On the other hand, key informants in the community should be assiduously cultivated, so they become the eyes and ears of the health services in the community. The medical officer in charge of the public health facility should investigate all rumors of epidemic prone diseases recorded in the rumor registry. The format for rumor registry is given in section dealing with syndromic surveillance. This data is sent at weekly intervals to the District Surveillance Officer along with the weekly reports of syndromic surveillance. 18 Community Informants Public Sector Rural Private sector Urban Rural Teachers, AWWs, Panchayat members, Ward members, ASHA (under NRHM) Urban SHG leaders, Health club / Youth club / Farmer’s club leaders etc. 5.2.2 Media The media is an effective source of information on any unusual health event in the community. This important source should not be neglected and ignored by the health authorities. Epidemic related rumor register at all Government Reporting Units District Action points for MO PHC Epidemiological workup Done Not done ORI Sample Epidemiological workup Taluk/block/sub division Source of information Village/urban ward Action Taken Description of rumor Date of rumor Unique Identifier reporting unit Remark Verification of rumor by health worker of the area within 48 hours If information correct then health worker does active case search Line listing of cases with info on age/sex/location/ immunization status etc. Confirmation of type of disease/syndrome by MO PHC Sample sent As specified for the disease/syndrome Outbreak Response Initiative (ORI) Specific ORI as per guidelines The weekly report on rumors should be action based indicating response to the rumor. This information needs to be informed to DSO immediately. 19 5.2.3 Review of routine data The first step in investigating an outbreak is to detect it. One of the common ways of early detection is to review the data from the routine surveillance and check if it crosses threshold levels. Details of this are provided in the annexure. If the cases are approaching the threshold level or has crossed it, then an outbreak should be suspected. Remember to review the lab data also. 5.2.4 Warning signs of an impending outbreak • Even a single case of measles, AFP, Cholera, Plague, dengue or JE • Acute febrile illness of unknown aetiology • Occurrence of two or more epidemiologically linked cases of meningitis • Shifting in age distribution of cases • Sudden increase / high vector density • Lab related warning signals 5.3 Reporting an Outbreak At the PHC and CHC level, the MO of the concerned institution will be the nodal officer who will be responsible to respond to an outbreak. At the district, District Epidemic Investigation Team/Rapid Response Team will have the primary responsibility to investigate outbreaks. If an outbreak is suspected, the local health team should verify the same. A First Information Report will be submitted to the District Surveillance Officer by the fastest route to facilitate action. The First Information Report should be submitted to the District Surveillance Officer by the reporting unit as soon as verification of the suspected epidemic is made by MO on the report from health worker or other sources. The fastest route of information available will be used and this may be by Telephone, Fax, Email, messanger or through IDSP computer network. 6.0 Analysis of Data • Analyse and interpret the data received within 24 hours • Compare analysis results with thresholds to identify outbreaks 20 While collection of good quality data is important for a surveillance programme, analysis and interpretation of this data is of equal significance. Without this, all the hard work put in by the workers becomes meaningless. Data Analysis provides three important outcomes: • Frequency count by reporting unit helps in identifying outbreaks or potential outbreaks. • During an outbreak, analysis of the data identifies the most appropriate and timely control measures. Analysis in terms of person, time and place will be able to focus the intervention; e.g. analysis of a suspected and confirmed cases of Malaria will be able to identify the affected families and the cause of the outbreak so that corrective action can be targeted at this cause. • Analysis of routine data provides information for predicting changes of disease rates over time and enables appropriate action. While, analysis should ideally be done at all level from the periphery upwards, the main people responsible for analysis is the District Surveillance Officer. The PHC MO will limit analysis to detection of outbreaks and anticipating seasonal trends. While the District Surveillance Officer would be doing all of the above, he/she will also be monitoring the effectiveness and efficiency of the health services. 6.1 Frequency of analysis and summary reports Daily1 No Summary Reports 1 Timeliness and completeness of reports 2 Description by time, place and person 3 Trends over time 4 Checking for crossing of threshold levels Weekly Monthly Yearly 7.0 Surveillance Action: Preset trigger levels for diseases will be identified and specific responses prescribed for various levels. The levels will depend on the epidemic potential, case fatality of the disease and the prevalence of the problem in the community. 1. Trigger Level-1 Suspected /limited outbreak – Local response 2. Trigger Level-2 Epidemic – Local & Regional Response 3. Trigger Level -3 Wide spread Epidemic – Local, Regional and state level response 1 In the event of an outbreak 21 a). In a non endemic area even 1 case of suspected epidemic prone disease should initiate a trigger response at various levels b). In an endemic region change in pattern of disease or evidence of clustering of disease should be considered a trigger event. In an established outbreak, the response includes the following simultaneous actions: 1. Emergency Case Management 2. Referral to an appropriate level of care 3. Epidemiological Investigations 4. Laboratory Investigations to identify the aetiology 5. Presumptive & definitive control measures 6. Upgrading response to a higher level by informing the DSO if outbreak is confirmed. 8.0 Feedback Feed back is essential to maintain and support the peripheral staff. Feed back report should be sent regularly once a month even when there are no epidemics in the area. The data should represent trends over time in the district. Feed back report should also be provided on the quality of data submitted to the district surveillance officer as given below 8.1 Completeness and Timeliness of data It is a reflection on the performance of the reporting units. DSU should maintain a list of the reporting units and disseminate to all concerned MOs. The MO monitors which of the reporting units are sending complete reports on time. A report (from a reporting unit) is said to be on time, if it reaches the designated level within the prescribed time period. If it reaches, later, then the report is considered to be late (and of lesser public health use). The timeliness of a reporting unit can be calculated by assessing how many of its expected reports have come on time.A report is said to be Complete if all the reporting units within its catchment area has submitted the reports on time. If 8 out of 10 only have submitted, then the report is said to be incomplete (or 80% complete) Timeliness and Completeness of reporting units is a proxy indicator of the alertness of the surveillance system. An alert system will have timeliness and completeness approaching 100%. Also completeness of reporting units gives one an idea about the reliability of the data; for example, if completeness of reports is only 50%, then the incidence of disease would be under reported by 50%. So the incidence rates and CFRs need to be read in conjunction with the Completeness reports. 22 Interpretation of the report: Grade Scenario Interpretation A Reporting unit is timely and complete An ideal scenario, everything is working well B Reporting unit is timely, but regularly incomplete The MO has understood the importance of reporting on time. But there are some reporting units under the jurisdiction who are not reporting on time. MO has to find out what the problem is. C Reporting unit is late, but reports are complete The MO has not understood the importance of reporting on time. He is probably waiting for all the reporting units under his jurisdiction to report before submitting his report. He needs to be impressed about the significance of timely reporting. D Reporting unit is late and the reports are incomplete. Major problem in this reporting unit – neither the MO I/C nor the MOs of the reporting units have understood the importance of surveillance and timely data. Figure 8.1 – Incidence rate of disease - 2001 The main purpose of this report is to understand the trends over time. 23 RESPONSE FEEDBACK M&E STATE LEVEL INVESTIGATION DISTRICT LEVEL ANALYSIS SUB DISTRICT LEVEL FUNCTIONARIES DATA ENTRY LEVEL DATA COLLECTION Summary Table on Roles and Responsibilities COMMUNITY INFORMANTS MPW / HAs + ++ ++ - + + ++ - - COMPUT/PHARM /LABAST - +++ - - - - - MO (PHC / CHC) +++ + + ++ +++ + +++ PRIVATE PRACTITIONER ++ ++ - - + + - MO (HOSPITALS) +++ +++ - + + - ++ PRIVATE HOSPITALS +++ + - - + - - MUNICIPAL MOs +++ + + ++ ++ - + DISTRICT DATA ENTRY PERSONAL - +++ - - - - - District RRT - - - +++ ++ - - Dt. SURVEILLANCE OFFICER - - +++ +++ ++ +++ +++ MUNICIPAL HEALTH OFF. + - ++ +++ +++ ++ + LAB TECHNICIAN (CHC/HOSP) +++ + - ++ - + - STATISTICIANS (CHC/Dt) - + +++ - - - - DISTRICT MAGISTRATE - - + - - - + NGOs +++ + - + + - - MEDICAL COLLEGES +++ + ++ ++ + + - STATE SURVEILLANCE OFFICER - - +++ ++ ++ +++ +++ NICD / ICMR / NIE/ INDICLEN - - - + + - ++ NATIONAL LEVEL WHO / WB + 24 ++ Annexure I: Epidemiology and Case Definitions 1. CHOLERA EPIDEMIOLOGY Agent: Vibrio cholerae serogroups O1 and O139. Produces diarrhoea by an enterotoxin. Biotype El Tor is less pathogenic as compared to the Classical biotype. Host: Humans are the only host. Affects all ages and both sexes equally. In endemic regions, children are more susceptible. Natural infection confers effective immunity. Chronic carriers are rare. Environment: Poor sanitary conditions facilitate the growth and transmission of V.cholerae. Of importance are contaminated water and food. Environmental reservoirs exist in association with zooplankton in brackish waters and estuaries. Mode of Transmission: From human to human through drinking or eating contaminated water or food. Rarely through direct transmission, i.e. faeco-oral route. Incubation Period: A few hours to 5 days, usually in the range from 2 to 3 days. Period of Infectivity: From onset of illness to about a week later. Rarely chronic carriers may increase the period of infectivity. Infectivity rate: Depends on the infective dose. About 1011 organisms are necessary to produce symptoms. A patient with cholera excretes an average of 107 – 109 vibrios per ml of stool. Signs and symptoms: Abrupt onset of profuse, painless watery diarrhoea with or without vomiting. The stool may have a ‘rice water appearance’. Soon the patient becomes severely dehydrated which may lead to death unless rapidly treated. At least 90% cases are mild and remain undiagnosed. Case Fatality Ratio: Depending on the effectiveness of the health services, the CFR may range from <1% to 50%. Epidemic Potential: It may cause rapidly progressive epidemics or worldwide pandemics. In endemic areas, sporadic cases& small outbreaks may occur. Lab Confirmation: Isolation of V. cholera O1 or O139 is the gold standard. Specimens may be transported from the field using transport media like Cary-Blair media. Details of transportation of specimens and lab diagnosis are given in laboratory Manuals. 25 CASE DEFINITION OF CHOLERA Clinical case description In an area where the disease is not known to be present Severe dehydration or death from acute watery diarrhea in a patient aged 5 years or more2 (Severe dehydration- lethargy, altered consciousness, decreased urine) In an area where Cholera is endemic Acute watery diarrhea, with or without vomiting in a patient aged 5 years or more. In an area where there is a cholera epidemic Acute watery diarrhea, with or without vomiting, in any patient. Laboratory criteria for diagnosis Isolation of Vibrio cholera O1 or O139 from stools in any patient with diarrhea. Case classification Suspect case: A case that meets the clinical case definition. Probable case: A suspect case diagnosed as Cholera by MO Confirmed case: A suspected case that is laboratory-confirmed. Outbreak definition Trigger-1 • A single case of Cholera /epidemiologically linked cases of Diarrhea • A case of severe dehydration/death due to diarrhea in a patient of > 5 yr of age. • Clustering of cases in a particular village/ urban ward where more than 10 houses have at least one case of loose stools irrespective of age per 1000 population Trigger-2; More than 20 cases of diarrhea in a village / geographical area of 1000 population 26 2. Typhoid/Para-typhoid Fever EPIDEMIOLOGY Agent: Salmonella enteric serotype Typhi, serotype Paratyphoid A, B and C. Host: In endemic areas typhoid fever is most common in school and preschool aged children i.e. 2 to 19 years. Mode of Transmission: By contaminated food and water with faeces and urine of patients and carriers. Important vehicles include raw fruits; vegetables fertilized by night soil and eaten raw, contaminated milk and milk products usually by hands of carriers and missed cases. Flies may infect food in which the organisms then multiply to achieve an infective dose. Incubation Period: The incubation period depends upon the size of the infecting dose from 3 days to three months with a usual range of 1-3 weeks. For paratyphoid fever it is as low as 1-10 days. Period of Communicability: As long as bacilli appear in excreta, usually from the first week throughout convalescence; variable thereafter (commonly 1-2 weeks for paratyphoid). About 10% of untreated typhoid fever patients will discharge bacilli for 3 months after onset of symptoms, and 2%-5% become permanent carriers. Diagnosis: The etiologic organisms can be isolated from the blood early in the disease and from urine and feces after the first week; A fourfold rise in somatic (O) agglutination titers in paired sera appears during the second week in less than 70% of cases of typhoid fever; when it occurs, it supports the diagnosis, provided vaccine had not been given recently. Clinical Manifestations: Disease is characterized by insidious onset of sustained fever, severe headache, malaise, anorexia, a relative bradycardia, and splenomegaly. Constipation more commonly than diarrhea in adults. In typhoid fever, ulceration of Peyer’s patches in the ileum can produce intestinal hemorrhage or perforation (about 1% of cases), especially late in untreated cases. Severe forms have been described with cerebral dysfunction. Paratyphoid fever presents a similar clinical picture, but tends to be milder, and the case-fatality rate is much lower. Relapses may occur in approximately 3%-4% of cases. Case Fatality Ratio: The usual case-fatality rate of 10% can be reduced to <1% with prompt antibiotic therapy. It is much lower in Paratyphoid fevers. Complications: Intestinal perforation, Typhoid encephalopathy and chronic carrier states are some of the complications. Relapses occur in 5%-10% of untreated cases and may be more common (15%-20%) following therapy with appropriate antibiotics. 27 CASE DEFINITION OF TYPHOID FEVER Clinical case description Any Patient with fever for more than one week and with any 2 of the following. Toxic look Coated tongue Relative bradycardia SplenomegalyLaboratory criteria for diagnosis: Serology – Typhi Dot Test + ve / Widal test Isolation of organisms from clinical specimen such as blood Case classification Probable case: Any case of fever diagnosed as typhoid by MO that is compatible with: Clinical description above Tyhpi Dot / Widal Test +ve (More than 1 week) Exposure to confirmed case Clinical presentation with complications eg. GI Bleeding, Perforation, etc Confirmed case: A suspected /probable case that is laboratory confirmed by Isolation of Salmonella typhi / paratyphi from blood or other clinical specimens Four fold rise in the agglutination titre in paired sera taken ten days apart. Outbreak Definition: TRIGGER -1 More than 30 cases in a week from the entire PHC area OR 5 or more cases per week from 1 sub centre of 30,000 population OR More than 2 cases from a single village/urban ward/1000 population Clustering of cases of fever TRIGGER-2: More than 60 cases from a PHC or more than 10 cases from a sub-center 28 3. Acute Viral Hepatitis Acute illness typically including the following: Acute jaundice (Yellow sclera/skin) Dark urine Anorexia, malaise Extreme fatigue Right upper quadrant tenderness Biological signs include: Increased urine urobilonogen >2.5 times the upper limit of serum alanine aminotransferase3. Laboratory criteria for diagnosis: Hepatitis A IgM anti HAV positive Hepatitis B Positive for HbsAg or IgM anti-HBc4 Hepatitis C Positive for anti-HCV Hepatitis D Positive for HbsAg or IgM anti-HBc Plus anti-HDV Hepatitis E Positive for anti-HEV Case Classification Suspect case As per clinical case definition Probable case Not applicable Confirmed case A suspect case that is laboratory confirmed. For Hepatitis A, a case compatible with the clinical description and with epidemiological link with a lab confirmed case of Hepatitis A. 2 Most infections occur in early childhood. A variable proportion of adult infections is asymptomatic. The anti-HBc IgM test, specific for acute infection, is not available in most countries. HbsAg, often available, cannot distinguish between acute new infections and exacerbations of chronic hepatitis B, although continued HBsAg seropositivity (>6 months) is an indicator of chronic infection. 3 29 4. Malaria EPIDEMIOLOGY Agent: There are four species of Malarial parasites. Plasmodium Falciparum Plasmodium Vivax Plasmodium Ovale Plasmodium Malaria a) P.Falciparum is the species that is responsible for virtually all the mortality associated with Malaria and for substantial portion of its morbidity. b) P.Vivax Malaria The classical description of the malaria paroxysm stage is more commonly seen in P.Vivax than in P.Falciparum malaria. The fever is of the Tertian type. The hot and cold stages are more commonly seen. Hepatosplenomegaly occurs frequently. The disease is rarely fatal, responds satisfactorily to combination of Chloroquine and Primaquine treatment. Vector: Anopheles Mosquito – breeds in fresh water containers in and around the residential areas, water coolers, flowerpots etc. Environment: The principal aim is to identify worst affected “high risk” malarious areas in the country. The Expert Committee has laid down the following criteria for the same. 1. Rural areas Recorded deaths due to malaria (on clinical diagnosis or microscopic confirmation) with P.falciparum infection during the transmission period with evidence of locally acquired infection in an endemic area, during any of the last three years. The slide Positivity Rate (SPR) is to be used for the identification of areas as follows: a) Doubling of SPR during the last three years provided the SPR in second or third year reaches 4% or more b) Where SPR does not show the doubling trend as above but the average SPR of the last three years is 5% or more. P.falciparum proportion is 30% or more provided the SPR is 3% or more during any of the last three years. An area having a focus of Chloroquine resistant P.falciparum A Chloroquine resistant PHC will be characterised by detection of more than 25% of R II and R III level cases in a minimum sample ;of 30 cases. Tropical aggregation of labor in project areas 30 New settlements in endemic/receptive and vulnerable areas. 2. Urban Areas A) The SPR 10% and above during any of the last three years is identified as high-risk areas. B) Population of 50000 or more and SPR more than 5% or the ratio of clinical malaria cases to fever cases more than one third as per hospital/dispensary statistics during the last Calendar year. Signs and symptoms: The presentation of uncomplicated PF.Malaria is very variable and can mimic many other diseases. Fever - Very common. Initially persistent and may or may not be accompanied by rigors. Jaundice and Anemia - May be present with Hepatosplenomegaly. The early diagnosis and prompt treatment is extremely essential to avoid fatal complications. Epidemic potential: For effective control of malaria the following parameters are used. 1) Annual Parasite Incidence (API): (API) = Total no. of blood smears +ve for MP in a year ————————————————————X 1000 Total population Epidemiological significance This parameter depends upon the adequacy of case detection mechanism i.e. Annual Blood Examination Rate (ABER). If ABER is adequate, this parameter is the most important criterion to assess the progress of eradication programme. At present this parameter is used for determining the areas to be brought under spray operations. 2) Annual Blood Examination Rate (ABER) No. of blood smears examined for MP in a year (ABER) = ————————————————————— X 100 Total population Epidemiological significance This parameter reflects the efficiency and adequacy of case detection mechanism. ABER should not be less than 1% per month during the transmission period. A minimum ABER of 10% per year was fixed under NMEP. 3) P. falciparum percentage (PF%) Total No. of blood smears found +ve for P. falciparum (Pf.%)= ———————————————————————————X 100 Total No. of blood smears +ve for malarial parasite 31 Epidemiological significance This parameter gives the relative proportion of P. falciparum infection and identifies trends of Pf incidence in relation to total caseload of malaria parasite in the community. 4) Slide Positivity Rate (SPR) Total no. of BS found +ve for MP (SPR)= ——————————————————X 100 Total no. of BS examined. Epidemiological significance This parameter is less dependent on ABER. Whenever the case detection mechanism (ABER) is adequate, this is a dependable parameter for determining the progress of containment measures and gives information of parasitic load in the community. It is more reliable than API even for areas where ABER fluctuates from the year to year. 5) Slide falciparum Rate (SfR) Total No. of blood smears found +ve for P. falciparum (SFR) = ———————————————————————— X 100 Total No. of blood smears examined. Epidemiological Significance This parameter also depends less on the case detection mechanism in space and time. If such a mechanism is adequate it pinpoints areas of P.falciparum preponderance and indicates the necessity for intensification of intervention measures on priority basis to control P.falciparum infection, which is responsible for Malaria mortality in India. 32 CASE DEFINITIONS OF MALARIA Clinical case description Malaria should be considered in any patient who presents with Fever and any 2 of the following. Chills, Sweating, Jaundice, Spleenomegaly Convulsions, Coma, shock, pulmonary edema and death may be associated in severe cases Laboratory criteria for diagnosis Demonstration of Malaria Parasite in blood film OR Positive Rapid Diagnostic Test for Malaria Case classification • Suspect case: Any Case of Fever * • Probable case: A case that meets the clinical case definition • Confirmed case: A suspected/probable case that is laboratory- confirmed Outbreak definition The states may set their own trigger levels based on the prevalence of malaria in the region.The following is a general guideline. Trigger-1 Even single case of smear + ve malaria in an area where malaria was not present for minimum three months. SPR rise more than double over last three months. Single death from malaria (clinical /microscopically proven). Single PF case of indigenous origin in a PF free region Trigger-2: Two fold rise in malaria in the region over the last 3 months More than 5 cases of PF of indigenous origin * Any case of fever in an endemic area may be more appropriate 33 5. JAPANESE ENCEPHALITIS (JE) Epidemiology Japanese Encephalitis (JE) is a disease of public health importance because of its epidemic potential and high case fatality rate. In patients who survive, complications may lead to life long sequelae. Though JE is primarily a disease of rural agricultural areas, where vector mosquitoes proliferate in close association with pigs and other animal reservoirs, its epidemics have also been reported in peri-urban areas where similar conditions may exist. Agent: JE is caused by a group B arbovirus (flavivirus). The virus is antigenically related to other flaviviruses including dengue, west Nile and yellow fever viruses. Host: Affects all, especially children under 15 years of age. 34 Vector: Mosquitoes belonging to the Culex vishnui group (Culex vishnui, Culex pseudovishnui, Culex tritaeneorhynchus) are the most important vector species in India. 11 more species of mosquito have been incriminated as vectors of JE. These mosquitoes generally breed in water bodies with luxuriant vegetation. Irrigated rice fields, shallow ditches and pools are common breeding places. Culex mosquitoes are zoophilic, feeding primarily on animals and wild birds. They rest outdoors in vegetation and other shaded places but in summer may also rest indoors. The mosquitoes are outdoor as well as indoor feeders. Female mosquitoes get infected after feeding on a viraemic host. They can transmit the virus to other hosts after an extrinsic incubation period of 9 to 12 days. The mosquitoes remain infected for life. The average life period of a mosquito is about 21 days. Culex mosquitoes can fly for long distances (1-3 kms or even more). Environmental factors: Epidemics usually coincide with the monsoons and post-monsoon period when the vector density is high. However, in endemic areas, sporadic cases may occur throughout the year. Mode of transmission: The infection is transmitted through the bite of an infected culicine mosquito. In human beings, viraemia is mild and lasts for a short duration. Infection in man is the dead end of transmission. Man to man transmission has not been documented. The transmission cycle is maintained in animals and birds. Reservoir of infection: JE virus has its natural cycle in wild or domestic vertebrates and mosquitoes. The animal hosts include pigs, cattle and horses. Water birds such as pond herons, cattle egrets, poultry birds and ducks play a significant role in the natural history of JE virus. Pigs are the major vertebrate hosts. Although, infected pigs do not manifest any overt symptoms of disease they develop tremendous viraemia and can infect the mosquitoes. The pigs are considered as amplifying hosts. Infection in man appears to be correlated with living in close proximity with animal reservoirs, especially pigs Incubation period: The incubation period in man, following mosquito bite varies from 5 to 15 days. Clinical manifestations: The clinical features of JE are those of encephalitis. The patient will give a history of acute onset with fever and change in behaviour or sensorium lasting for more than 24 hours. Focal neurological deficits may or may not be present. There may also be loss of bladder and bowel control. The focal neurological signs may be stationary or progressive. In majority of the cases, however, the infection is mild with no overt clinical symptoms or mild fever with headache. Individuals develop immunity after infection. In endemic areas cases are, therefore seen more often in children less than 15 years of age. Patients who recover from the acute episode may have neurological sequelae. These occur with variable frequency and depend on age and severity of the illness. The commonly observed sequelae are: 35 Mental impairment Severe emotional instability Personality changes Paralysis Case fatality rate and sequelae: Case fatality rate is high in severe cases (20 to 40%). 36 CASE DEFINITION - JAPANESE ENCEPHALITIS Clinical case description Febrile illness of variable severity associated with neurological symptoms ranging from headache to meningitis or encephalitis. Symptoms can include: Headache, fever, meningeal signs, stupor, disorientation, coma, tremors, paresis (generalized), hypertonia, and loss of coordination. (The encephalitis cannot be distinguished clinically from other central nervous system infections). Laboratory criteria for diagnosis Presumptive Detection of an acute phase anti-viral antibody response through one of the following: Elevated and stable serum antibody titres of JE virus through ELISA, haemagglutination or virus neutralization assay, or Ig M antibody to the virus in serum (Appears after 1 week of disease) Confirmatory5 Detection of the JE virus, antigen or genome in tissue, blood or other body fluid by immuno-chemistry or immuno-fluorescence or PCR, or JE virus-specific IgM in the CSF, or Fourfold or greater rise in JE virus-specific antibody in paired sera (acute and convalescent phases) through IgM /IgG, ELISA, haemagglutination inhibition test or virus neutralization test Case classification Suspect case of JE: Any case with fever of acute onset and altered consciousness / Convulsions and change in behaviour Probable JE: Any suspected cases diagnosed as JE by the MO (or) Any suspect case with presumptive lab results An epidemiologically linked case of fever with proven JE case Confirmed JE: A suspect or probable case confirmed by laboratory tests Trigger -1: Clustering of two or more similar case from a locality in one week Trigger-2: More than 4 cases from a PHC (30,000 population) in one week 5 Antigen for conducting the tests is not yet commercially available. Antigen for detection of IgG antibody is produced in limited quantities for operational research and outbreak investigations at the National Institute of Virology (20-A, Dr. Ambedkar Road, Pune - 411 001; Phone:-020 6127301, 6127302; FAX: 6122669). 37 6. DENGUE FEVER (DF) EPIDEMIOLOGY Agent: The viruses of dengue fever are flaviviruses and include serotypes 1, 2, 3 and 4. The same viruses are responsible for dengue hemorrhagic fever. Host: Affects all age groups, but children usually have a milder disease than adults. Recovery from infection with one serotype provides lifelong immunity but does not provide protection against other serotypes, and instead may exacerbate subsequent infections Environment: Outbreaks of dengue are usually reported after rainfall due to collection of artificial water around peridomestic areas. The ambient temperature range for dengue transmission is 16 to 40 degrees C. Reservoir: The viruses are maintained in a human-Aedes aegypti mosquito cycle. Mode Of Transmission: Dengue is transmitted by the bite of infective mosquitoes, principally Aedes aegypti. Vector: Aedes aegypti mosquito is a day-biting species with increased biting activity for 2 hours after sunrise and several hours before sunset. Both Ae. aegypti and Ae. albopictus are found in urban settings. The mosquito has characteristic white stripes on the back and legs and is also known as tiger mosquito. The mosquito is a domestic breeder and breeds in artificial collection of water, water containers, discarded tyres, coconut shells, desert coolers, overhead tanks, etc. Incubation Period: Three to fourteen days, commonly 5-7 days. Period Of Communicability: Not directly transmitted from person to person. Patients are usually infective for mosquitoes from shortly before the onset of fever to the end of the febrile period, an average of about 6-7 days. The mosquito becomes infective 8-12 days after the viremic blood meal and remains so for life. Clinical Signs and Symptoms: An acute febrile viral disease characterized by sudden onset, fever for 3-5 days, intense headache, myalgia, arthralgia (Break bone fever), retroorbital pain, anorexia, In patients with severe or fatal dengue, shock is usually the principal pathophysiologic defect. Coincident with defervescence, the patient’s condition suddenly worsens with marked weakness, severe restlessness, facial pallor and circumoral cyanosis. Extremities are cool, skin blotchy, pulse rapid and weak; patients may be hypotensive with a narrow pulse pressure. Hemorrhagic phenomena are seen frequently and include scattered petechiae, a positive tourniquet test, easy bruisability, and less frequently, epistaxis, bleeding at venipuncture sites, a petechial rash and gum bleeding. GI hemorrhage is an ominous prognostic sign that usually follows a prolonged period of shock. The liver may be enlarged, usually 2 or more days after defervescence. Case Fatality Ratio: CFR is high in DHF and DSS and in untreated or mistreated shock have been as high as 40%-50%; but with good physiologic fluid replacement therapy, rates should be about 3.5 % but low in dengue fever by itself. 38 CASE DEFINITIONS OF DENGUE FEVER Clinical Case Definition: An acute febrile illness of 2-7 days duration with 2 or more of the following: Headache, Retro-orbital pain, Myalgia, Arthralgia, Rash Haemorrhagic manifestations Leucopenia Case classification of dengue. Probable: A case diagnosed by MO as Dengue fever based on the clinical case definition OR A case with fever with blood negative for MP and not responding antimalarials Supportive serology (reciprocal haemagglutination-inhibition antibody titre, comparable IgG EIA titre or positive IgM antibody test in late acute or convalescent-phase serum specimen). Epidemiologically linked with a confirmed case of dengue fever (occurrence at same location and time as other confirmed cases of dengue fever). High Vector Density Confirmed: Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy samples Demonstration of a fourfold or greater change in reciprocal IgG or IgM antibody titres to one or more dengue virus antigens in paired serum samples (depending on the diagnostic kit used) Demonstration of dengue virus antigen in autopsy tissue by immunohistochemistry or immunofluorescence or in serum samples by EIA Detection of viral genomic sequences in autopsy tissue, serum or CSF samples by polymerase chain reaction (PCR). A case compatible with the clinical description and confirmed by positive IgM ELISA rapid Test in the laboratory. 39 All Above plus evidence of: Dengue Haemorrhagic Fever (DHF) A probable or confirmed case of dengue 1. And Haemorrhagic tendencies evidenced by one or more of the following: Positive tourniquet test Petechiae, ecchymoses or purpura Bleeding: mucosa, gastrointestinal tract, injection sites or other Haematemesis or melaena 2. And thrombocytopenia (100,000 platelets or less per mm3) 3. And evidence of plasma leakage* due to increased vascular permeability, manifested by one or more of the following: Pleural effusion, ascites hypoproteinaemia Dengue Shock Syndrome (DSS) All the above criteria, plus evidence of circulatory failure manifested by rapid and weak pulse, and narrow pulse pressure (<_20 mm Hg) or hypotension for age, cold, clammy skin and altered mental status. Trigger -1: Clustering of two similar cases of probable dengue fever A single case of suspected Dengue heamorragic fever or shock syndrome Trigger-2 More than 4 cases of Dengue Fever in a village / Geographical area of 1000 population * >_Signs of plasma leakage (pleural effusion, ascites, hypoproteinaemia) 40 7. MEASLES EPIDEMIOLOGY Host: Common in children between 9 months to 3 years of age. Newborns and young infants are protected by maternal antibody transferred through placenta. This protective factor is equally effective among male and female infants. Humans are the only known host. Environment: It is a highly contagious disease and often responsible for epidemics, especially in conditions of overcrowding and poverty, where large numbers of non-immunized children are in close contact. In temperate and tropical climates, measles occurs primarily in the late winter and early spring (November-April). Agent: Paramyxovirus (Morbillivirus) only one sero type Mode of Transmission: human-to-human via airborne droplet spread, direct contact with nasal or throat secretions, etc. Incubation Period: The incubation period is usually about 10 days and varies from 7 to 18 days. Thus during an epidemic/outbreak, immunization of susceptible can avert more cases. Period of Infectivity: An infected person can infect others from 4 days prior to onset of rash to 5 days after appearance of rash. The vaccine virus has not been shown to be communicable. Infectivity Rate: The agent is highly infectious and most susceptible exposed to the agent acquire the disease. Signs and Symptoms: The first sign of infection is high fever lasting 1-7 days. During this period there may be running nose, cough, red and watery eyes and also Koplik’s spots. After a few days (usually 4th day) a slightly raised erythematous rash develops which spreads over the face and upper neck down to the body, then to the hands and feet over a period of about three days. It lasts for 5-6 days and fades successively from the same areas. There may also be loss of appetite and loose stools especially in infants. Case Fatality Ratio: Deaths are common in developing countries ranging from 5 – 30% depending on the nutrition status of the patient and the effectiveness of the health services. Recovery is usually associated with lifelong immunity. Complications: In developing countries, complication rates can be as high as 75%. Complications occur particularly in children under 5 years and can be diarrhoea, pneumonia, malnutrition,Vit. A deficiency, otitis media, encephalitis (including sub-acute sclerosing panencephalitis (SSPE)) and deaths. 41 CASE DEFINITIONS OF MEASLES Clinical case description: Any person with Fever and Maculo popular rash lasting for more than 3 days Cough or coryza or conjunctivitisLaboratory criteria for diagnosis: At least a four fold increase in the anti body titre or Isolation of measles virus or Presence of measles specific IgM anti bodies Case classification Suspect case: Probable case: Any case with fever & rash Any suspect case who is diagnosed as measles by MO on basis of clinical case description Confirmed case: A case that meets the clinical case definition and that is Laboratory confirmed or linked epidemiological to a lab confirmed case Trigger Level-1 A single case of measles in a tribal area More than 2 cases of fever with rash in a village / geographical area of 1000 population Trigger Level-2 More than 4 cases of fever with rash in a geographical area of 1000 population Similar illness in more than 1 village reported in the same week 42 8. TUBERCULOSIS Tuberculosis (TB): TB kills more adults in India than any other infectious diseases. More than 1000 people a day – one every minute – die of TB in our country. It is estimated that there are 14 million TB cases in our country out of which 3.5 million are sputum positive. About 1 million sputum positive cases are added every year. Agent: M.tuberculosis and M.bovis are the bacteria causing Tuberculosis in humans. M.bovis infections are rare and M.tuberculosis is synonymous with tubercle bacillus. It is an aerobic, non sporing, non motile bacillus. The term acid fast refers to staining characteristics of the bacillus where tubercle bacilli does not decolorize after Zeil Neilson stain when washed with acid alcohol. Host: Humans are the only reservoir of M.tuberculosis. Tuberculosis has also become concentrated in certain medically underserved populations- the urban poor, alcoholics, HIV infected subjects, migrant workers, Prison inmates Transmission of TB: When a sputum positive pulmonary TB patient coughs or sneezes, he spreads M.tuberculosis into the air in the form of tiny droplets. If a healthy person inhales these tiny particles, he may contract TB. Diagnosis: Bacteriological examination of sputum is, as a rule the only way by which diagnosis of pulmonary TB can be confirmed. Diagnosis by X-ray is unreliable because other chest diseases often resemble TB. Patients with abnormal chest X-ray should not be started on treatment until three sputum samples have been examined for AFB. Clinical Manifestation: Any person with cough of more than 3 weeks should be suspected to have pulmonary Tuberculosis and should be investigated. Revised National TB Control Programme( RNTCP): The goal of the RNTCP is to ensure that at least 85% of all newly detected sputum positive cases are cured and thus transmission of TB is interrupted. Clinical case description Pulmonary tuberculosis Any person with Cough of more than 3 weeks duration and with at least 2 of 3 initial sputum smear examinations (direct smear microscopy) positive for AFB. Often associated with Fever Wt loss X-ray may show infiltration/ fibrocavitary changes 43 Laboratory criteria for diagnosis: Sputum positive for AFB in 2 out of 3 sputum smear examination Sputum positive for AFB in at least 1 out of 3 smear examination with X-ray evidence of TB Sputum culture grows Acid Fast Bacilli Case classification: Suspect case Any patient having cough more than 3 weeks duration Probable case Patient with symptoms suggestive of pulmonary TB (cough of 3 weeks with or without fever) diagnosed by MO as TB with or without radiological signs consistent with pulmonary TB. Confirmed case A case that meets the clinical case definition and that is positive for laboratory criteria Trigger Levels: Not Applicable 44 Additional Definitions (RNTCP) CASE DEFINITIONS TYPES OF CASES TREATMENT OUTCOMES Cured: Initially smear positive patient who has completed TB in a patient with at least 2 initial sputum A patient who had never had treatment and has negative smear examinations (direct microscopy) treatment for tuberculosis or has sputum smears on at least 2 taken anti-tuberculosis drugs for occasions, one of which was at positive for AFB less than one month completion of treatment. OR: TB in a patient with one sputum examination positive for AFB ad radiographic Relapse: Completed: A patient declared Treatment abnormalities consistent with active TB as cured of TB by a physician, but Sputum smear positive case determined by the treating MO who reports back to the health who has completed treatment Pulmonary TB, Smear positive: New: OR: TB in a patient with one sputum specimen unit and is found to positive for AFB and culture positive for M.Tb bacteriologically positive Pulmonary TB, Smear Negative TB in a patient with symptoms suggestive of TB with at least 3 sputum examinations negative for AFB ad radiographic abnormalities consistent with active pulmonary TB as determined by an MO, followed by a decision to treat the patient with full course of antituberculosis therapy. OR: Diagnosis based on positive culture but negative AFB sputum examinations. be with negative smears at the end of this initial phase but none at the end of treatment. Transferred in: OR: Sputum smear negative TB patient who has received a full A patient who has been received course of treatment has not into tuberculosis Unit/ District, become smear positive during after starting treatment in another or at the end of treatment. unit where he has been recorded. OR: Extra pulmonary TB patient Treatment after Default: who has received full course of A patient who received anti- treatment and has not become tuberculosis treatment for one smear positive during or at the month or more from any source end of treatment. and who returns to treatment after having defaulted, i.e., not taken anti-TB drugs consecutively for two months or more. Died: Patient who died during treatment regardless of cause. Failure: Smear positive case who is smear positive at 5 months or more after starting treatment. Also a patient who was initially smear negative but Failure: A smear positive patient has become smear positive Extra-pulmonary TB who is smear positive for 5 during treatment. TB of organs other than the lungs, such as the months or more after staring pleura, Lymph nodes, abdomen, genitor- treatment. Failure also includes Defaulted: A patient who, at any urinary tract, skin, joints and bones, tubercular a patient who was initially smear time after registration, has not meningitis, tuberculoma of brain etc. negative but who becomes taken anti-TB drugs for 2 smear positive during treatment. months or more consecutively. Diagnosis should be based on one cultureTransferred out A patient who positive specimen from the extra pulmonary has been transferred to another site, or histological evidence, or strong clinical Tuberculosis Unit/ District and evidence consistent with active extrahis/her treatment results are not pulmonary TB followed by an MO’s decision to known. treat with full Anti-TB drugs. Pleuracy is classified as extra-pulmonary TB. A patient diagnosed with both pulmonary and Chronic: A patient who remains extra pulmonary TB should be classified as smear positive after completing a treatment regimen. pulmonary TB “Other” A patient who does not fit into the above mentioned categories. Reasons for putting a patient in this category must be specified. 45 9. POLIO (AFP Surveillance) Epidemiology Agent: The Poliomyelitis is an enterovirus. There are three serotypes- types 1, 2 and 3, All three can cause paralysis, although type 1 causes paralysis most often, type 3 less frequently, and type 2 rarely. Most epidemics are due to type 1. Cases of paralytic associated with OPV are usually caused by types 3 and 2. The overall risk of vaccine associated with paralytic poliomyelitis (VPP) is extremely low. The overall risk of VPP is one case per 2.5 million doses of trivalent OPV with the highest risk being associated with the first dose. During eradication, the first serotype to disappear is type 2, due to better OPV “ take” rates, followed by serotypes 3 and 1. Environment: Poliomyelitis exits worldwide except where it has been eradicated as in the Americas. In temperate climates as in Europe and North America it is seasonal, occurring more commonly in summer and early autumn. In India, The incidence increases during July to September coinciding with the rainy season. Where poliomyelitis is common, 3 to 10 out of every 1,000 young children will develop paralytic disease without an immunization Programme. Host: Man is the only reservoir, and infection is spread from person to person. Given the large number of inapparent infections it is difficult to find the source of a case. A long – term carrier state is not known to occur. The half – life of excreted virus in the sewage in warm tropical climate is approximately 48 hours. Spread of infection through sewage can only occur during this period. These facts, apart from the properties of OPV, are the major reasons why polio is a candidate for eradication. Transmission: Person to person faeco-oral transmission is most common where sanitation is poor. One week after onset, little virus remains in the throat, but it contains to be excreted in stools for 6 to 8 weeks. Cases are most infectious during the first few days before and after the onset of symptoms. Incubation Period: The incubation period from exposure to the virus till the onset of symptoms is 7-10 days (range of 4-33 days). The initial illness is followed by a few days, which are relatively free of symptoms before the onset of paralysis. Clinical Presentation: An AFP case is any case of acute flaccid paralysis in a person under 15 years of age for any reason other than severe trauma, or paralytic illness in a person of any age in which polio is suspected. The classification of AFP is temporary. Within 90 days of onset the case should be finally classified as polio, polio compatible or “discarded” as not polio. It should be stressed that surveillance is carried out for all cases of acute flaccid paralysis (AFP) and not just for poliomyelitis. Therefore, all AFP cases should be reported, regardless of the final diagnosis. Because paralytic poliomyelitis is one cause of AFP, maintaining a high sensitivity of AFP reporting will ensure that all cases of paralytic poliomyelitis are detected, reported, and investigated, resulting in preventive control measures to interrupt transmission of disease. The aim of AFP surveillance is to detect poliovirus transmission and the earlier stool is collected the greater the chance that poliovirus may be detected 46 Polio is a disease under eradication phase. Acute Flaccid Paralysis is the most common clinical presentation of polio. The medical officer will also undertake AFP surveillance as part of intensive phase activity. All the surveillance activities under NPSP will be continued and supported by IDSP. CASE DEFINITIONS POLIO Clinical case description: A case of AFP is defined as any child aged <15 years who has acute onset of flaccid paralysis for which no obvious cause (such as serve trauma or electrolyte imbalance) is found, or paralytic illness in a person of any age in which polio is suspected. Cases of AFP without isolation of wild poliovirus may be classified as “polio compatible” if: Stool specimens were inadequate AND Residual weakness was present 60 days after onset of paralysis or 60-day follow-up was not done (due to death or absence) AND Expert review” concludes that these cases could not be discarded as “non-polio” based on available data. Laboratory criteria for diagnosis: Wild poliovirus isolated from any stool specimen Case classification Suspect case: Syndromic case of AFP – Fever with abrupt onset of paralysis of leg or arm Probable case: Epidemiologically linked case Confirmed case: A suspected case that is laboratory-confirmed. Trigger Level Even a single case of AFP reported will trigger the outbreak investigation 47 10. PLAGUE Epidemiology Agent: The agent is a gram-negative cocco-bacilli – Yersinia pestis; which has a bipolar (safety pin) appearance on aniline staining. Sunlight, high temperatures and desiccation have a destructive effect, and ordinary disinfectants such as Lysol and preparations containing chlorine kill it within 1 to 10 minutes. Reservoir: Wild rodents are the natural reservoirs. In India the reservoirs are mainly the wild rats – Bandicoota bengalensis, Tatera indica etc. They are susceptible to infection but not the disease. Others like wild squirrels, rabbits and wild carnivores may also be a source of infection. Plague remains in the wild due to various factors – e.g. rat – flea –rat cycle; survival of fleas in rat burrows for long periods of time; survival of plague bacilli in the rat burrows, eating of infected rodents by carnivore, etc. Vector: The main vector is the Oriental rat flea – Xenopsylla cheopis Transmission: There are at least 6 potential modes of transmission: Wild rodent > Flea > Peridomestic rodents > Flea > Domestic rodent > Flea > Humans Human with pneumonic plague > droplet infection > Humans Wild rodents > Flea > Humans (when humans enter the forests etc where the sylvatic cycle is maintained) Handling infected rodent tissue (wild / domestic) or any other infected material e.g. pus from buboes Domestic cats eat infected rodents > develop pneumonic plague > Droplet infection > Humans Plague bacilli > Bioterrorism > Humans Host: All ages and both sexes are susceptible. People with occupations like hunting and grazing are more susceptible. There is no natural immunity and one can contract the disease even after previous illness. Environment: Plague in North India is seasonal – higher chances in the winter. In the south, there are no definite seasonal trends. Any environmental condition that disturbs the rodent’s natural environment e.g. floods and causes the overlap between the wild rodents and the peridomestic rodents is a potential source for plague in humans. Incubation period: For Bubonic and septicemic plague – 2 to 6 days; for pneumonic plague – 1 to 3 days. The person is not infective during this period. 48 CASE DEFINITION PLAGUE Disease characterized by rapid onset of fever, chills, headache, severe malaise, prostration with Bubonic form: extreme painful swelling of lymph nodes at axilla, groin and neck.(buboes) Pneumonic form: cough with blood-stained sputum, chest pain, difficult breathing Septicemia form: toxic changes in the patient. Laboratory criteria for diagnosis: Giemsa smear should be positive Direct fluorescent antibody testing of smears (for anti-F1 antibody) PCR test 4 fold increase in antibody titres against F1 antigen (by PHA tests) Isolation of the bacteria by culture and phage lysis Case classification Probable case: A case consistent with clinical case description with H/0 rat fall. Or Y.pestis F1 antigen detected in clinical materials by direct fluorescent antibody testing or by some other standardized antigen detection method, or Isolate from a clinical specimen demonstrates biochemical reactions consistent with Y.pestis or PCR positivity, or A single serum specimen is found positive for diagnostic levels of antibodies to Y.pestis F1 antigen, not explainable on the basis of prior infection or immunization Epidemiological link with a confirmed case. Confirmed case: a suspected or probable case that is lab-confirmed Isolate identified as Y. pestis by phage lysis or cultures; or A significant (4-fold) change in antibody titre to the F1 antigen in paired serum specimens. Trigger-1 Rat fall Trigger -2 Even 1 probable case of plague in the community 49 11. HIV HIV is not under regular surveillance by IDSP from reporting units. Unlinked anonymous surveillance of sero-prevalence will be carried out as part of the National AIDS control organization at each district. The data will be collected, analyzed and shared with health and non-health sector in each district through the IDSP network. Clinical case description There is no clinical description; the diagnosis is based on lab criteria Laboratory criteria for diagnosis: HIV positive serology (ELISA) Confirmation should be a second ELISA6. 6 Confirmation by a second serological test is necessary only in settings where estimated HIV prevalence is known to be <10% 50 ANNEXURE II: Syndromes under Surveillance The paramedical health staff will undertake disease surveillance based on broad categories of presentation. The following clinical syndromes will be under surveillance in IDSP: 1. Fever Less than 7 days duration without any localizing signs With Rash With Altered Sensorium or Convulsions Bleeding from Skin or mucus membrane Fever more than 7 days with or without localizing signs 2. Cough more than 3 weeks duration 3. Acute Flaccid Paralysis 4. Watery Diarrhea 5. Jaundice 6. 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 the Integrated Disease Surveillance Project. DISEASES OF INTEREST UNDER EACH SYNDROME Fever with & without localizing signs Malaria, Typhoid, JE, Dengue, Measles Cough more than 3 weeks Tuberculosis Acute Flaccid Paralysis Polio Diarrhoea Cholera Jaundice Hepatitis, Leptospirosis, Dengue, Malaria, Unusual Syndromes Anthrax, Plague, Emerging epidemics 51 Syndrome of fever – Definition All new patients with fever should be included under this definition. Further sub categories are as follows a). Fever less than 7 days with: Rash and coryza or conjunctivitis (suspected Measles) Altered sensorium (suspected JE or suspected Malaria) Convulsions (suspected JE) Bleeding from skin, mucus membrane, vomiting blood or passing fresh blood or black motion (suspected dengue) With none of the above (suspected malaria) b). Fever > 7 days (suspected typhoid)Trigger: More than 2 similar case in the village (1000 Population) Syndrome of cough – 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 3 weeks). Suspect ARI b) Long duration cough (Cough of > 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 Syndrome of Diarrhoea – Definition Syndrome of Acute Watery Diarrhea: Any new case of watery diarrhoea (passage of 3 or more loose or watery stools in the past 24 hours) with or without dehydration. The total duration of illness should be less than 14 days. Trigger: More than 10 houses with diarrhoea in a village or urban ward or a single case of severe dehydration or death in a patient less than 5 years with diarrhoea. Syndrome of Jaundice – Definition Clinical Description: A New Patient 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 quadrant of abdomenTrigger: More than 2 cases of Jaundice in different houses irrespective of age in a village or 1000 population 52 INTEGRATED DISEASE SURVEILLANCE PROJECT MEDICAL OFFICERS MANUAL May 2005 Government of India Directorate General of Health Services Ministry of Health & Family Welfare Nirman Bhavan, New Delhi 53 INDEX Sl. No Topic Page Abbreviations 1.0 Introduction .................................................................................................... 1 1.1 What is public health surveillance? ................................................................... 1 1.2 What are the Key Elements of Surveillance System? ........................................ 2 1.3 What are the levels where surveillance activities are performed? ..................... 2 1.4 Why do we need to do surveillance?................................................................. 2 2.0 Integrated Disease Surveillance Project (IDSP) ......................................... 3 2.1 Objectives of the Integrated Disease Surveillance Project ................................ 3 2.2 Core conditions under surveillance in IDSP ...................................................... 4 2.3 Pre-requisites for effective surveillance ............................................................ 5 3.0 Types of surveillance in IDSP ....................................................................... 6 3.1 Surveillance by Medical Officers ....................................................................... 7 3.1.1 Methods of data collection ................................................................................ 7 3.1.2 Routine reporting (institutional based or passive reporting) .............................. 7 3.1.3 Sentinel surveillance ......................................................................................... 7 3.1.4 Regularity of reports ......................................................................................... 8 3.1.5 Frequency of reporting ..................................................................................... 8 3.1.6 Active surveillance ............................................................................................ 9 3.1.7 Laboratory surveillance ..................................................................................... 9 3.1.7.1 Biosafety ........................................................................................................ 10 3.1.8 Sample surveys .............................................................................................. 11 3.1.9 Special studies ............................................................................................... 11 3.1.10 Outbreak investigations .................................................................................. 11 4.0 Reporting Units participating in regular passive surveillance under IDSP ................................................................................................... 12 4.1 Role of the various functionaries in routine surveillance .................................. 12 4.2 Formats for Reporting .................................................................................... 15 5.0 Outbreak Response .................................................................................... 18 54 5.1 Setting for Case Based Active Surveillance ................................................... 18 5.2 Detecting an outbreak .................................................................................... 18 5.2.1 Rumor register................................................................................................ 18 5.2.2 Media ............................................................................................................. 19 5.2.3 Review of routine data .................................................................................... 20 5.2.4 Warning signs of an impending outbreak ........................................................ 20 5.3 Reporting an outbreak .................................................................................... 20 6.0 Analysis of Data ........................................................................................... 20 6.1 Frequency of analysis and summary reports ................................................... 21 7.0 Surveillance Action ...................................................................................... 21 8.0 Feedback ...................................................................................................... 22 8.1 Completeness and Timeliness of data ............................................................ 22 Annexure I: Epidemiology and Case Definitions ............................................. 25 Annexure II: Syndromes under surveillance ..................................................... 51 55 ABBREVIATIONS AFB Acid Fast Bacilli AFP Acute Flaccid Paralysis CDC Centers for Disease Control and Prevention CFR Case Fatality Ratio CHC Community Health Center DSO District Surveillance Officer EMR Emergency Medical Relief HBV Hepatitis B Virus HCV Hepatitis C Virus HIV Human Immunodeficiency Virus IDSP Integrated Disease Surveillance Project MO Medical Officer NACO National AIDS Control Organization NCD Non Communicable Disease NGO Non Governmental Organization NICD National Institute for Communicable Diseases ORI Outbreak response immunization PHC Primary Health Center RRT Rapid Response Team RTA Road Traffic Accidents SPP Sentinel Private Practitioner TB Tuberculosis There is no value to surveillance system unless the information is used for action that prevent or control diseases 56
