A FIELD MANUAL - وحدة تنسيق الدعم | ACU | · A FIELD MANUAL Roles and ... Poliomyelitis) Appendix 11-6 ... In particular, epidemic-prone diseases can be a major cause

Early Warning Alert & Response Network

A FIELD MANUAL

Roles and responsibilities for

surveillance staff in Syria

To Contact Us:

[email protected]

Page#Subject6Introduction7Section One General Overview8EWARN Framework13Section Two - Roles and Responsibilities14 Health Facility Staff/Field Level Surveillance Officer

(FLO)19District Level Surveillance Officer (DLO)20Central Level Surveillance Officer (CLO)23Section Three -Alerts and Outbreaks24Alert Notifications, Verification and Outbraek

Infestigation Procedures29Appendix 1 - Weekly Reporting Form Case

Definitions35Appendix 2 Sample Patient Register37Appendix 3 - Contact List39Appendix 4 - Sample Alerts Register41Appendix - Sample Alert Notification Form43Appendix 6 -Sample Standard Alert Verification

Questions45Appendix 7 -Sample Outbreak Investigation Form -

Line List

Content

Page#Subject49Appendix 8 - Steps to Conduct an Outbreak

Investigation51Appendix 9 - Checklist of Materials - Supplies53Appendix 10 - Diagnostic Testing and Proper

Specimen Collection - Storage and Transport55Appendix 10-1 - Specimen Collection Methods59Appendix 11 - Outbreak Response Plans for Priority -

Diseases/Conditions63Appendix 11-1 - Acute Bloody Diarrhoea (Suspected

Shigellosis)69Appendix 11-2 - Acute Watery Diarrhoea: Suspected

Cholera75Appendix 11-3 - Acute Jaundice Syndrome79Appendix 11-4 - Severe Acute Respiratory Illness81Appendix 11-5 - Acute Flaccid Paralysis (Suspected

Poliomyelitis)85Appendix 11-6 - Suspected Measles89Appendix 11-7 - Suspected Meningitis93Appendix 11-8 - Suspected Typhoid97Appendix 11-9 - Cutaneous leishmaniasis

Content

6

Introduction

Surveillance is the ongoing, timely, systematic collection, analysis, interpretation and

dissemination of health information for public health action.

The objectives of disease surveillance are to:

• Detect and rapidly respond to epidemics

• Determine the main health priorities and estimate the magnitude of the problem.

• Follow trends in health status

• Target resources to areas of greatest need

• Plan and guide health programs and interventions

An effective disease surveillance system relies on timely, complete, and accurate data. These

factors will ultimately determine the utility of the system in providing useful health information

on the population it serves through weekly reporting for priority diseases and immediate reporting

of possible outbreaks. The users of the system (community, health staff, surveillance officers, and

health authorities) play a significant role in the overall performance.

This field manual was created to help with the effective transfer of information from the health

facility to the central level. It is meant to supplement regular trainings, not to replace them. The

various surveillance tasks and procedures outlined here must take into account the changing and

challenging country context within Syria. This manual will be updated as the system continues

to improve and strengthen. For comments and feedback, please contact EWARN Coordinator, by

email: [email protected].

This manual is organized in four sections:

Section 1 – General overview

Section 2 – Roles and responsibilities by level

Section 3 – Alert and outbreaks

Section 4 – Appendices (forms, charts, references)

EARLY WARNING ALERT AND RESPONSE NETWORKA FIELD MANUAL

7

Section One

General Overview

EARLY WARNING ALERT AND RESPONSE NETWORKA FIELD MANUAL

8

1. EWARN FRAMEWORK:

1-1. Background and Purpose:

The conflict in Syria has displaced millions of people, disrupted basic health services, destroyed

water and sanitation infrastructure, and greatly increased the risk of disease outbreaks among the

affected populations.

Those affected may be settled in temporary locations with high population densities,

inadequate food and shelter, unsafe water, poor sanitation and lack of health infrastructure. These

circumstances can increase the risk of transmission of communicable diseases and other conditions.

In particular, epidemic-prone diseases can be a major cause of morbidity and mortality. The Early

Warning and Alert Response Network (EWARN) is a simplified system for disease surveillance

which can be quickly set up in the affected areas during the acute phase of an emergency. It is

designed as a temporary stopgap measure when public health information systems are disrupted

or non-functional. EWARN should be integrated into this larger system once the acute phase of the

emergency is over. The primary purpose of EWARN is rapid detection of and prompt response to

epidemics among the affected population.

1-2. Priority Diseases/Conditions under Surveillance:

A limited number of priority diseases/conditions were selected based on a) their potential to

cause epidemics, b) their association with high morbidity and mortality, and c) the existence of

interventions in Syria. See Appendix 1 for reporting form, case definitions, and alert thresholds.

Table 1: Priority Diseases/ Conditions under surveillance

Acute Bloody Diarrhoea (Suspected Shigellosis) Suspected Measles

Acute Watery Diarrhoea (Suspected Cholera) Suspected Meningitis

Acute Jaundice Syndrome Unusual Cluster of Health Events

Severe Acute Respiratory Illness Unexplained Death

Acute Flaccid Paralysis Suspected Poliomyelitis) Unexplained Fever

Leishmaniasis Suspected typhoid fever

1-3. Operational Structure of EWARN:

EWARN has two primary functions:

I. Immediate reporting of unusual health events, such as potential outbreaks or cluster of deaths

with the same signs or symptoms, from all sources (exhaustive surveillance).

II. Weekly reporting and trend analysis of aggregated case data from selected health facilities

(sentinel surveillance).

1-4. Data Flow :

Immediate alerts can signal the early stages of an outbreak in the community or health facility.

9

This information must be transmitted up the reporting chain immediately. Depending on the local

capacity and current situation (security, resources, etc.), this may be to the district or central levels.

Aggregated weekly data from patient registers must be submitted to the next reporting level,

i.e., health center level (field level) → district level → central level for analysis, interpretation, and

dissemination. If current situation (security, resources, etc.) prohibits reporting to the next level,

data can continue up the reporting level by alternate methods (i.e., non-government organizations

[NGO]). Surveillance officers at all reporting levels should be informed of this alternative method

so EWARN records and database may be updated at the various levels accordingly (Figure 1). It is

essential for participating health facilities to use a patient registry for recording consultations. See

Appendix 2 for sample patient register.

Figure 1: EWARN Data Flow

1-5. Inclusion Criteria for Health Facilities:

Due to the dynamic situation in Syria, only select health facilities will be included in the weekly

aggregation of data for sentinel surveillance. Efforts will be made to ensure representativeness;

however, priority will be given to the following health facilities:

• Adequate resources:

� Staff – physician, surveillance officer or focal point

� Resources – patient registers, method of communication

• Stability and security

• Accessibility

Sentinel sites will be evaluated periodically to determine the addition/removal of health facilities

based on performance indicators (timeliness, completeness, regularity of reporting). Temporary

institutions will not be included. Note: all sources are included for alert notification.

10

1-6. EWARN Staffing:

Health and surveillance staff play an important role in the timely and accurate transfer of

EWARN data. Data will be transmitted by an identified Field Level Surveillance Officer (FLO) from

the health facility to the district level on a weekly basis.

The District Level Surveillance Officer (DLO) will then transfer data from the health facilities in

their province to the Central Level Surveillance Officer (CLO). The number of DLOs per province

will depend on population size, access, and geography. Health facility staff and NGOs will also

assist EWARN surveillance officers with alert verification and outbreak investigations (Figure 2).

Figure 2: EWARN Staff Roles and Responsibilities

1-7. Reporting Schedule:

The epidemiological week is from Sunday to Saturday. Data must be submitted according to

the predetermined schedule in order to ensure timely dissemination of information (See Figure 3).

Figure 3: EWARN Reporting Schedule

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1-8. Analysis and Interpretation:

Notification of alerts and simple trend analysis at the health facility and district levels can detect

early changes in disease. These analyses occur at the most peripheral level, the level closest to

the field where immediate action can take place. More detailed analysis and interpretation of the

findings occur at the central level.

1-9. Dissemination:

Feedback is critical for ensuring full engagement. Surveillance data must be shared with partners,

stakeholders, and the community for decision-making, advocacy, and to inform public health

efforts. The health bulletin with epidemiological data is published weekly with current findings,

interpretations, and recommendations.

1-10. Monitoring and Evaluation:

Data from EWARN must be regularly reviewed to ensure integrity and accuracy of the

information being collected. Every effort must be made to trace missing or incomplete data to the

original source.

These efforts begin with the health facility staff/Field Level Surveillance Officer, continue with

the District Level Surveillance Officer, and finally with the Central Level Surveillance Officer.

Monitoring via routine data quality checks and internal evaluations will be conducted at all reporting

levels once the system has been established and is functioning. A formal external evaluation occurs

once the emergency is over or approximately every 12-18 months in protracted situations.

12

13

Section Two

Roles and Responsibilities

14

2. Health Facility Staff/Field Level Surveillance Officer (FLO):

2-1. Data collection procedures:

2-1-1. Key principles when recording diseases:

• Strictly adhere to the EWARN case definitions. These may differ from previous surveillance

case definitions and from clinical case definitions. For example, acute diarrhoea should not be

confused with suspected cholera. Note: EWARN case definitions are not to be used for case

management and are not an indication of intention to treat.

• Only assign one main health disease/syndrome to each patient.

• Only record new cases during weekly aggregation of data.

� If a patient presents to the health facility for the same condition multiple times, this is

considered a repeat visit and should only be counted once.

� If a patient is transferred from another health facility, only count as a new case if the referring

health facility is not part of EWARN (not a sentinel site).

• Document every alert (regardless of source) presenting at the health facility in the alerts section

of the weekly reporting form.

2-1-2. How to complete the EWARN reporting form for weekly reporting:

Weekly aggregated data must be recorded on the EWARN weekly reporting form and transmitted

to the district level. This may be done by hand or electronically depending on the health facility and

local capacity.

The top section of the reporting form is for general information (location, date, name of responsible

person, etc.). The next section is for case counts disaggregated by age and sex. For each section, complete

each space on the reporting form. Do not leave any spaces blank. See Figure 4 and Appendix 1.

1. For each health facility, indicate:

a. Name of reporter

b. Job title

c. Governorate

d. Health District

e. Health center name

f. Catchment population, if known

g. Reporting period: From the start date of the epidemiological week being reported (Sunday

of the previous week) to the end date of the epidemiological week being reported (Saturday

of the previous week)

h. Name of DLO responsible for receiving the weekly reporting form

i. Date the reporting form was submitted to the DLO

j. DO NOT complete the sections titled “Date received by DLO” or “Date entered in database

by the DLO”.

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2. Add up all the cases of the reportable conditions from the patient registers and write (or type)

these numbers into the corresponding boxes on the reporting form. Case counts should be

disaggregated by age (0-4 and ≥ 5 years), and sex, and total number of cases are entered in the

last column.

3. Only the 8 priority conditions under surveillance should be aggregated and reported (rows 1-8);

all other conditions should be grouped under the ‘all other diseases’ category (row 9).

4. All conditions with no cases should be marked with a zero.

5. Total number of consultations is the number of priority conditions plus ‘others’ (row 10). Make

sure to calculate this number correctly. This information will help estimate the proportional

morbidity, or the burden of a specific disease from the total number of patient visits, and will be

used to monitor trends.

6. The last section is to further explain all unusual health events, cluster of health events or

unexplained deaths reported for that week.

7. All efforts should be made to ensure conditions are not counted more than once (i.e., registers

should be cross-checked to avoid duplications).

8. The Field Level Surveillance Officer should print or type there name and sign at the bottom of

the form.

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EWARN Weekly Report

Name of reporter Job title Governorate Health District

Health Center Name Catchment Population

Report Period From: Until: DD MM DD MM

Name of DLO Date submitted to DLO (___/___/201 (DD/MM)

Date Received by DLO* (___/___/201 (DD/MM) Date entered into Database by DLO

(___/___/201 (DD/MM)

*If report sent via SMS or phone, DLO should fill out a paper copy of the report and note how reported _____

Reporting of cases

DISEASE Code 0 - 4 years ≥ 5 years

TOTAL Male Female Male Female

Acute bloody diarrhoea(suspected shigellosis)

ABD

Acute watery diarrhoea (suspected cholera)

AWD

Acute jaundice syndrome AJS Severe acute respiratory illness SARI 5 Acute flaccid paralysis

(Suspected poliomyelitis) AFP

Suspected Measles MEA Suspected Meningitis MEN Other a. Unusual cluster of health event UCE

b. Unexplained deaths UXD

c. Unexplained fevers : FUO d. Suspected Typhoid Fever STF e. Leishmaniasis LEISH All other diseases Total consultations ±Please explain any unusual case, cluster of health event, or unexplained deaths:

Please note: Immediately notifiable diseases should be reported during the first 24 hours (DO NOT WAIT until

the end of the week). HOTLINE CONTACT: [email protected] Report cases that are registered only during this week. Report new cases only (first visit). Write ‘ ’ (zero) if no case has been reported for any of the above listed diseases. Do not leave any

spaces blank. Name of the reporter (Field Level Surveillance Officer):

Signature

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2-2. Case Definitions:DISEASE / SYNDROME CODE DEFINITION THRESHOLD

1. Acute bloody diarrhoea (suspected shigellosis)

ABD

Acute diarrhoea (three or more abnormally loose or fluid stools in the past 24 hours) with visible blood in stool (preferably observed by the clinician).

≥ 5 cases in 1 location in 1 week or double the weekly average*

2. Acute watery diarrhoea (suspected cholera)

AWD Age five years or older with sudden onset of acute watery diarrhoea with severe dehydration or death with or without vomiting.

1 case

3. Acute jaundice syndrome

AJS

Acute onset of jaundice (yellowing of sclera of eyes or skin or dark urine), AND Severe illness with or without fever ≥ 38°C, AND; The absence of any known precipitating factors.


4. Severe acute respiratory illness

SARI

Acute respiratory illness onset within the last 7 days with History of fever or measured fever (≥ 38°C) Cough Requires hospitalization (whether possible or

not)

≥ 5 cases in the same week in the same location or double the weekly average OR 1 death

5. Acute flaccid paralysis (suspected poliomyelitis)

AFP

Any child < 15 years with acute flaccid paralysis, OR; Any paralytic illness in a person of any age if poliomyelitis is suspected (NOT traumatic paralysis).

1 case

6 Suspected measles

MEA

Any person with fever ≥ 38°C, AND; maculopapular (nonvesicular) generalized rash, AND ONE of the following: Cough, runny nose (coryza) or red eyes (conjunctivitis), OR; Any person in whom a clinician suspects measles.

1 case

7 Suspected meningitis

MEN

Any person with sudden onset of fever ≥ 38°C, AND ONE of the following signs: Neck stiffness. A bulging fontanel (in a child < 1 year). Difficulty in suckling and irritation (in an

infant < 2 months). Altered consciousness. Petechial or purpural rash. Fatigue or lethargy. Convulsions: < 6 months- > 6 years: any convulsion crises

(seizure). 6 months to 6 years: any long and localized

convulsion crises or two or more generalized convulsion crisis during 24 hours.

1 case in a crowded camp setting

Population ≥30,000: 5

cases per week/100,000 population

Population <30,000: 2 cases per week

8a. Unusual cluster of health events

UCE

Any emerging disease or event of an unknown cause that is of public health concern or any communicable disease with an increased number from the expected particularly if clustered (cases that are closely grouped in time and/or place: several cases from the same family, school or workplace).

1 cluster

DISEASE / SYNDROME CODE DEFINITION THRESHOLD

8b. Unexplained death UED Any deaths due to unknown or unidentifiable causes

1 case

8c. Unexplained fever FUO fever ≥ 38°C for > 48 hours AND without known etiology


9.Suspected Typhoid fever STF

fever ≥ 38°C > days with (headache, malaise, anorexia, relative bradycardia, constipation or diarrhea, and nonproductive cough)or symptomatic case contacted with confirmed case


10.Leishmaniasis LEISH

A person showing clinical signs (skin lesions). A papule appears, which may enlarge to become an indolent ulcerated nodule or plaque. The sore remains in this stage for a variable time before self healing and typically leaves a depressed scar. Other atypical forms may occur.

>50 new case in one area or health facility .

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2-3. Data reporting procedures (due by 10:00 am Monday):

2-3-1. Immediate alerts:

• Report immediately notifiable diseases using the fastest means possible (phone, short message

service [SMS], email, fax, local transport). A contact list of whom to notify should be posted

in every health facility for easy reference. This list should include the name and contact

information of the DLO responsible for the health facility and the CLO (See Appendix 3 for

Sample Contact List).

2-3-2. Weekly data:

• Use the facility-based register to tally EWARN reportable diseases and all other total

consultations from the prior epidemiologic week (Sunday – Saturday). Complete the weekly

EWARN reporting form accordingly.

• If you are completing the reporting form by hand, maintain a hard copy (duplicate page of

forms) on site. If you are completing the reporting form electronically, save a copy in a file/

folder. Make sure files are routinely backed-up.

• By 5:00 pm Sunday: submit the EWARN weekly reporting form to the DLO for the health

facility.

It is the responsibility of all participating health facilities to ensure

timely and complete submission of their reporting forms.

Did you.....• Use EWARN case definitions when making diagnoses?

• Calculate cases correctly?

• Report all notifiable alerts to a EWARN surveillance officer?

• File a copy of the weekly reporting form?

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3. District Level Surveillance Officer (DLO):


Ensure all reporting forms for the prior epidemiological week have been received on time.

District Level Surveillance Officers must conduct data entry of the weekly reporting forms into the

District EWARN database.

3-2. Data reporting procedures (due by 10:00 am Wednesday):

3-2-1. Immediate alerts:

• Relay information/updates of alerts and ongoing outbreak investigation to the Central Level

Surveillance Officer.

• Ensure alert notification and verification data are documented in the alerts register. See Appendix

4 for sample alerts register.

3-2-2. Weekly data:

• Conduct data quality checks on all submitted reporting forms for the following:

� Completeness - All fields on the weekly forms are completed (no blank spaces).

� Accuracy – All fields are completed correctly (do the totals add up?)

� Screen for alert notification – Check the reporting forms if any criteria meet immediate alert

notification are present and have not already been reported.

• E-mail the EWARN weekly reports database and the alerts register for the week to the Central

Office.

It is the responsibility of all District Level Surveillance Officers to ensure timely and

complete submission of their EWARN databases.

Did you.....• Collect all weekly reporting forms?

• Send updated weekly reports database and alerts register to

central office?

• Ensure all alerts are logged and updated in the alerts register?

• Identify any unreported alerts?

• Follow-up any problems?

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4. Central Level Surveillance Officer (CLO):


Ensure all district EWARN data have been received by 5:00 pm Monday and merge into central

database.

• Conduct data analysis for indicated disease parameters by province:

� Timeliness

� Completeness

� Proportional Morbidity

� Summary of all health events under surveillance

• Meet with all Central Level staff for technical review and interpretation of data by 10:00 am

Thursday

• Finalize and disseminate weekly health bulletin to partners, stakeholders, community by 4:00

pm Friday

• Monitor status of outbreak investigations and maintain updated alerts/outbreaks database

The CLO is responsible for documenting and addressing challenges

encountered in meeting surveillance expectations. Follow-up any discrepancies

or outstanding issues with field staff

Did you.....• Follow-up any alerts/outbreaks and update the central level

alerts database?

• Review health bulletin for technical and editorial content?

• Follow-up any problems?

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22

23

Section Three

Alerts and Outbreaks

24

5. Alert Notifications, Verification and Outbraek Infestigation Procedures:

5-1. Alert Notification:

An alert is an unusual health event that can signal the early stages of an outbreak. It is triggered

when a critical number, level, or point has been crossed. It is the basis on which decision to report

an outbreak is made.

An alert is used to:

• Sound an early warning

• Launch a verification and possible investigation

• Implement control measures to contain or prevent an epidemic

Alerts can be triggered from:

• Surveillance data

• Health facilities

• Community informants or leaders, religious leaders, traditional healers

• Media rumors

• The affected population

5-2. What happens when an alert threshold for a disease is reached?

Alerts are recorded in the patient registry, similar to other morbidity data. In addition, an alert

form must also be completed and must be immediately reported to the DLO for that region and

the CLO (if respective DLO is not reachable, alert should be reported to a neighboring DLO or

directly to the CLO). Alerts must be reported using the fastest means possible (phone, SMS, etc.).

See Appendix 5 for sample alert notification form.

Potential outbreaks can be recognized by:

• Astute observation of a single event or cluster of events by health staff

• Report of one or more cases with similar signs and symptoms from the same area

• Routine surveillance activities

5-3. Alert Verification:

Once an alert has been received, a systematic verification must occur within 24 hours to

determine if further investigation is needed. This process should be conducted by the DLO, under

the supervision of the Central Level, in collaboration with the health provider. This can be done

by telephone and should include a standard set of questions. See Appendix 6 for standard alert

verification questions.

To verify an alert, the information below should be collected:

• Was the case definitions used?

• What were the symptoms and signs of cases?

• What was the date of onset of symptoms of the first and the most recently detected cases?

25

• Where was the place and date of consultation or hospitalization?

• What is the age, sex and vaccination status of patients, where relevant?

• Where is the place of residence at onset of illness?

• Where are the cases occurring (community-level data)?

5-4. Outbreak Investigation:

Outbreaks can spread very quickly. Once an alert has been verified, an outbreak investigation

must be conducted. An outbreak investigation determines the cause of the outbreak in order to

implement control measures and ultimately reduce morbidity and mortality. Standardized case

investigation forms and line lists should be used during an investigation. See Appendix 7 for

sample case investigation form and line list).

Details on how to conduct an investigation are presented elsewhere,1 See Appendix 8 for a

summary of key steps.

The main objectives of an outbreak investigation are:

1. Identify the causative agent

2. Identify persons at risk

3. Identify mode of transmission and vehicle

4. Identify source of contamination

5. Identify additional risk factors

6. Implement control measures to contain current outbreak and prevent future ones

5-5. Outbreak Preparedness:

Thorough investigation will require several resources including transportation, specimen

collection materials, a multi-sectorial outbreak control team (OCT), outbreak response plans,

standard treatment protocols, identification of isolation sites, and pre-positioned stockpiles of

essential treatment supplies. It is critical to have these resources identified beforehand to ensure a

timely and effective response. It is the responsibility of the DLO to maintain an updated checklist of

required materials, supplies, and tools. See Appendix 9 for sample checklist of required materials

and supplies.

1 Gregg MB, Field Epidemiology, 2nd ed. Oxford University Press, 2002.

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5-5-1. Roles and responsibilities of Outbreak Control Team:

For an effective response, outbreak investigations require a range of skills and expertise and

coordination of many sectors.

These include, but are not limited to:

• Team leader or Central Level Surveillance Coordinator

• District Level Surveillance Officer

• Clinician

• Sector specialist (for example, water, sanitation, hygiene or nutrition)

• Laboratory personnel

• NGO health officer

• Logistician

• Health educator

See Appendix 3 for sample OCT contact list. This list must be updated regularly considering the

revolving partners and staff during an acute phase of an emergency.

Primary functions of an OCT are to:

• Coordinate human and material resources (surveillance, treatment, information management,

risk communication)

• Strengthen surveillance (staff training, updated line list, daily review of indicators such as

attack rates and case-fatality ratios)

• Implement and evaluate control measures/interventions

• Coordinate with partners, stakeholders (media, donors, health staff, community)

• Communicate findings, disseminate results

5-6. Laboratory support:

Routine reporting of diseases/conditions that do not reach an alert threshold do not require

laboratory confirmation. However, laboratory confirmation of cases is important when an

outbreak is suspected. Therefore, a reference laboratory with varying capacity should be identified

beforehand and all samples sent for testing must be documented.

The following laboratories, indicated by testing capability, are listed below for each district area:

Table 2: List of laboratories:Name of laboratory Location Province Testing capability

5-7. Response and control measures:

Control measures should be initiated as soon as possible. It is not necessary to wait for the results

of the outbreak investigation. Some common control measures are:

27

• Interruption of environmental sources (ex., provision of safe water)

• Interruption of transmission (ex., vaccination, prophylaxis, bed nets)

• Isolation of infected people

• Improved hygiene and/or sanitation practices (ex., health education and messaging, provision

of soap)

See Appendix 10 for general overview of diagnostics testing, and proper specimen collection,

packaging, and transportation; see Appendix 11 for outbreak response plans for selected priority

diseases/conditions.

5-8. Feedback and Dissemination:

Feedback of information must be shared with partners, stakeholders, and the community to

monitor the progress of the outbreak and inform public health efforts. This information should be

communicated at health coordination meetings and/or other venues, where appropriate. All alerts

must be incorporated into the weekly bulletin.

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29

Appendix 1

Weekly Reporting Form

Case Definitions

30

EWARN Weekly Report

Name of reporter Job title Governorate Health District

Health Center Name Catchment Population

Report Period From: Until: DD MM DD MM

Name of DLO Date submitted to DLO (___/___/201 (DD/MM)

Date Received by DLO* (___/___/201 (DD/MM) Date entered into Database by DLO

(___/___/201 (DD/MM)

*If report sent via SMS or phone, DLO should fill out a paper copy of the report and note how reported _____

Reporting of cases

DISEASE Code 0 - 4 years ≥ 5 years

TOTAL Male Female Male Female

Acute bloody diarrhoea(suspected shigellosis)

ABD

Acute watery diarrhoea (suspected cholera)

AWD

Acute jaundice syndrome AJS Severe acute respiratory illness SARI 5 Acute flaccid paralysis

(Suspected poliomyelitis) AFP

Suspected Measles MEA Suspected Meningitis MEN Other a. Unusual cluster of health event UCE

b. Unexplained deaths UXD

c. Unexplained fevers : FUO d. Suspected Typhoid Fever STF e. Leishmaniasis LEISH All other diseases Total consultations ±Please explain any unusual case, cluster of health event, or unexplained deaths:

Please note: Immediately notifiable diseases should be reported during the first 24 hours (DO NOT WAIT until

the end of the week). HOTLINE CONTACT: [email protected] Report cases that are registered only during this week. Report new cases only (first visit). Write ‘ ’ (zero) if no case has been reported for any of the above listed diseases. Do not leave any

spaces blank. Name of the reporter (Field Level Surveillance Officer):

Signature

31

32

Alert Threshold Definition Code Disease / Syndrome

Double the weekly average

Acute diarrhea (three or more abnormally loose or fluid stools in the past 24 hours)

AD Acute diarrhea

≥ 5 cases in 1 location in 1 week or double the weekly average

Acute diarrhea (three or more abnormally loose or fluid stools in the past 24 hours) with visible blood in stool (preferably observed by the clinician).

ABD Acute bloody diarrhea (suspected shigellosis)

One case Age five years or older with sudden onset of acute watery diarrhea with severe dehydration or death with or without vomiting.

AWD Acute watery diarrhea (suspected cholera)


Acute onset of jaundice (yellowing of sclera of eyes or skin or dark urine), AND Severe illness with or without fever ≥ 38°C, AND The absence of any known precipitating factors

AJS Acute jaundice syndrome

Double the weekly average

Acute respiratory illness onset within the last 7 days with

History of fever or measured fever (≥ 38°C) Cough

ILI Influenza Like Illness

≥ 5 cases in 1 location in 1 week or double the weekly average or 1 death

Acute respiratory illness onset within the last 7 days with

History of fever or measured fever (≥ 38°C) Cough Requires hospitalization (whether possible or not )

SARI Severe Acute Respiratory Illness

One case

Any child < 15 years with acute weakness or flaccid paralysis, OR; Any paralytic illness in a person of any age if poliomyelitis is suspected

AFP Acute flaccid paralysis (suspected poliomyelitis)

One case

Any person with fever ≥ 38°C, AND; maculopapular (nonvesicular) generalized rash, AND ONE of the following:

Cough Runny nose (coryza) Red eyes (conjunctivitis), OR; Any person in whom a clinician suspects measles

MEA Suspected Measles

1 case in a crowded camp setting

Any person with sudden onset of fever ≥ 38°C, AND ONE of the following signs:

MEN

CASE DEFINITIONS

33

or Population ≥30,000: 5 cases per week/100,000 population

Neck stiffness. A bulging fontanel (in a child < 1 year). Difficulty in suckling and irritation (in an infant < 2

months). Altered consciousness. Petechial or purpuric rash. Fatigue or lethargy. Convulsions:

- < 6 months- > 6 years: any convulsion crises (seizure). - 6 months to 6 years: any long and localized

convulsion crises or two or more generalized convulsion crisis during 24 hour

Suspected Meningitis

1 cluster

Any emerging disease or event of an unknown cause that is of public health concern or Any communicable disease with an increased number from the expected particularly if clustered (cases that are closely grouped in time And/or place: several cases from the same family, school or workplace).

UCE Unusual cluster of health events

1 case Any deaths due to unknown or unidentifiable causes UED Unexplained death


children with fever >(38 ºC) of at least 8 days' duration, in whom no diagnosis is apparent after initial and careful history and physical examination and initial laboratory assessment

FUO Fever of Unknown Origin


fever ≥ 38°C > days with (headache, malaise, anorexia, relative bradycardia, constipation or diarrhea, and nonproductive cough) or symptomatic case contacted with confirmed case

STF Suspected Typhoid Fever

≥ 50 of new case in one area or health sociality

A person showing clinical signs (skin lesions). A papule appears, which may enlarge to become an indolent ulcerated nodule or plaque. The sore remains in this stage for a variable time before self-healing and typically leaves a depressed scar. Other atypical forms may occur.

LEISH

Leishmaniasis

34

35

Appendix 2

Sample Patient Register

36

Facility Name:

Dat

e

ID

Nam

e

Age

Sex

(M/F

)

Addr

ess

or c

onta

ct

info

rmat

ion

Firs

t Vis

it fo

r th

is p

robl

em

(Y/N

)

Sign

s an

d Sy

mpt

oms

Dia

gnos

is

Trea

tmen

t

Rem

arks

(r

efer

ral,

tran

sfer

pat

ient

, or

sam

ples

col

lect

ed

37

Appendix 3

Contact List

38

Alert Notification Contact ListPlease complete the following table with the names and contact information of the EWARN

surveillance staff, NGO Health Officer or health facility director, community and local health

authorities, and others responsible for alert and outbreak activities at your facility. These individuals

should be notified in case of an alert or potential outbreak. Please post this list for easy reference

and update, as necessary.

Title Name Mobile # EmailDLO –first contact

CLO-if not able to reach DLO

NGO Health Officer

Local Health Authority

Other

Other

Outbreak Investigation Team Contact ListThe following list constitutes individuals or agencies that can support an investigation. Not

every individual will be required during an investigation, but key persons should be identified

immediately. This list must be updated regularly.

Role/Responsibility Name Mobile # Email

Team lead/surveillance officer

Local authority/partnerClinicianSector specialist (WASH, vector)Laboratory technician (or person capable of specimen collection)

NGO health officer

LogisticianHealth educatorSecurity personnel

39

Appendix 4

Sample Alerts Register

40

41

Appendix 5

Sample Alert Notification Form

42

Alert Notification Form

Health Facility: _______________ Date: _____ / _____ / ______ (DD/MM/YYYY)

Name of Reporting Officer: _____________________________________

Suspected Disease/ Syndrome(Tick ONE box only)

Symptoms and Signs(You can tick several boxes)

€ Acute Bloody Diarrhoea (suspected shigellosis)€ Acute Watery Diarrhoea (suspected cholera)€ Acute Jaundice Syndrome€ Severe Acute Respiratory Illness€ Acute Flaccid Paralysis (suspected poliomyelitis)€ Suspected Measles€ Suspected Meningitis€ Unusual Cluster of Health Event€ Unexpected Death€ Unexplained Fever€ Suspected Typhoid Fever€ Leishmaniasis

€ Visible blood in stool€ Watery or loose stool€ Jaundice (yellow skin or eyes)€ Acute paralysis or weakness€ Fever€ Cough€ Rash€ Neck stiffness€ Vomiting€ Papule or skin nodule€ Other (describe below)

Total Number of Cases Reported: (refer to weekly thresholds)

Other signs and symptoms:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name and signature of Reporting Officer

43

Appendix 6

Sample Standard Alert Verification Questions

44

Your Name: _____________________

Governorate: ________________________

•Primary mode of alert notification (i.e. how were you notified of this alert, for example, via rumor,

health facility, etc.?)________________________

•Name of person who reported the alert:__________________________________________________

•Name of health facility or community with alert:___________________________________________

•Date patient was seen _____________________

•Age __________ (years)

•Sex ___________ (M/F)

•Vaccination status (if applicable) _______________________________________________________

•What are the signs and symptoms of cases (this is to verify the diagnosis and consider other

diagnoses)?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

•Was the case definition used? YES NO

•Epidemiological information

o Who is affected (age groups, sex, specific groups, vaccination status (if applicable) etc.)?

___________________________________________________________________________

o Where (geographic location of affected area)?

___________________________________________________________________________

o Date of onset for first case? ______________________

o Most recent case? ______________________

o How many affected (number of cases)? ______________________

o Any reported deaths (How many?)? YES (________) NO

45

Appendix 7

Sample Outbreak Investigation Form

Line List

46

Outbreak Investigation Form

Reporting Officer Governorate

District/Town Health Facility

Date Alert Initially Reported Date Case Initially IdentifiedBrief Summary of Initial Report

SUSPECTED DISEASE OR SYNDROME(RECORD NUMBER OF CASES OF EACH)

SIGNS AND SYMPTOMS (S&S)(CHECK ALL THAT APPLY)

Number of cases Disease / Syndrome Check if

observedS&SCode

Signs and Symptoms (S&S)

Acute watery diarrhea (AWD) 1 Acute watery diarrheaAcute bloody diarrhea (ABD) 2 Bloody diarrheaAcute jaundice syndrome (AJS) 3 FeverSevere acute respiratory illness (SARI) 4 Rash

Acute flaccid paralysis (AFP) 5 Other skin lesion

Suspected measles (SMS) 6 CoughSuspected meningitis (SMN) 7 Vomiting

Cluster of health event (specify)___________________________ 8 Jaundice

Unexplained death 9 Neck stiffness

Suspected Typhoid Fever (STF) 10 Convulsions / Seizures

Leishmaniasis (LEISH) 11 Muscle weakness

12 Increased secretions / sweating / drooling

13 Altered level of consciousness

14 Other: _________________________________

15 Other: __________________________________

Total Number of Cases 16 Other: __________________________________

Actions Taken

Name and signature of Reporting Officer

47

Line List

Report completed by: …………………………………………………………………………………….

…………………………………..…

Health Facility _____________________________ Governorate: ___________________________

___

Agency/NGO: …………………………..…………………. Date:

… … … . … / … … … . … / … … … . …

Cas

e N

o.

Age

(add

m o

r y to

num

ber)

0

Add

ress

Sex

(M/F

)

Dat

e of

ons

et(d

d/m

m/Y

Y)

Lab

spec

imen

take

n¹

Trea

tmen

t giv

en(Y

es/N

o)

Out

com

e² (I

, R, D

, X)

Fina

l dia

gnos

is

Con

tact

with

cas

e?³

(Yes

/No)

0 M=months, Y=years

¹Laboratory specimens: B=Blood, S=Stool, C=CSF, U=Urine, O=Other

²Outcome:, I=Currently ill, R=Recovering or recovered, D=Died, X=Default

³ Known to have contact with a previously identified case (list case no. for which patient had

contact, might be family member, friend, relative, school mate or co-worker, attended the same

activity)

48

49

Appendix 8

Steps to Conduct an Outbreak Investigation

50

Below is a summary of key steps on how to conduct an investigation:

1. Prepare to investigate

a. Verify initial reports

b. Notify appropriate authorities (DLO, CLO, local council, NGO partners, Health Facility

Directors)

c. Contact outbreak investigation team; execute phone tree/contact list

d. Examine cases, interview contacts

e. Secure necessary supplies and arrange logistics

2. Verify the diagnosis and confirm outbreak

a. Get laboratory confirmation; collect samples, perform rapid tests, as appropriate

3. Implement immediate control measures

4. Develop case definition which includes person/place/time. Note: this will usually be more

specific than the surveillance case definition.

5. Case identification

a. Conduct systematic search based on case definition

b. Create line list of possible cases (people exposed)

c. Establish extent of outbreak by counting the number of cases

6. Perform descriptive epidemiology

a. Person/place/time

b. Mapping

c. Epidemic curve

7. Develop hypotheses to explain exposure and disease

a. Design questionnaire

8. Expand surveillance activities, as necessary. For example, increase reporting frequency from

weekly to daily to monitor progress of ongoing outbreak.

9. Implement additional control measures and communicate public health messages

10. Refine hypotheses and perform epidemiological studies, as necessary

11. Communicate findings

a. Disseminate outbreak investigation report

b. Educate community

These steps may not necessarily happen in sequence; however control measures should be

implemented as soon as possible. In the initial stages, the cause of the outbreak may not be known,

but general control measures should be instituted based on available data.

51

Appendix 9

Checklist of Materials

Supplies

52

Before embarking on an outbreak investigation, consider the disease or syndrome that you are

going to investigate and determine whether any of the following items are needed.

1. What personnel do I need to contact to be on the investigation team? Note that one person can fulfill more than one role.

€ Lead investigator€ Clinician (doctor, nurse, medical assistant,

local or NGO partners)€ WASH or Environmental officer€ Data collectors / interviewers€ Logistics management (tracking supplies,

setting up tents)€ Laboratory technician€ Vector control€ Health educator

2. What guidelines and references are needed?

€ Treatment protocols€ Reporting protocols€ Hospital / health facility contact

information

3. What is needed for medical treatment and patient care?

€ Knowledge of local facilities and beds available

€ Oral rehydration kits€ Vaccines€ Vaccine cards€ Vitamin A€ Zinc€ Antibiotics€ Disinfectant / bleach solution€ Water purification methods€ Field hospital tent

4. What logistics do I need to arrange?€ Security€ Transportation€ Overnight stays / housing

5. What is needed for data collection?€ Alert verification forms€ Case investigation forms€ Line list forms or paper for line lists€ Pens, pencils, folders, paperclips

6. What is needed for sample collection and testing? Consider the sample that will be taken given the disease or syndrome you are investigating.

€ Submission forms€ Specimen collection tubes, cups, and/or

kits€ Cooler/Cold Pack€ Gloves € Syringes/Needles€ Tourniquet€ Band-Aids€ Sharps Container€ Rubbing Alcohol€ Labels for specimens€ N-95 mask

53

Appendix 10

Diagnostic Testing and Proper Specimen Collection

Storage and Transport

54

TRADITIONAL TESTS:

Normally, routine reporting of conditions under surveillance do not require laboratory

confirmation. However, laboratory confirmation of suspected cases is important when an outbreak is

suspected. A regional reference laboratory, such must be identified (e.g. for antimicrobial sensitivity

or confirmation of RDTs). If no such laboratory exists, laboratories in the area need to be used. There

must be an efficient mechanism for correctly recording, packaging and safely transporting samples

from the patient to the laboratory, and for transmitting results back to the surveillance team and the

clinical workers. The surveillance team, in conjunction with the clinical workers, are responsible for

setting out sample collection methods, the type of samples collected (see below), tests conducted,

the transport requirements (such as media, safety boxes and cold chain). An updated log of samples

submitted for laboratory testing, their results and follow-up action must be maintained. Putting

these standard operating procedures and contact details of reference laboratories in writing will

ensure optimum specimen management.

RAPID DIAGNOSTIC TESTS (RDTs):

There are RDTs not only for malaria, but also for cholera, dengue, diphtheria, hepatitis A and E,

leptospirosis, measles or rubella, bacterial meningitis, shiga-toxin-producing Escherichia coli and

Shigella spp., and typhoid fever. Follow the manufacturer’s instructions precisely when using any

of these tests. Reagents should be kept refrigerated between 2 °C and 8 °C when not in use. Product

deterioration occurs at higher temperatures, especially in tropical climates, and test results may

become unreliable before the expiry date of the kit. Latex suspensions should never be frozen. Note

that some kits have a working temperature range and tropical temperatures may be above the

recommended upper limit, such as for the malaria RDTs.

55

Appendix 10-1

Specimen Collection Methods

56

BLOOD SPECIMEN COLLECTION:Venous blood samples

Materials for collection:

• Skin disinfection: 70% alcohol (isopropanol, ethanol) or 10% povidone iodine, swabs, gauze pads,

adhesive dressings.

• Disposable latex or vinyl gloves.

• Tourniquet, Vacutainer or similar vacuum blood collection devices, or disposable syringes and

needles.

• Vacutainer or sterile screw-cap tubes (or cryotubes if indicated), blood culture bottles (50 ml for

adults, 25 ml for children) with appropriate media.

• Labels and indelible marker pen.

Method of collection:

• Full infection control measures must be taken, with gowns, gloves, masks and boots for suspected

viral hemorrhagic fever such as Lassa fever or Ebola.

• Place a tourniquet above the venipuncture site. Disinfect the tops of blood culture bottles.

• Palpate and locate the vein. The venipuncture site must be meticulously disinfected with 10%

povidone iodine or 70% alcohol by swabbing the skin concentrically from the center of the

venipuncture site outwards. Let the disinfectant evaporate. Do not palpate the vein again. Perform

venipuncture.

• If using conventional disposable syringes, withdraw 5–10 ml of whole blood from adults, 2–5 ml

from children and 0.5–2 ml from infants. Using aseptic technique, transfer the specimen to the

appropriate cap transport tubes and culture bottles. Secure caps tightly.

• If using a vacuum system, withdraw the desired amount of blood directly into each transport tube

and culture bottle.

• Remove the tourniquet. Apply pressure to site until bleeding stops, and apply dressing.

• Label the tube, including the unique patient identification number, using indelible marker pen.

• Do not recap used sharps. Discard directly into the sharps disposal container.

• Complete the case investigation and the laboratory request forms using the same identification number.

Handling and transport:

• Blood specimen bottles and tubes should be transported upright and secured in a screw-cap

container or in a rack in a transport box. They should have enough absorbent paper around them

to soak up all the liquid in case of spill.

• For serum samples (e.g. measles, yellow fever, HIV), the blood cells must be separated from

serum. Let the clot retract for 30 minutes then centrifuge at 2000 rpm for 10–20minutes and pour

off serum. If no centrifuge is available, place sample in refrigerator overnight (4–6 hours) and pour

off the serum for transport in a clean glass tube.

57

• Do not attempt this in case of suspected viral hemorrhagic fever unless you are a clinician/

laboratory technician experienced in management of the disease. Full protection and infection

control measures must be taken.

• If the specimen will reach the laboratory within 24 hours, most pathogens can be recovered from

blood cultures transported at ambient temperature. Keep at 4–8 °C for longer transit periods,

unless the bacterial pathogen is cold-sensitive.

FECAL SPECIMEN COLLECTION:

Stool specimens are most useful for microbiological diagnosis if collected soon after onset of

diarrhea (for viruses <48 hours and for bacteria <4 days), and preferably before the initiation of

antibiotic therapy. If required, two or three specimens may be collected on separate days. Stool is

the preferred specimen for culture of bacterial, viral and parasitic diarrheal pathogens. Rectal swabs

showing feces may also be used from infants but are not useful for the diagnosis of viruses.


• Tubes with Cary-Blair transport medium

• Clean, dry, leak-proof, screw-cap container and tape if Cary-Blair transport medium is not

available.

• Appropriate bacterial transport media for transport of rectal swabs from infants (ideally Cary-

Blair).

• Parasitology transport pack: 10% formalin, polyvinyl isopropyl alcohol (PVA).

Method of collection: stool specimen:

If Cary-Blair transport medium is available:

• Place sterile swab in freshly passed stool to allow it soak up stool.

• Place swab in the Cary-Blair transport medium inside the tube.

• Break off the top part of the stick without touching the tube and tighten the screw cap firmly.

• Label the specimen tube.

If CARY-BLAIR transport medium is not available, collect freshly passed stool, 5 ml liquid or 5 g

solid (pea size), in a container. Label the container.

Method of collection: rectal swab from infants:

• Moisten a swab in sterile saline.

• Insert the swab tip just past the anal sphincter and rotate gently.

• Withdraw the swab and examine to ensure that the cotton tip is stained with feces.

• Place the swab in sterile tube/container containing the appropriate transport medium.

• Break off the top part of the stick without touching the tube and tighten the screw cap firmly.

• Label the specimen tube.

58


• Stool specimens should be transported in a cold-box at 4–8 °C. Bacterial yields may fall significantly

if specimens are not processed within 1–2 days of collection. Shigella is particularly sensitive to

elevated temperatures. If transport medium is not available, do not allow specimen to dry – add

few drops of 0.85% sodium chloride solution.

• Specimens to be examined for parasites should be mixed with 10% formalin or PVA, 3 parts stool

to 1 part preservative. Transport at ambient temperature in containers sealed in plastic bags.

CEREBROSPINAL FLUID (CSF) SPECIMEN COLLECTION :

The specimen must be taken by a physician or a person experienced in the procedure. CSF is used

in the diagnosis of viral, bacterial, parasitic and fungal meningitis/encephalitis.


A lumbar puncture tray should be used that includes:

• sterile materials: gloves, cotton wool, towels or drapes, local anesthetic, needle, syringe

• skin disinfectant: 10% polyvidone iodine or 70% isopropanol

• two lumbar puncture needles, small bore with stylet

• six small sterile screw-cap tubes and tube rack

•water manometer (optional)

•microscope slides and slide boxes

Method of collection:

As only experienced personnel should be involved in the collection of CSF samples, the method

is not described here. CSF is collected directly into the separate screw-cap tubes. If the sample is not

to be promptly transported, separate samples should be collected for bacterial and viral processing.


In general, specimens should be delivered to the laboratory and processed as soon as possible.

CSF specimens for bacteriology are transported at ambient temperature, generally without

transport media. They must never be refrigerated, as these pathogens do not survive well at low

temperatures.

CSF specimens for virology do not need a transport medium. They may be transported at 4–8 °C

for up to 48 hours or at –70 °C for longer periods.

59

Appendix 11

Outbreak Response Plans for Priority Diseases/Conditions

60

Surveillance:Surveillance is essential for early outbreak detection and timely response. Surveillance data

includes information about the persons affected by the outbreak – the traditional epidemiological

triad of “time, place, and person”. It may also be useful to collect additional data such as place of

residence, recent movement (into or out of the camp or region) and secondary attack rate. Regular

reviews of available information on previous outbreaks, prevailing risk factors, and other data

sources such as health information systems should be done to determine whether an outbreak is

likely. Surveillance sites can include health facilities (hospitals and health posts) and the broader

communities. Environmental surveillance may also be necessary to identify communities at risk

and ensure they are informed about sources of contamination and ways to avoid infection.

Basic Control and Prevention Measures:• Educate the community and promote awareness about sources of contamination and ways to

avoid infection

• Observe basic principles of sanitary human waste disposal, particularly protecting water sources

• Practice basic hygiene (i.e. thorough hand washing)

• Implement active case finding when needed

• Protect contacts of cases and health care staff

• Implement immunization campaigns when needed

• Isolate cases where indicated (Pertussis, Measles)

• Ensure proper collection and handling of specimens

• Utilize protective materials (i.e. gloves for RVF)

• Protect against mosquito bites

Detection:

� Routine surveillance

� Alert threshold exceeded, alert verified

� Activate outbreak control team

Response:

� Notify required officials

� Complete Outbreak Investigation Form

Investigation and Confirmation:

� Active case finding

� Laboratory confirmation of cases and contacts

� Epidemiologic investigation (descriptive data, mode of transmission, risk factors, etc.)

61

Control:

� Ensure case reporting

� Follow lead of outbreak control team

� Prevent exposure and infection

� Treat cases according to guidelines

Evaluation:

� Assess timeliness or detection and response

� Provide recommendations to improve performance in future outbreaks

If the alert threshold is exceeded, immediate action should be taken. In general, the steps in the

management of a communicable disease outbreak (outlined below) should be followed.

62

63

Appendix 11-1

Acute Bloody Diarrhoea (Suspected Shigellosis)

64

Acute Bloody Diarrhoea (Suspected Shigellosis):

Case Definition:

≥3 abnormally loose or fluid stools in the past 24 hours) with visible blood in stool (preferably

observed by the clinician).

Basic Facts:

• Bacillary dysentery is an acute bacterial disease involving the large and small intestines. It is the

most important cause of acute bloody diarrhoea.

• Two-thirds of cases and most deaths occur in children aged less than 10 years.

• Of the four Shigella serogroups (S. dysenteriae, S. flexneri, S. sonnei and S. boydii), S. dysenteriae

type 1 (Sd1) causes the most severe disease and is the only cause of large-scale epidemics.

Shigella dysenteriae type 1:

�Most severe in young children, the elderly and malnourished.

�Displaced populations are at high risk in situations of overcrowding and poor sanitation/water.

�High risk patients include children under 5 years and especially infants, children who are

malnourished and those that have had measles within the last 6 weeks. Other high risk groups

include older children and adults that are malnourished, patients that are severely dehydrated

and adults over 50 years of age.

�Transmission is by faecal–oral route from person to person and through contaminated food and

water. Transmission by flies has been implicated in some Shigella outbreaks.

�Highly contagious: as few as 10–100 bacteria have caused disease in volunteers.

�Treatment is with antimicrobials, which reduce severity and duration of illness. Monitoring of

antimicrobial susceptibility is important as Sd1 is frequently resistant.

�Not usually associated with marked loss of fluid and electrolytes.

�Without prompt effective treatment, case-fatality rate can be as high as 10%.

�As infectious dose is low, shigellosis is associated with high secondary attack rates.

65

Clinical Features:

• Causes bloody diarrhoea often associated with fever, abdominal cramps and rectal pain.

• Incubation period usually 1–3 days, but may be up to 1 week.

• Complications include hemolytic uraemic syndrome, seizures, sepsis, and rectal prolapse and

toxic megacolon.

• Diagnosis is by observing blood in a fresh stool specimen or asking the patient or mother of a child

whether the stools are bloody.

Diagnosis:

• Diagnosis confirmed by isolation of Shigella dysenteriae type 1 (Sd1) from stool samples.

Collection and Transport of Specimens:

1. Within 4 days of illness onset, collect a fresh stool sample including portions with blood and/or

mucus from suspected cases.

2. Whole stool samples should be collected as soon as possible and before administration of

antibiotics for eligible patients. If a stool specimen cannot be obtained, a rectal swab should be

done.

3. Fresh stool should reach the lab within 2 hours; if this is not possible, place samples in Cary-Blair

transport media and refrigerate at 4⁰ C. Samples should be cultured within 48 hours of collection.

4. Properly label the specimen with name, date of birth, health facility name, and date of collection.

5. All stool samples and rectal swabs should be sent to the pre-identified laboratory Laboratory

Name: .......

6. The specimens should be packaged in accordance with the guidelines for the transport of

dangerous biological goods (triple packaging using absorbent material).

7. Specimens should be transported in a cold box at 4 degrees C.

Resources Needed:

� Screw-top cups for whole stool collection

� Screw-top tubes of Cary-Blair media

� Dry, cotton-tipped rectal swab (moisten in sterile Cary-Blair media before inserting into anus).

� Designated cold chain for culture transport and an adequate number of ice packs. The kit

should consist of at least one cold box (e.g. vaccine carrier) and four ice packs.

� Readily available communication to the laboratory for communication of results

Outbreak Response:

1. Immediately refer severe cases of bloody diarrhoea or those with increased risk of death

including children under 2 years, adults over 50 years, or individuals with malnutrition to the

health facility.

2. Initiate active case finding through community leaders.

66

a. Refer any case of bloody diarrhoea found in the community to the health facility.

3. Establish a line list at facility and community level.

a. Send weekly summaries of line lists by email to DLO, who will forward it to CLO

4. Prophylaxis with antibiotics among contacts is NOT recommended as this can increase rates of

resistance.

5. Use of anti-motility agents (e.g., loperamide) with dysentery patients is NOT recommended as

this can prolong illness.

6. Immediately report any deaths associated with suspected shigellosis to the CLO.

7. Complete Outbreak Investigation Form

Public Health Awareness and Education:

• Inform community of outbreak through identified community leaders

• Conduct health education activities for community on signs and symptoms, what to do when sick,

and how to avoid infection

• Train community leaders including religious leaders on simple signs and symptoms to assist in

community surveillance and referral from the community level to the health facilities.

• Hand-washing with soap is a key prevention measure. Ensure regular distributions of soap

(250g/person/month; in addition to soap for laundry).

• Provide the community with messages on the importance of hand washing with soap

• Promote cooking food well, keeping it covered, eating it hot, and peeling fruits and vegetables.

• Ensure the safe disposal of human waste by always using latrines.

• Encourage continuation of breastfeeding of infants and young children

• Ensure safe and clean drinking water is available

• Implement fly control measures such as the covering of latrines, storage of food in covered

containers

• Implement disinfection of public or community latrines with chlorine solution (0.2%)

Health Facility Interventions:

� Provide plenty of water and soap for hand-washing, preferably in easily accessible, highly

visible locations

� Wash hands with soap before and after examining each patient

� Ensure that health workers who care for dysentery patients (or other diarrhoea patients) do not

prepare or serve food

� Dispose of stools of dysentery patients in a latrine or toilet (if this is not possible, bury them)

� Wash and disinfect the clothes and bed linen of dysentery patients frequently.

67

Funerals:

• Promptly and thoroughly disinfect a patient’s clothing, personal articles and immediate

environment using chlorinated lime powder, 2% chlorine solution, and a 1-2% solution of phenol.

• Wash clothes thoroughly with soap and water and then boil or soak them in a disinfectant

solution. Dry clothes in direct sunlight

• Wash utensils with boiling water or disinfectant solution; Do not wash materials in rivers or

ponds

• Hold funerals of persons who die with diarrhoea quickly and close to the place of death.

68

69

Appendix 11-2

Acute Watery Diarrhoea: Suspected Cholera

70

Acute Watery Diarrhoea: Suspected Cholera:

Case Definition:

Age ≥ 5 with sudden onset of acute watery diarrhoea with severe dehydration or death with or

without vomiting.

Basic Facts:

• Cholera is an acute bacterial enteric disease with profuse watery stool.

• It is caused by a Gram-negative bacillus Vibrio cholerae, which produces a powerful enterotoxin

that causes copious secretory diarrhoea.

• Transmission is by the faecal–oral route. Infection results from ingestion of organisms in

contaminated water or food, or to a lesser extent from indirect person-to-person contamination

(unwashed hands).

• Particularly vulnerable groups for cholera include individuals that are malnourished and those

living with HIV/AIDS.

• Acute carriers, including those with asymptomatic or mild disease, are important in the

maintenance and transmission of cholera. Patients discharged from a cholera treatment center can

still transmit cholera.

• Cholera is asymptomatic in about 75% of infected cases.

• Attack rates in displaced populations can be as high as 10–15%; in normal situations, it is estimated

at 1–2%.

• Mass chemoprophylaxis and cordon sanitaire are generally ineffective in controlling an outbreak

and are not recommended.

• Rehydration with appropriate fluids is chief in reducing mortality.

• Case-fatality rates (CFR) can be as high as 40% if untreated.

• With appropriate treatment (oral rehydration salts [ORS] in most cases), the CFR can be reduced

to 1% or less.

71

Clinical Features:

• Incubation period is less than 1 day (symptom onset within several hours) to 5 days.

• Onset of symptoms is abrupt, with copious watery diarrhea, classic “rice-water” stool with or

without vomiting.

• Vomiting without associated nausea may develop, usually after the onset of diarrhoea.

• Fluid loss can lead to rapid and profound dehydration, low serum potassium and acidosis.

• Severe dehydration leads to loss of skin turgor, malaise, tachypnoea and hypotension.

• Fever is unusual, except in children.

Diagnosis:

• Confirmed through isolation of Vibrio cholera from stool specimens or rectal swab

• Rapid diagnostic tests (RDT) allow quick testing at the patient’s bedside, all positive RDTs should

then be culture-confirmed.


• Whole stool samples should be collected as soon as possible and before administration of

antibiotics for eligible patients. If a stool specimen cannot be obtained, a rectal swab should be

done.

• Fresh stool collected at health facilities should reach the lab and be refrigerated within 2 hours; if

this is not possible, place 2 stool swabs in Cary-Blair transport media and ensure they reach the

lab as soon as possible.

• Stool swabs properly stored in Cary-Blair transport media can culture V. cholera up to 7 days after

collection, but for outbreak detection purposes, identification should proceed quickly.

• Properly label the specimen with name, date of birth, health facility and date of collection.

72

• All stool samples and rectal swabs should be sent to the pre-identified laboratory

• Depending on availability, the hospitals may use rapid diagnostic tests for Vibrio cholerae from

the stool specimen of patients with AWD and severe dehydration before forwarding it for culture.

• The specimens should be packaged in accordance with the guidelines for the transport of


• Specimens should be transported in a cold box at 4 degrees C.

• Once an outbreak has been confirmed it is not necessary to collect specimens for all suspect cases.

However, additional specimens should be tested over the course of the outbreak for antibiotic

sensitivity testing.

Resources needed::

�Screw-top cups for whole stool collection

�Screw-top tubes of Cary-Blair media

�Dry, cotton-tipped rectal swab

�Designated cold chain for culture transport and an adequate number of ice packs. The cholera

kit should consist of at least one cold box (e.g. vaccine carrier) and four ice packs.

�Readily available communication to the laboratory for communication of results

Outbreak Response:

• Immediately bring a suspected cholera case to the health facility

• Treat with (ORS) immediately before administration of antibiotics

• Obtain stool specimens at the first opportunity (before antibiotics are given)

• Initiate active case finding through community leaders

• Refer any case of suspected cholera/acute watery diarrhoea found in the community to the health

facility

• Inform the community and encourage them to report suspected cases promptly

• Establish a line list of all cases at health facility and community level

• Provide relatives and/or caretakers of patients with ORS, soap, disinfectant (0.2% chlorine) and

hygiene education to allow them to protect themselves and relatives

• Communicate with Water, Sanitation, and Hygiene (WASH) sector in the Outbreak Control Team

to implement control measures. Information on locations of new cases should be promptly shared

with the Outbreak Control Team.

• Immediately report any deaths associated with suspected cholera to the CLO

• Complete Outbreak Investigation Form

Prevention

� Ensure adequate disinfection of all drinking water supplies. Water providers should target a

73

concentration of 1.0 mg/l of free residual chlorine at all tap stands during a cholera outbreak

� Monitor levels of chlorine residual on daily basis from a sample of points in each distribution

system and all tankered water.

Public Health Awareness and Health Education:

• A multidisciplinary approach based on prevention, preparedness and response, along with

an efficient surveillance system, is key for mitigating cholera outbreaks, controlling cholera in

endemic areas and reducing deaths

• Work with Outbreak Control Team and CLO to develop appropriate communication strategies

and engage the community

• Intensify the free flow of information from the DLO to avoid panic in the community

• Key to reducing mortality from cholera is prompt rehydration. Suspect patients should seek care

as soon as possible. If unable to reach a health facility, rehydration with ORS should be initiated

at household level

• Health education activities for community members on topics including hand washing, sanitation,

safe food preparation and storage, and hygiene

5 Basic Cholera Prevention Messages:

� Drink and use safe water

� Wash your hands often with soap and safe water

� Use latrines or bury your feces; do not defecate in any body of water

� Cook food well, keep it covered, eat it hot, and peel fruits and vegetables

� Clean up safely—in the kitchen and in places where the family bathes and washes clothes

• Special attention should be given to ensure proper hygiene and sanitation in markets, restaurants

and other establishments that prepare food

• Encourage continuation of breastfeeding for infants and young children.

Health Facility Interventions:

Supplies and equipment:

� Establish a system to monitor use of buffer and emergency stocks and ensure their prompt

replacement.

� Determine emergency supply requirements and assign individuals to coordinate their

procurement and distribution

� Supplies and equipment needed have been calculated on an attack rate of 0.2, that is 200 cases

may be expected to occur in a population of 100,000.

� This is only for calculating initial stocks to cope with the beginning of an epidemic of cholera.

� A review based on weekly actual figures will help to reassess actual needs and prompt

replacements

Infection risk reduction and isolation:

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• Isolate patients being treated to limit the spread of infection

• If needed, establish a functioning Cholera Treatment Centre (CTC) to relieve pressure on the

hospital

• See WHO Communicable Disease Control in Emergencies. A Field Manual, Annex 7 page 236 for

organization of an isolation centre, essential rules in a CTC, and disinfectant preparation)

• MSF manual at ____

• Apply standard precautions (hand-washing stations with chlorine solutions, safe disposal of

contaminated articles) as well as enteric precautions. Adapt from the following website:

http://www.wsha.org/files/82/ContactEntericPrecautions.pdf

Funerals :

• Funerals should be held quickly and near the place of death.

• Those who prepare the body for burial must be meticulous about washing their hands with soap

and clean water. Persons handling the body should not be involved in food handling for 24 hours

and wash hands thoroughly with soap under running water or with 0.05% chlorine solution

• Bodies should be disinfected with a 2% chlorine solution and the orifices blocked with cotton

wool soaked in 2% chlorine solution; they must then be buried in plastic sacks as soon as possible.

• Disinfect the clothing and bedding of the deceased by stirring them in boiling water or by drying

them thoroughly in the sun

http://www.wsha.org/files/82/ContactEntericPrecautions.pdf

75

Appendix 11-3

Acute Jaundice Syndrome

76

Acute Jaundice Syndrome:

Case Definition:

• Acute onset of jaundice (yellowing of whites of the eyes or skin or dark urine), AND

• Severe illness with or without fever , AND

• Absence of any known precipitating factors

Alert threshold:


Basic Facts:

• Acute jaundice syndrome can be caused by many different diseases including (yellow fever,

leptospirosis, and acute hepatitis). Hepatitis A and E are more epidemic prone in acute

emergencies and likely exist in Syria.

• Outbreaks of hepatitis A and hepatitis E have been documented in refugee and internally

displaced person camps

• Clusters of cases of acute jaundice should lead to epidemiological investigations to exclude

transmissible diseases with important public health implications.

• Both are spread by faecal-oral route from contaminated food and water.

• Both can cause fulminant hepatitis, however this is rare for hepatitis A.

• Hepatitis E can have a mortality of up to 20% in pregnancy.

Clinical Features:

• Can range from asymptomatic infection, acute uncomplicated jaundice and fulminant hepatitis

• Signs and symptoms of viral hepatitis include jaundice with yellowing of eyes and dark-colored

urine, loss of appetite, an enlarged tender liver, abdominal pain and tenderness, nausea and

vomiting, moderate fever

• Careful clinical examination should detect other causes of jaundice possibly requiring specific

treatment (e.g. surgery and antimicrobial or anti-parasitic therapy for obstructive jaundice).

Diagnosis:

• Laboratory serologic diagnosis of hepatitis A and E can be done with IgM antibodies from a blood

sample


• Collect 5 ml blood by venipuncture in a sterile tube labeled with patient identification and

collection date.

• Whole blood should be centrifuged at 1000g for 10 minutes to separate the serum.

• If there is no centrifuge the blood should be kept in a refrigerator until there is complete retraction

of the clot from the serum.

• Blood can be stored at 4-8°C for up to 24 hours before the serum is separated. Do not freeze whole

blood.

http://en.wikipedia.org/wiki/IgM

77

• Carefully remove the serum, avoid extracting red cells, and transfer aseptically to a sterile labeled

vial.

• Properly label the specimen with name, date of birth, name of health facility, and date of collection.

• Store the serum at 4-8°C until shipment takes place.

• Serum should be sent to the pre-identified laboratory. Name of Laboratory.......



Outbreak Response:

1. Immediately refer case of Acute Jaundice Syndrome to the health facility.

2. Initiate active case finding (especially pregnant women) through community leaders

3. Establish a line listing at the facility

4. Immediately report any deaths associated with acute jaundice syndrome to CLO



• Inform community of outbreak through identified community leaders.


and how to avoid infection.

• Train community leaders (local council) on simple signs and symptoms to assist in community

surveillance and referral from the community to the health facilities.



• Provide the community with messages on the importance of hand washing with soap



• Encourage continuation of breastfeeding of infants and young children.

• Ensure safe and clean drinking water is available.

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79

Appendix 11-4

Severe Acute Respiratory Illness

80

Severe Acute Respiratory Illness:

Case Definition:

• Acute respiratory illness onset within the last 7 days with

� History of fever or measured fever (>38°C)

� Cough

� Requires hospitalization

Alert threshold:

≥ 5 cases in the same week in the same location OR double the weekly average OR 1 death

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Appendix 11-5

Acute Flaccid Paralysis (Suspected Poliomyelitis)

82

Acute Flaccid Paralysis (Suspected Poliomyelitis):

Case Definition:

• Any child < 15 years with acute flaccid paralysis, OR;

• Any paralytic illness in a person of any age if poliomyelitis is suspected (Not traumatic paralysis)

Alert threshold:1 case

Basic Facts:

• Polio (poliomyelitis) mainly affects children under five years of age.

• Highly infectious and caused by a virus that invades the nervous system.

• The virus spreads by direct person-to-person contact, by contact with infected mucus or phlegm

from the nose or mouth, or by contact with infected feces.

• The virus enters the body through the mouth and multiplies in the intestine.

• The incubation period ranges from 5 – 35 days with an average of 7 – 14 days.

• There is no cure for polio; it can only be prevented. Polio vaccine, given multiple times, can protect

a child for life.

• Cases have decreased over 99% since 1988, and only parts of four countries remain endemic for

the disease.

Clinical Features:

• In most cases (90%), polio may cause no symptoms and no sequalae.

• Initial symptoms are fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the

limbs.

• One in 200 infections leads to irreversible paralysis (usually in the legs). Among those paralyzed,

5% to 10% die when their breathing muscles become immobilized.

Diagnosis:

• A sample of throat secretions, stool, or cerebrospinal fluid can be cultured to confirm the diagnosis.

• A test for levels of antibodies to the polio virus can also be done.


• Collect at least 2 stool specimens taken 24 hours apart within 14 days of the onset of paralysis.

• Each specimen should be 8 grams – each about the size of one adult thumb and collected in a clean,

dry, screw-capped container. The container need not be sterile and no preservative/transport

media should be used.

• Properly label the specimen with name, date of birth, health facility, and date of collection.



• After the specimens are collected and labeled, transport them in the “cold chain” – on frozen ice

packs or ice, in a stool specimen carrier or a vaccine carrier specifically designated for this purpose

• Specimens will be sent to the pre-identified laboratory for testing Name of Laboratory:......

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Outbreak Response:

1. Initiate a full and rapid investigation

2. Implement the four core strategies to stop transmission

� High infant immunization coverage with four doses of oral poliovirus vaccine (OPV) in the first

year of life

� Supplementary doses of OPV to all children under five years of age during supplementary

immunization activities

� Surveillance for poliovirus through reporting and laboratory testing of all acute flaccid paralysis

(AFP) cases among children under fifteen years of age

� Targeted “mop-up” campaigns once poliovirus transmission is limited to a specific focal area

3. Report immediately by phone to CLO of deaths associated with poliomyelitis



• Inform community of outbreak through community leaders, health authorities.


community surveillance and referral from the block level to the health facilities.

• Health education activities for community on signs and symptoms and the importance of

vaccination.

• Provide messages on ways to reduce the spread of polio including improving public sanitation

and careful personal hygiene (proper hand washing, ensure safe food preparation, avoid contact

with infected individuals).

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85

Appendix 11-6

Suspected Measles

86

Suspected Measles:

Case Definition:

• A generalized rash

• AND fever

• And ONE of the following

� cough

� runny nose

� red eyes

• Any person in whom a clinician suspects measles

Alert threshold: 1 case

Basic Facts:

• Highly communicable viral infection transmitted through airborne spread of respiratory

droplets from person to person, or by direct contact with nasal and throat secretions of infected

persons, or via objects that have been in close contact with an infected person.

• Caused by the measles virus, which damages epithelial surfaces and the immune system.

• Can increase susceptibility to other infections such as those caused by the pneumococcus and

Gram-negative bacteria.

• Can lead to or exacerbate vitamin A deficiency, increasing susceptibility to xerophthalmia,

blindness and premature death.

• The most vulnerable age groups are children aged between 9 months and 5 years in developing

countries, but this depends on the immunization coverage rates.

• Complications develop in 5–10% of cases.

• Deaths are mostly the result of complications such as pneumonia, croup and diarrhea and are

frequently associated with malnutrition.

87

Clinical Features:

• Incubation period is usually 10 days from exposure to onset of fever.

• Initial symptoms and signs are high fever, rash, runny nose, cough, conjunctivitis; Koplik spots

(small white spots on the buccal mucosa) may be seen.

• Characteristic erythematous (red) maculo-papular (blotchy) rash appears on day 3−7, starting

behind the ears and on the hairline and then spreads to the rest of the body.

• Temperature subsides after 3–4 days and the rash fades after 5–6 days.

• Measles is highly infectious from the start of the prodromal period until approximately 4–5

days after the rash appears.

• Case-fatality rates are estimated to be 3–5% in developing countries but rates may reach as

much as 10–30% in displaced populations.

Diagnosis:

• Requires history of fever and rash, with at least one of the three C’s (cough, coryza, conjunctivitis)

• Observation of Koplik’s spots is also diagnostic of measles

• Laboratory diagnosis of measles can be done with confirmation of positive measles IgM antibodies

or isolation of measles virus RNA from respiratory specimens


• Measles outbreak must be confirmed by serum testing

• Collect 5 ml blood by venipuncture in a sterile tube labeled with patient identification and

collection date

• Whole blood should be centrifuged at 1000g for 10 minutes to separate the serum.

• If there is no centrifuge the blood should be kept in a refrigerator until there is complete retraction

of the clot from the serum.

• Blood can be stored at 4-8°C for up to 24 hours before the serum is separated.

• Do not freeze whole blood.

• Carefully remove the serum, avoid extracting red cells, and transfer aseptically to a sterile labeled

vial.

• Properly label the specimen with name, date of birth, health facility name, and date of collection

• Store the serum at 4-8°C until shipment takes place



• Alert the Central Level Surveillance Officer. The serum will be sent to the pre-identified laboratory.

Laboratory Name: ......

• In addition to the blood specimen, the Central Level Surveillance Officer/ Outbreak Control

Team may request the collection of nasopharyngeal (NP) swab specimen.

• Once measles IgM positive result is reported, no additional blood specimens are needed. Measles

http://en.wikipedia.org/wiki/IgM

88

outbreak shifts from suspected to confirmed

• If there have been recent vaccination campaigns, there might be false positives. It is important to

be aware of vaccination history and should include date of most recent measles vaccine when

specimens are sent for testing

Resources Needed:

� 5-ml vacutainer (non-heparinized) tube with a 23 gauge needle or sterile disposable syringe

and needle Tourniquet

� Sterilizing swabs

� Serum storage vials

� Specimen labels

� Band-aid

� Zip-lock plastic bags

� Specimen referral form

� Cold box with ice packs

Outbreak Response:

1. Initiate rapid assessment to determine the extent of the outbreak

2. Assess initial control measures and needs

3. Isolate patients

4. Initiate active case finding

5. Step up defaulter tracing and routine immunization activities

6. Send all identified complicated cases to hospital isolation facilities

7. Record pertinent details in the line listing at the hospital, health post and community level

8. Report immediately by phone to CLO of deaths associated with measles

9. Assess the need for supplementary immunization activities



• Initiate a communication plan to inform the community of the measles outbreak.


community surveillance and referral from the block level to the health facilities.

• Reinforce sensitization to the community leaders to advise new arrivals to report to health facilities

if symptomatic

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Appendix 11-7

Suspected Meningitis

90

Suspected Meningitis:

Case Definition:

• Any person with sudden onset of fever ≥ 38°C, AND ONE of the following signs:

� Neck stiffness

� A bulging fontanel (in a child < 1 year)

� Difficulty in suckling and irritation (in an infant < 2 months)

� Altered consciousness

� Petechial or purpural rash

� Fatigue or lethargy

� Convulsions:

• < 6 months- > 6 years: any convulsion crises (seizure)

• 6 months to 6 years: any long and localized convulsion crises or two or more generalized

Alert threshold: 1 case in a crowded camp setting;

� Population ≥30,000: 5 cases per week/100,000 population

� Population <30,000: 2 cases per week

Basic Facts:

• Meningococcal meningitis is a bacterial form of meningitis, a serious infection of the meninges

(thin lining that surrounds the brain and spinal cord).

• Bacteria are transmitted from person-to-person through droplets of respiratory or throat secretions.

• Close and prolonged contact –such as kissing, sneezing, or coughing on someone, or living in

close quarters, sharing eating or drinking utensils with an infected person facilitates the spread

of the disease.

91

• The average incubation period is 4 days (range: 2-10 days).

• 80% of cases of meningococcal meningitis occur in those under 30 years of age (in epidemics those

most at risk are six months to 30 years).

• Without appropriate treatment, the case-fatality rate in meningococcal meningitis can be as high

as 50%; with appropriate treatment this can be reduced to 5–15%.

• Attack rate during epidemics is around 500/100,000 persons.

Clinical Features:

• Sudden onset of intense headache, fever, nausea, vomiting, photophobia, stiff neck.

• Examine for common signs including: meningeal rigidity, i.e. neck stiffness, lethargy, delirium,

coma, purpura (characteristic sign of meningococcal septicemia) or symptoms of shock (low blood

pressure).

• In children aged <1 year, classic signs are rare; look for fever, diarrhea, vomiting, drowsiness,

convulsions, or bulging fontanels.

Diagnosis:

• Complete lumbar puncture for the first 25 cases during an epidemic to confirm diagnosis and

serogroup

• Once serogroup identified and confirmed, no need to do lumbar puncture on every case


• Collect 1 to 2 ml of CSF aseptically in 2 tubes (each tube containing at least 20 drops of CSF,

depending on the tests to be requested (gram stain, cell count, latex agglutination and culture)

• The first 25 cases will need gram stain, cell count and culture/sensitivity

• If a culture is planned reserve one sterile tube for this purpose

• Properly label the specimen with name, date of birth, health facility


dangerous biological goods (triple packaging using absorbent material)

• CSF should be sent for culture to pre-identified laboratory as soon as possible Name of Laboratory:

Outbreak Response:

• Refer all patients to hospital

• Ensure prompt and appropriate case management with oily chloramphenicol or ceftriaxone

• Chemoprophylaxis of contacts is not recommended in emergency situations

• Initiate active case finding and update outbreak linelist with identified suspect cases

• Decide whether a vaccine campaign is indicated, determine vaccine availability, and reactivate

campaigns as necessary

• Report immediately by phone to CLO of deaths associated with meningitis

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• Complete Outbreak Investigation Form


• Initiate a communication plan to inform the community of the outbreak.


community surveillance and referral from the community to the health facilities.

• Reinforce sensitization to the community leaders to advise new arrivals to report to health facilities

so that immunization status can be ascertained.

• Disseminate public health education messages to the community to inform them of ways to avoid

infection. Messages to include are:

� Information about how the disease is spread (person-to-person)

� Information about what to do when sick (seek medical care immediately; take appropriate

treatment)

� Proper and thorough hand washing with soap and water

� Practice “respiratory etiquette” by covering ones mouth when coughing, sneezing, or laughing

� Avoid sharing utensils that go in the mouth (like plates, cups, forks, water bottles)

� If a mass vaccination is initiated, inform the community about the importance of vaccination

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Appendix 11-8

Suspected Typhoid

94

Suspected Typhoid:

Case Definition:

• fever ≥ 38°C > days with (headache, malaise, anorexia, relative bradycardia, constipation or

• diarrhea, and nonproductive cough)or symptomatic case contacted with confirmed case

Basic Facts:

• Transmitted by food and water contaminated by faeces and urine of patients or carriers

• Shellfish, raw fruits and vegetables, contaminated milk and milk products have been vehicles

• Flies may spread organism to food, person to person transmission is uncommon

• Incubation period is usually 8-14 days (but can be from 3- 60 days)

• Period of communicability first week of illness until convalescence

• 10 percent of untreated patients shed the organism is stool for more than 3 months

Clinical Features:

• Typhoid fever typically presents with insidious onset of fever, headache, malaise,

• anorexia, dry cough, relative bradycardia and hepatosplenomegaly (50 percent).

• Less commonly, there may be rose spots on the trunk (30 percent of Caucasians), abdominal pain

(20–40 percent), constipation (38 percent), diarrhoea (10 percent) and cerebral dysfunction.

• Treat typhoid fever cases with antibiotics. More than 90 percent of patients can be managed

at home with oral antibiotics, reliable care and close follow up for complications or failure to

respond to therapy.

• Untreated may last for 3-4 weeks and complications include intestinal perforation (3-10 percent)

or haemorrhage, death (12-30 percent) or relapse (up to 20 percent).

Diagnosis:

• Diagnosis confirmed by isolation of Salmonella typhi from a blood culture


• Collect blood culture specimens and properly label with name, date of birth, health facility name

and date of collection.

• All blood culture specimens should be transported at room temperature to the pre-identified

laboratory. Laboratory Name: ......



Resources Needed:

� Skin disinfection: 70% alcohol (isopropanol, ethanol) or 10% proviodone iodine, swabs, gauze

pads, adhesive dressings.

� Disposable latex or vinyl gloves.

� Tourniquet, Vacutainer or similar vacuum blood collection devices, or disposable syringes and

needles.

95

� Blood culture bottles (50 ml for adults, 25 ml for children) with appropriate media.

� Labels and indelible marker pen.

Outbreak Response:

• Refer severe cases with persistent vomiting, severe diarrhoea and abdominal distention to the

health facility.

• Initiate active case finding through community health workers, hygiene promoters, and

community leaders.

• Establish a line list at facility and community level.

• Search for case/carrier that is the source of the outbreak and for the vehicle (water or food)

through which infection is transmitted.

• Identify areas/populations at high risk to identify source(s) and mode(s) of transmission in order

to prevent and control the disease.

• Support provision of clean water and proper sanitation to affected populations. Chlorinate

suspected water supplies. All drinking water should be chlorinated or boiled before use.

• Communicate with the Outbreak Control Team to implement control measures. Information on

locations of new cases should be promptly shared with the Outbreak Control Team.

• Discuss with Outbreak Control Team if there is a need for mass vaccinations.

• Immediately report any deaths to Central Level Surveillance Officer.

• Complete Outbreak Investigation Form.

• Send weekly summaries of line lists by email to DLO, who will forward it to CLO.


• Inform community of outbreak through identified community leaders

• Work with Outbreak Control Team and Central Level Surveillance Officer to develop appropriate

communication strategies and engage the community


how to avoid infection, the importance of hand washing with soap

• Conduct health education programmes on hygiene with simple messages on safe water, safe food

handling practices, hygiene and handwashing





• Encourage continuation of breastfeeding of infants and young children

• Intensify the free flow of information from the DLO to avoid panic in the community

• Special attention should be given to ensure proper hygiene and sanitation in markets, restaurants

and other establishments that prepare food

96

97

Appendix 11-9

Cutaneous leishmaniasis

98

Cutaneous leishmaniasis:

A person showing clinical signs (skin lesions). A papule appears, which may enlarge to become

an indolent ulcerated nodule or plaque. The sore remains in this stage for a variable time before

self healing and typically leaves a depressed scar. Other atypical forms may occur.

Basic Facts:

• The causing agent of cutaneous leishmaniasis is a single-celled parasite called Leishmania.

• Leishmania parasites are transmitted from animal to animal, from human being to human being

or from animal to human being by a tiny 2–3 mm-long insect vector, the phlebotomine sandfly.

Only the female sandfly bites vertebrates and can therefore transmit the parasite.

• Epidemics of cutaneous leishmaniasis are often associated with migration and the introduction of

non-immune people into areas with existing transmission.

• Poverty increases the risk for leishmaniasis in many ways. Poor housing and sanitary conditions

may increase sandfly numbers.

• The procedure used to find parasites in lesions is important in order to reduce discomfort and

enhance the probability of confirming the diagnosis.

• Many different therapeutic interventions, including local, systemic and physical treatments have

been used and tested in cutaneous leishmaniasis.

Clinical Features:

A clinical history suggestive of cutaneous leishmaniasis is characterized by the appearance of

one or more lesions, typically on uncovered parts of the body. The face, neck, arms and legs are the

commonest sites.

In localized cutaneous leishmaniasis, a typical lesion starts as a raised papule at the site of

inoculation. It grows over several weeks to reach a final size of a nodule or a plaque.

If left without therapy, lesions usually heal gradually over months or years, usually leaving a

depressed scar.

99

Diagnosis:

• Positive parasitology (stained smear or culture from the lesion).

• Mucocutaneous leishmaniasis only: positive serology (indirect immunofluorescent antibody

test, enzyme-linked immunosorbent assay).

• Polymerase chain reaction (more sensitive than microscopic examination).


Skin sampling is taken as following:

� Clean the whole lesion and border using 70% alcohol at least 3 minutes before injecting the

anaesthetic.

� Inject 0.1–0.5 ml of lidocaine with adrenaline, using a short 23-gauge needle thereby creating

a blanching area. It is not necessary to anaesthetize the whole lesion. For lesions on fingers or

toes use lidocaine without adrenaline (necrosis risk).

� Pinch strongly the lesion to further prevent bleeding.

� Remove the crust, remove blood with a gauze, scratch firmly (using a sterile scalpel with a

short angle curved blade) the border and the centre of the lesion until tissue material is visible

on the blade .

� Gently move the blade on the surface of a slide to deposit a thin layer of the scraped material.

� Repeat the procedure on different parts of the anaesthetized zone until at least half of the

surface of each of three slides is covered with material.

� Dry the three slides at room temperature.

� Fix the slides and stain them with Giemsa according to validated procedures (see below).

Procedure of Giemsa staining:

� Fix air-dried slides in methanol . � let slides to dry in air.

� Stain with diluted Giemsa stain (1:20 vol/vol) for 20 minutes.

� Wash by briefly dipping the slides in a jar of buffered water.

� Let air dry.

� Examine the slides under the microscope (100× oil immersion lens).

� Read smears for at least 20 minutes (1000 fields)

� A smear can be reported positive when at least two amastigotes are observed.

100

Materials:

� Reagents: Giemsa stain and Giemsa buffer.

� Supplies: glass slides, alcohol washed, glass marker

� Equipment: microscope, binocular with mechanical stage; low (10×), high dry (40×) and oil

immersion (100×) lens.

Outbreak Response:

• Early case detection and treatment are the most important control measures for leishmaniasis.

• Treatment reduces or eliminates parasite loads, and this in turn reduces transmission.

• In severe situations such as epidemics and highly endemic areas vector control is also used. It

consists of house spraying or the use of insecticide-impregnated bed nets.


Social mobilization and strengthening partnerships – mobilization and education of the

community with effective behavioral change interventions with locally tailored communication

strategies. Partnership and collaboration with various stakeholders and other vector-borne disease

control programmes is critical at levels.

To Contact Us:

[email protected]

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A FIELD MANUAL - وحدة تنسيق الدعم | ACU | · A FIELD MANUAL Roles and ... Poliomyelitis) Appendix 11-6 ... In particular, epidemic-prone diseases can be a major cause