disease surveillance bulletin...volume 3 1 3rd quarter (july-september) 2015 1. surveillance of...

DISEASE SURVEILLANCE BULLETIN

Volume 1 1 1st Quarter (January – March) 2015

Contents Page No

Surveillance of Diarrhea Etiologic Agents among children under 5 years

1 - 2

Surveillance of Multi Drug Resistance 2 – 4

Influenza Surveillance 4 - 8

Measles and Rubella Surveillance 8 - 9

Acute Encephalitis Syndrome Surveillance 9

Leptospirosis Surveillance 9 - 10

Scrub Typhus 10

HIV Confirmation 10 - 11

Surveillance on Urban Drinking Water 11 - 14

External Quality Assessment Programme 14 - 16

Summary of Disease Outbreaks Report 16

Summary of National Notifiable Diseases 17

Third Quarter 2015

Department of Public Health Ministry of Health www.phls.gov.bt

PUBLIC HEALTH LABORATORY


Volume 3 1 3rd Quarter (July-September) 2015

1. Surveillance of Diarrhea Etiologic

Agents among children under 5 years

A total of 357 samples were collected from children

below five years who presented with diarrhea from

JDWNRH. All the samples were subjected to different

Microbiological methods to identify the diarrheal

etiologic agents (Microscopy, Culture, Multiplex

Polymerase Chain Reaction, Antimicrobial

Susceptibility Test and ELISA).

1.1 Microscopy

Microscopic examination of stool specimens was able

to detect some parasites, most commonly Giardia cyst

and Taenia species.

1.2 Culture/Isolates

Five different types of organism were isolated from

357 samples, all of which were subjected to bio-typing,

sero-typing, geno-typing and antimicrobial

susceptibility test where necessary (Table 1).

1.3 Multiplex PCR.

A total of 170 isolates of both LF and NLF Escherichia

coli were subjected to multiplex PCR to confirm and

differentiate the strains of Diarrheagenic E-coli

(Figure 1). The commonly genotyped Diarrheagenic

E-coli are Enteroagregative E-coli and

Enterotoxogenic E-coli.

1.4 Antimicrobial susceptibility test (AST)

Antimicrobial susceptibility testing showed that of all

Shigella species 89% (n=9) were resistant to

Sulfamethoxazole and 67% to Ciprofloxacin but 100%

susceptible to Ceftriaxone. Other bacterial isolates

(Salmonella) were found susceptible to Ampicillin,

Sulfamethoxazole and Ceftriaxone. Diarrheagenic

E.coli showed resistance to Ampicillin but were

susceptible to Ceftriaxone, Ciprofloxacin and

Tetracycline (Table 2).

1.5 ELISA

Test result for enteric viruses (rotavirus, norovirus and

adenovirus) are still pending due to shortages of test

kits.

Table 1: Common organism isolated

Organism isolated Total

Shigella 9

Campylobacter spp. 5

Salmonella 1

LF E-coli 118

NLF E-coli 52

Figure 1: Multiplex PCR showing different Diarrheagenic E-

coli

56%

9%

9%

20%

6%

EAEC

EIEC

EPEC

ETEC

STEC



Table 2: Antibiotic Susceptibility pattern of bacterial isolates

Isolates AMX CIP SXT CRO NAL GEN CHL TCY

Shigella S 2 5 9 2 9 7 1

(N=9) I 1 1

R 7 4 8 0 6 2 8

Salmonella S 1 1 1 1 1 1 1 1

(N=1) I

R

EAEC S 4 11 11 15 3 15 16 13

(N=19) I 1 2 1 1 1 1

R 14 8 6 3 15 3 3 5

EIEC S 1 3 2 3 3 3 3 3

(N=3) I

R 2 1

EPEC S 1 3 2 3 2 3 3 1

(N=3) I

R 2 1 1 2

ETEC S 3 4 6 6 3 7 7 5

(N=7) I

R 4 3 1 1 4 2

STEC S 1 1 1 1

(N=2) I

R 2 2 1 1 2 1 1 2

S = Susceptible, I = Intermediate, R = Resistant

AMX: Amoxycillin, CIP: Ciprofloxacin, SXT: Sulfamethoxazole,

CRO: Ceftriaxone, NAL: Nalidixic acid, GEN: Gentamycin,

CHL: Choloramphenicol, TCY: Tetracycline.

2. Surveillance of Multi Drug

Resistance Tuberculosis

a. Culture & Drug Susceptibility Testing

A total of 144 patient sputum samples were received

for culture and Drug Susceptibility Testing (DST) at

National TB Reference Laboratory (NTRL), among

which 73 were culture positive, 9 culture negative, 3

contaminated and rest are under incubation. 202 extra-

pulmonary (EPTB) samples were also processed for

MTB culture among which 15 were culture positive,

71 negative, 19 contaminated and rest are under

incubation.

DST was completed for 44 samples (PTB) and 4

samples (EPTB). 5 confirmed MDR-TB cases from

PTB and 2 confirmed MDR-TB cases from EPTB

were reported for the given period.

Apart from routine sample processing for culture and

DST, NTRL has received and processed 140 patient

samples for MDR-TB culture follow-up and 7 patient

samples for ruling out TB by culture for the purpose of

medical certificate.

Table 3: Number of TB cases among different types of TB

Pulmonary TB

Extra -

PTB New

Sme

ar

Posit

ive

New

smear

Negative

Re-

treatment

/ Failure

Relapse

Unknow

n

Sample

received

for culture

& DST

100 12 3 9 20 202

Culture

Positive

60 2 1 1 9 15

DST

completed

33 1 1 1 8 4

MDR-TB

detected

4 0 1 0 0 2



Figure 2: Number of samples received for culture & DST from hospitals

Figure 3: Type samples received for culture & DST

Descriptive analysis of MDR-TB cases

Seven MDR-TB cases were confirmed by NTRL in the

third quarter of 2015, among which four were new

smear positive, one retreatment and two extra

pulmonary cases. The MDR-TB cases were reported

among the productive age group (21 to 48 years) and

the youngest one is 11 years old. Sex ratio show more

number of MDR-TB being reported among Female

(71.4%).

Table 4: Number of MDR-TB case reported from hospitals

Name of the Hospital Numbers

JDWNRH 6 (including EPTB)

Samdrup Jongkhar 1

Total 7

0 13 2

0 0 0 0 0 1

11

36

1 02 2

5 40

47

16

0 0 15

11

20

40 0 0 1 0

0

5

10

15

20

25

30

35

40

45

50Total sample received from various hospital

Totalsamplereceivedfromvarioushospital

No

. of

sam

ple

s

Districts Hospitals

138

16

13

13

6

12

FNAC

Urine

Pus

Pleural Fluid

Ascitic Fluid

Biopsy

Different type of sample



Figure 4: MDR-TB cases among different categories

Figure 5: Sex distribution of MDR-TB cases

Figure 6: Age Distribution for MDR-TB cases

3. Influenza Surveillance

3.1 Influenza Like-Illness Surveillance (ILI) –

Epidemiological Component

Out of total 95,518 OPD visits at seven sentinel sites

(Paro, Punakha, Samtse, Trongsa, Tsirang,

Trashigang and SamdrupJongkhar hospitals); a

cumulative of 2,870 ILI visits had been recorded for

this quarter. Average ILI incidence was 30 cases per

1000 outpatient visits (Figure 7). The highest ILI

cases among sentinel sites was detected in Paro

Hospital (1637 cases) followed by Trongsa Hospital

(344 cases).

4

1

2

NSP

Retreatment

EPTB

MDR -Tb

1

3

1 1

0.0

1.0

2.0

3.0

10-14 15-19 20-24 25-28 29-32 33-37 38-42 42-47 48-52 53-56 57-61

Age Range for MDR TB

Age Range

No

of

MD

RTB

0

2

4

6

Female Male

5

2

sex distribution

sex distribution

N0

. of

MD

R-T

Bca

ses

Sex



Figure 7: Average number of ILI cases reported for the 3rd Quarter (week 27 to 39); (Data source: Online weekly reporting from

sentinel sites).

ILI cases, as usual, were commonly observed in age

group of 5-14 years (30.56%) (Table 5).

Table 5: Distribution of ILI cases by age groups

Age (Years) ILI cases

Number Proportion (%)

0-1 118 6.29

2-4 242 12.91

5-14 573 30.56

15-29 566 30.19

30-64 300 16.00

65+ 76 4.05

3.2 Influenza Like-Illness Surveillance –

Virological Component

Out of 459 ILI samples received and tested by RT-

PCR, 8.71 % (40/459) were positive for Influenza

virus, which comprises of Influenza A pandemic

2009 (A/pdm H1) –55% (22), A/H3 strain -10% (4);

Flu B- 35% (14). Number of specimens positive for

various influenza subtypes by week is illustrated in

Figure 7.

Like in the second quarter, this quarter also had

A/pdm H1 subtype as the most predominantly

circulating influenza virus strain in Bhutanese

population followed by Influenza B (Figure 8).

Influenza A/pdm H1 cases were mostly detected

from western region sentinel sites (Figure 9).

A high positivity rate was detected among 5-14 years

age group (30%) and was mostly A/pdm H1 strain

(Figure 10).



Figure 8: Influenza virus subtype by week. (Data source: FluNet ( www.who.int/flunet ), GISRS)

Figure 9: Influenza virus subtype distribution by site

http://www.who.int/flunet



Figure 10: Influenza virus subtype and positivity rate by age group

3.3 Severe Acute Respiratory Illness Surveillance

(SARI) - Epidemiological Component

A total of 3961 in-patients were recorded across the

sentinel sites during this quarter (only relevant wards

included in Regional and National Referral Hospital).

Of these, 248 were SARI cases. Average SARI

incidence was 6 cases per 100 hospitalized patients

(Figure 11). The highest SARI cases were detected

in MRRH (44 cases) followed by Tsirang Hospital (39

cases). No death cases were reported from any of the

sites.SARI cases were commonly observed in children

of age group 2-4years of age (Table 6).

Table 6: SARI case distribution by age groups

Age Cases (Numbers) Proportion (%)

0-1 60 24.19

2-4 63 25.40

5-14 47 18.95

15-29 30 12.09

30-64 40 16.12

65+ 8 3.22

3.4 Severe Acute Respiratory Infection

Surveillance- Virologicalcomponent

Total of 181 throat swab specimens were received

from SARI cases across the sentinels sites. Mongar

Regional Referral Hospital collected the maximum

number of samples (35 samples) followed by Tsirang

Hospital (27 samples). The samples were tested for

influenza and other respiratory viruses like

Respiratory syncytial virus (RSV),human meta-

pneumo virus (hMPV) and Adenovirus.

Out of 181 samples, 4.97% samples tested positive for

Influenza Virus, (A/pdm H1- 3&A/H3-1&Flu B-5)

and 4.97% positive for (hMPV). However, none

tested positive for RSV and Adenovirus (Figure 12).

Most of the SARI cases were detected in the age group

less than 5 years and these cases were mostly due to

infection byhMPV (Table 7).

0.00

10.00

20.00

30.00

40.00

0

2

4

6

8

10

0-1 2-4 5-14 15-29 30-64 65+ unknown

Nu

mb

er o

f In

flu

enza

Po

siti

ves

Age group

Influenza positive by age distribution

A/pdmH1 A/H3 Flu B Percentage



Figure 11: No. of SARI cases reported weekly

Figure 12: Trend of influenza virus and other non-influenza virus

Table 7: Respiratory viruses detected according age groups

Age A/PdmH

1 (n*=3)

A/H3

(n*=1)

Flu B

(n*=5)

hMPV

(n*=9)

Total

0-1 1 0 3 4 8

2_4 1 1 1 2 5

5_14 0 0 1 1

15-29 0 0 1 1 2

30-64 0 0 0 2 2

65+ 1 0 0 0 1

n* = number of cases

4. Measles & Rubella Surveillance

Of the twenty eight samples tested for measles and

rubella, no samples tested positive for Rubella IgM.

However one sample tested positive for Measles

IgM in August and another in September (Table 8).

The cases were a 30 year old man and a one year old

female child, both samples were referred in from

Paro hospital. Repeat samples have been collected

and retested as positives. Throat swab has been

referred to NRL Thailand for confirmation. The

throat swab has tested positive and has been

identified as D8 genotype. This is the very first time

that measles virus isolated from Bhutan has been

genotyped.

0

10

20

30

40

50

0

1

2

3

4

5

27 28 29 30 31 32 33 34 35 36 37 38 39

Pe

rce

nta

ge P

osi

tive

No

. Po

siti

ve S

pe

cim

en

s

WeekA/H1 A/H3 A/pdm09 A/ unsubtype B

RSV hMPV Adeno Virus Positivity rate (%)



Table 8: Measles and Rubella Testing Report

5. Acute Encephalitis Syndrome

(AES) Surveillance

A total of 15 CSF has been received from JDWNRH

with none testing positive for JE-IgM but 3 serum

samples tested positive for the same. IDSL has tested

a total of 37 serum samples referred in from

JDWNRH, Gelephu, Punakha and Phuntsholing. No

positives were detected from sites other than

JDWNRH (Table 9).

Table 9: Number of samples tested for JE

Hospital Number of samples

Result Result

CS

F

Neg Eqi Po

s

Ser

um

N

eg

Eq

i

Po

s

JDWNR

H

15 15 0 0 30 25 2 3

Gelephu 0 0 0 0 4 4 0 0

Punakha 0 0 0 0 2 2 0 0

Phuntsho

ling

0 0 0 0 1 1 0 0

Total 15 0 0 0 37 32 2 3

Pos: Positive Equi: Equivocal Neg: Negative

6. Leptospirosis Surveillance

In Bhutan, clinical evidence for presence of

leptospirosis is apparent however, no systematic

surveillance has been conducted to establish the

presence of the disease and its prevalence. This

surveillance aims to determine the sero-prevalence

and serovars in circulation in human. The study

involves testing of blood from any patients more

than 2 years of age; history of exposure to animal

and or contaminated environment AND acute fever

(oral temp. ≥38°C, rectal temp. ≥38°C, axillary

temp. ≥37°C) / history of fever within 10 days with

headache, severe myalgia (particularly calf muscle)

and prostration associated with any of the following

symptoms: Conjunctival suffusion, anuria or

oliguria, jaundice, cough, haemoptysis and

breathlessness, haemorrhages, meningeal irritation,

Cardiac arrhythmia or failure, Skin rash or if

clinicians suspect a case.

IDSL tested 61 samples in the 3rd quarter of which 5

tested positive. The 2 positives from Samtse were of



people exposed to infected cattle. However, no

follow-up serum has been received for any of the

cases (Table 10).

Table 10: Number of samples tested for leptospirosis

Referring site Total samples Positive

1 JDWNRH 34 3

2 Samtse 17 2

3 Haa 01 0

4 Mongar 05 0

5 Punakha 02 0

6 S’jongkhar 01 0

7 Trashigang 01 0

Total 61 5

Note: Laboratory uses Rapid chromatographic tests, ELISA and

MAT (Microscopic agglutination test) to detect and confirm

cases of leptospirosis.

7. Scrub typhus

Scrub typhus sero-prevalence study is a nationwide

screening program for scrub typhus IgG, IgM and

IgA in subjects with undifferentiated fever. Many

scrub typhus cases have gone underdiagnosed or

misdiagnosed as typhoid fever or others mainly due

to the overlapping signs and symptoms. There is no

indicative study data that hints at the probable sites

of endemicity in the country. This epidemiological

surveillance study aims to understand locate the

regions of prevalence to enable interventions.

Sample collection, shipment and testing is currently

in progress. Samples are tested using principles of

ELISA and rapid chromatographic assays. Figure

13 shows the serum samples testing positive for

OrientiatsutsugamushiIgM (ELISA), IgA, IgM and

IgA (RDT)

Figure 13: Scrub typhus samples tested

8. HIV confirmation

IDSL has carried out 51 HIV confirmatory tests for

samples that has tested positive in their respective

referring centres (Figure 14) of which 24 were

confirmed positive by IDSL, using test kits other

than that used in the primary testing centres. The

HIV testing algorithm requires 2 out of 3 tests

positive/ reactive to interpret the final test a positive.

IDSL uses three testing principles namely (i) ELISA

(Genscreen), (ii) Gelatin particle agglutination

(Serodia) and (iii) rapid chromatographic assay

(Determine) for screening the referred serum

samples.

0 100 200 300 400

Gelephu

Mongar

Paro

S'jongkhar

Sarpang

Sipsoo

Samtse

372

70

53

20

109

18

12

6

0

1

8

1

10

2

Scrub typhus

Positive No. of sample tested



Figure 14: Total number of samples received and tested for

HIV confirmation

9. Drinking Water Quality

Monitoring 3rd Quarterly Report 2015

9.1 Microbiological Report

A total of 568 samples were collected and tested for

fecal coliformfrom all the districts laboratories for

the 3rd quarter of the year 2015(July-September).

The test results show that 196 samples were safe

water and the remaining 372 samples were found

unsafe. Among the 372 unsafe samples, 180

samples are categorized as low health risk, 174 as

Intermediate to High health risk and 81 as grossly

polluted sample.

Figure 15: Microbiological report of 20 districts water for 3rd quarter.

Note: 0=Safe water; >1=Unsafe water

28

2 25 2 2 1

8

1

16

0 2 3 11 0 0 11 1

0

5

10

15

20

25

30

HIV confirmation

Total Positives Indeterminate



Figure 16: Categorization of bacteriological report VS health risk.

Note; 0 CFU=Safe water (SW); 1-10 CFU =Low Health Risk (LHR); 11-50 CFU=Intermediate to High Health Risk (IHHR); >50

CFU=Grossly Polluted

9.2 Thimphu Thromde Physico-Chemical Test Report

The reports for physiochemical parameters viz. Residual Chlorine, pH, Turbidity, Total Dissolved Solids &

Conductivity, from Thimphu Thromdey at various sampling points are shown in (Figure 17, 18, 19, and 20).

Figure 17: Residual Chlorine.

Note: MTP-Motithang Treatment Plant;JTP- Jungshina Treatment Plant; BPT: Break Pressure Tank

0

10

20

30

40

50

60

70

80

Nu

mb

er

of

feca

l co

lifo

rm

Dzongkhag

Bacteriological report from 20 districts

GPW

IHHR

LHR

SW

01234567

Acc

ep

tab

le v

alu

e (

0.2

-0.5

mg/

L)

Sampling station

April

May

June



Figure 18: pH

Figure 19: Turbidity

5.5 6 6.5 7 7.5 8

JTP(Source)

JTP(Treated)

MTPlant (Source)

MTP (Treated)

BPT R1 Tank

Three Tank Lower Motithang

Tank above NPPF colony

Reservoir Tank near BCCI office

Tank above JDWNRH

Tank near Swimming pool

Changjiji Tank

Changjiji Pump House

pHAcceptable value(6.5-8.5)

Sam

plin

g St

atio

n

September

August

July

02468

10121416

Turb

idit

y A

ccep

tab

le v

alu

e (<

5N

TU)

Sampling stations

July August September



Figure 20: Total Dissolve Solids (TDS and Conductivity (CND)

10. External Quality Assessment Programme

10.1 National External Quality

Assessment System: 31st Round

Proficiency Testing for TB Microscopy

The 31st round of proficiency testing for TB

microscopy was carried out for 35 District

hospital laboratories during the 2ndquarter of

2015 (1st April to 31st July). Five laboratories

didn’t sent back the feedback report. Two High

False Negatives (major error)were reported while

the minor error was at 5.7%. The overall findings

of the panel testing carried out for 2015 is given

below.

.

0

50

100

150

200

250

300

350

400

450

TDS CND TDS CND TDS CND TDS CND TDS CND TDS CND

JTP (Source) JTP (Treated) MTP (Source) MTP (Treated) Changjiji ColonyTank

Changjiji ColonyPump House

mg/

L(TD

S) o

r µ

S/cm

(CN

D)

Sampling stations

July August September



Table 11: Results of 31st Round Proficiency Testing for TB Microscopy for 35 laboratories.

Sl

No

Lab ID No. Name of Hospital Total

Slide

HFN HFP LFN LFP QE Total

errors

OAR% Total

Score

Remarks

1 LAB-01 Wangdue Hospital 10 0 0 0 0 1 1 90 95

2 LAB-06 Bali BHU-1 10 0 0 0 0 1 1 90 95 Screened by

1 technician

3 LAB-02 Bumthang Hospital 10 0 0 0 0 1 1 90 95 Screened by 3

technicians

4 LAB-37 Chukha BHU-I* 10 0 100 100

5 LAB-28 Dagana BHU-1 10 1 0 1 0 0 2 80 85

6 LAB-29 Dagapela Hospital 10 0 0 0 0 0 0 100 100

7 LAB-25 Damphu Hospital 10 0 0 0 0 0 0 100 100

8 LAB-03 Dewathang Military

Hospital

10 0 0 1 1 0 2 80 90 Screened by

2

technicians

9 LAB-36 Gasa BHU-I* 10 0 100 100

10 LAB-04 Gedu Hospital 10 0 0 0 0 0 0 100 100

11 LAB-05 Gelephu RRH 10 0 0 0 0 0 0 100 100 Screened by

2

technicians

12 LAB-27 Gidakom Hospital 10 0 0 1 0 0 1 90 95

13 LAB-12 Gomtu Hospital 10 0 0 0 0 1 1 90 95

14 LAB-33 Kanglung BHU-I 10 0 0 0 0 0 0 100 100

15 LAB-34 Lhamoyzingkha

BHU-I*

10 0 100 100

16 LAB-08 Lhuentse Hospital 10 0 0 0 1 0 1 90 95

17 LAB-07 Lungtenphu Military Hospital

10 1 0 1 0 1 3 70 80

18 LAB-09 Mongar RRH 10 0 0 0 0 0 0 100 100

19 LAB-10 Paro Hospital 10 0 0 0 0 1 1 90 95 Screened by

7

technicians

20 LAB-11 PemaGatshel

Hospital

10 0 0 0 0 0 0 100 100

21 LAB-38 JDWNR Hospital 10 0 0 0 0 0 0 100 100

22 LAB-13 Phuntsholing Hospital

10 0 0 0 0 0 0 100 100 Screened by 2

technicians

23 LAB-14 Punakha Hospital 10 0 0 0 0 1 1 90 95 Screened by 2

technicians

24 LAB-16 Riserboo Hospital 10 0 0 0 0 0 0 100 100

25 LAB-17 Samdrupjongkhar Hospital

10 0 0 0 0 0 0 100 100 Screened by 3

technicians

26 LAB-32 Rangjung BHU-I* 10 0 100 100

27 LAB-18 Samtse Hospital 10 0 0 0 0 0 0 100 100 Screened by 4

technicains

28 LAB-19 Sarpang Hospital 10 0 0 0 0 0 0 100 100

29 LAB-20 Sipsoo Hospital 10 0 0 0 0 1 1 90 95

30 LAB-22 Tashigang Hospital 10 0 0 0 0 1 1 90 95

31 LAB-21 Tashiyangtse Hospital

10 0 0 0 0 0 0 100 100

32 LAB-23 Trongsa Hospital* 10 0 100 100

33 LAB-24 Tsimalakha

Hospital

10 0 0 0 0 1 1 90 95 Screened by

2 technicians

34 LAB-26 Yebilaptsa Hospital 10 0 0 0 0 0 0 100 100

35 LAB-35 Zhemgang BHU-I 10 0 0 0 0 1 1 90 95



Criteria for acceptable performance:

1. Set of 10 slides, each slides is worth 10 points, total possible score= 100.

2. HFP and HFN scores 0.

3. LFP, LFN and QE score 5.

4. Passing score 90.

Table 12: Summary report of 31st Round Proficiency Testing for TB Microscopy

Total number

of slides sent

out

Major Error Minor Error

High False

Negative (HFN)

High False

Positive (HFP)

Low False Negative

(LFN)

Low False

Positive (LFP)

Quantification

Error (QE)

300 02 0 04 02 11

11. Summary of Disease Outbreaks Report

Figure 21: Disease Outbreak Notification Report from July to September 2015



12. Summary of National Notifiable Diseases Surveillance

Table 13: National Notifiable Diseases Surveillance Summary during the 3rd Quarter 2015

Week BUM CHU DAG GAS HAA LHU MON PAR PEM PUN SJK SAM SAR THI TRG TRY TRO TSI WNG ZHE Total

# % % % % % % % % % % % % % % % % % % % % %

31 0 0 0 0 0 13.3 17.86 0 0 0 0 0 0 0 0 0 0 0 0 0 1.55

32 0 0 10 0 0 53.3 67.86 0 0 0 0 0 0 0 52 36.4 0 13 0 0 11.6

33 0 0 30 0 0 53.3 92.86 0 0 0 0 0 20 0 80 63.6 0 25 0 0 18.2

34 16.7 0 20 0 0 60 96.43 0 0 0 0 0 33.3 0 84 63.6 10 38 0 0 21.05

35 83.3 5.26 50 25 25 66.7 96.43 0 0 55.6 0 0 13.3 7.69 84 90.9 40 13 20 64.7 37

36 83.3 10.5 10 75 50 100 96.43 20 0 88.9 0 6.25 13.3 0 88 81.8 50 0 33.33 64.7 43.55

37 83.3 0 40 75 100 100 92.86 40 0 88.9 0 0 33.3 23.1 88 81.8 40 0 60 70.6 50.8

38 83.3 26.3 90 75 100 100 96.43 100 0 77.8 8.33 6.25 73.3 30.8 84 81.8 50 100 60 70.6 65.65

39 66.7 26.3 100 75 100 100 85.71 100 0 100 8.33 12.5 86.7 46.2 92 72.7 50 100 60 76.5 67.9

40 66.7 79 100 75 100 100 78.57 100 90 100 66.7 93.8 80 53.9 84 72.7 50 100 66.67 82.4 81.95

41 50 68.4 90 75 100 80 60.71 80 95 88.9 83.3 93.8 93.3 61.5 84 63.6 50 88 66.67 70.6 77.1

*Note: Since NEWARS Training was started from 30th July and ended on 19th September 2015, reporting to the system started has been started as and after the training has been

conducted for each batch.

disease surveillance bulletin...volume 3 1 3rd quarter (july-september) 2015 1. surveillance of...

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