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NEWARS

National Notifiable Disease Surveillance System and Epidemiology Unit

Public Health Laboraotry

2014

NEWARSCopyright © 2014 Public Health Laboratory

Cover by: Tshering Dorji

All rights reserved. No part of this book may be re-produced in any form by any electronic or mechanical means including photocopying, recording, or informa-tion storage and retrieval without prior permission in writing from the author.

ISBN: 978-99936-947-7-9

Give feedback on the book at:[email protected]

www.phls.gov.bt

Printed in Bhutan

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National Early Warning, Alert & Response Surveillance

Communicable diseases continue to be a major public health problem in the developing countries. Majority of these diseases cause massive outbreaks periodically in the community causing high morbidity and mortality. While the emerging diseases are on the rise, some of the communicable diseases have re-emerged causing dent to the progress of public health measure. Simi-larly, the public health in Bhutan is also threatened by the existing, emerging and the re-emerging communi-cable diseases. Despite the implementation of multiple public health activities to prevent infectious diseases and promote the health care system, communicable diseases such as acute respiratory infection and diar-rheal disease continue to be a burden in the country.

Although Bhutan made good progress in controlling and preventing some vaccine preventable diseases like polio, measles and rubella, the country is now un-der threat from the emerging and re-emerging tropical and zoonotic diseases. If evidence based interven-tion is not implemented in advance, the country will be burdened with many new diseases in addition to existing endemic diseases. To understand the burden of existing communicable diseases and its trend, and emergence of new diseases, surveillance plays a criti-cal role. The sound disease surveillance system will provide scientific information of diseases incidence, burden, and trend including prediction of outbreaks for those diseases that have high epidemic potential to cause high morbidity and mortality which will be use-ful for implementation of control and prevention mea-

Preface

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sures.

Prior to 2009, Bhutan had no systematic disease sur-veillance system in place for infectious diseases al-though few list of notifiable disease were reported. In 2009, following Annual Health Conference, the Minis-try of Health entrusted the Public Health Laboratory to institute notifiable disease surveillance system on priority diseases of national concern. In 2010, the Pub-lic Health Laboratory developed first edition of national notifiable disease surveillance guideline. However, due to changes in disease pattern and some practi-cal problem faced in implementation of the previous surveillance guideline, list of national notifiable dis-ease and surveillance guideline has been revised to reinforce and strengthen existing disease surveillance system.

This revised guideline also includes event-based sur-veillance (EBS) which will complement and supple-ment the indicator based notifiable diseases surveil-lance. However, unlike previous guideline, this revised guideline does not cover Outbreak investigation which is being developed as a separate guideline. Therefore the name of the current revised guideline is changed to “National Early Warning Alert and Response Surveil-lance (NEWARS)”.

This guideline is developed by the Public Health Lab-oratory in collaboration with Communicable Disease Division (CDD) under Department of Public Health, Ministry of Health Bhutan and with technical support from WHO.

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Table of Content

Preface ...................................................................... 3Table of Content ........................................................ 5Acronyms .................................................................. 7Contributors ............................................................... 8Acknowledgement .................................................. 101. Introduction ....................................................... 122. Objectives ......................................................... 143. Features & attributes of NEWARS .................... 154. Roles & responsibilities ..................................... 16

1. The Surveillance System .....................................282. Identification of the diseases or syndromes .......293. Sources of data ...................................................304. How the surveillance system works ..................305. The operational components ...............................336. Data Management ...............................................477. Data Analysis .......................................................488. Laboratory testing ................................................509. Feedback .............................................................5010. Monitoring & evaluation .......................................5111. Supervisory Visit .................................................551. What is Even-based Surveillance (EBS)? ...........572. What are events? .................................................583. The operational aspects ......................................594. Maintaining database ..........................................645. Assessment of an event ......................................656. Responding to an event .......................................667. Feedback .............................................................678. Public Health Events of International Concern

(National IHR Focal Point) ...................................68

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5. References ........................................................ 70Annex 1 ............................................................. 72Annex 2 ............................................................. 82Annex 3 ............................................................. 83Annex 4 ............................................................. 84Annex 5 ............................................................. 85Annex 6 ............................................................. 86

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ABD Acute Bloody Diarrhoea

AES Acute Encephalitis Syndrome

AFP Acute Flaccid Paralysis

ARI Acute Respiratory Infection

AWD Acute Watery Diarrhoea

BHU Basic Health Unit

CDD Communicable Disease Division

DHO District Health Office

EBS Event-Based Surveillance

ER Emergency Room

DoPH Department of Public Health

IBS Indicator Based Surveillance

ICT Information & Communication Technology

IHR International Health Regulation

ILI Influenza like Illness

MDR-TB Multi Drug Resistant Tuberculosis

NADSAE National Disease Surveillance & Epidemiology

NNDSS National Notifiable Disease Surveillance system

NEWARS National Early Warning, Alert & Response Surveil-lance

OPD Out Patient Department

PHEIC Public Health Event of International Concern

PHL Public Health Laboratory

SARS Severe Acute Respiratory Syndrome

SFP Surveillance Focal Point

WHO World Health Organization

Acronyms

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ContributorsTshering Dorji Senior Laboratory Officer/HeadNational Disease Surveillance & Epidemiology UnitPublic Health LaboratoryDepartment of Public Health Ministry of Health

Sonam WangchukChief Laboratory Officer/Microbiologist Public Health LaboratoryDepartment of Public HealthMinistry of Health

Chimmi DorjiDeputy Chief Laboratory OfficerPublic Health LaboratoryDepartment of Public HealthMinistry of Health

TenzinEpidemiologistNational Centre for animal Health Department of LivestockMinistry of Agriculture & Forests

Karma Lhazeen Chief Programme OfficerCommunicable Disease Division, DoPHNational International Health Regulations (2005) Focal PointDepartment of Public HealthMinistry of Health

Christian WinterMedical Epidemiologist

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WHO Country Office, Bhutan

Thinley Jamtsho Information Communication and Technology OfficerInformation Communication and Technology Unit, Public Health LaboratoryDepartment of Public HealthMinistry of Health

Karchung Tshering Senior Medical Technologist/HeadNational Tuberculosis Reference LaboratoryPublic Health Laboratory Department of Public Health Ministry of Health

Roma Karki Programme OfficerCommunicable Disease DivisionDepartment of Public Health Ministry of Health

Pelden Wangchuk Chief Medical Officer Trashigang Hospital Trashigang

Choeda Gyeltshen Chief Medical Officer Punakha HospitalPunakha

Tenzin Chief Nurse Central Regional Referral HospitalGelephu

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Acknowledgement

Public Health Laboratory would like to express deep-est appreciation to all those who provided various possibilities to complete this national guidelines for notifiable disease surveillance and event based sur-veillance. We are indebted for constant support and guidance rendered by the Secretary of Ministry of Health, Dr. Dorji Wangchuk, who was then the Direc-tor General of Department of Public Health. PHL also thank him for his stimulating suggestions and encour-agement, which has helped PHL in completing these guidelines on time.

PHL would like to acknowledge the invaluable contri-bution made by the contributors of the guidelines. All the participants of the Event based surveillance guide-line development workshop held in Paro in April 2014 are also duly acknowledged for their tireless effort put in for bringing shape to these document.

A special thanks goes to the participants and field people who were actively involved in disease notifica-tion and providing constructive and frank feedbacks. These feedbacks have very much helped improve the surveillance system and are all incorporated in this edition of the guideline.

Furthermore PHL would also like to acknowledge with much appreciation the crucial role of some of the staffs of Public Health Laboratory, who despite their busy schedule, proof read the document with utmost dedication and diligently going through each word,

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each sentence and making corrections.

Last but not least, PHL would also like to acknowledge the technical support provided to us by WHO and oth-ers who have invested their effort in helping the team in achieving the goal.

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1. Introduction

Infectious disease surveillance undergirds infectious disease control and prevention. Functional and inte-grated disease surveillance provides information for action against infectious disease that are of public health concern for the country. Disease surveillance is the ongoing systematic collection, analysis and in-terpretation of specific data for planning, implementa-tion and evaluation of disease control and prevention. The current notifiable diseases surveillance had been useful in understanding infectious disease pattern but it is inadequate to capture information in the event of new emerging infectious diseases because it is dis-ease specific indicator based surveillance. The difficul-ty of identifying unknown etiological agents is one of the main reasons for delays between the occurrence and recognition of new infectious diseases. Therefore more systematic approach for the early detection of unknown infectious agents and notification is needed. Hence revision of existing “Operational Manual for Na-tional Notifiable Diseases Surveillance and Outbreak Investigation” was deemed necessary. In this revised guideline, syndromic approach has been adopted to improve the sensitivity of the surveillance. In addition event based surveillance is being incorporated to sup-plement and complement revised indicator based No-tifiable Disease Surveillance System (NDSS) for rapid detection and response to any public health concern including bioterrorism.

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Target audience

This guide is intended to provide reference and practi-cal assistance to conduct notifiable disease and event based surveillance for all levels of health centers in-cluding Surveillance Focal Points (SFP) and Rapid Re-sponse Teams (RRTs). The target audiences include clinicians, district health officers, laboratory personnel and other health workers.

Goals of guideline

The goal of the guideline is to explain the structure and procedures of the national notifiable disease surveillance system (NDS) and Event Based Sur-veillance (EBS) for diseases which have potential to cause outbreaks or events of public health concern. It is organized in a systematic manner which explains everything required for effective disease surveillance, including the roles and responsibilities of health per-sonnel at different levels of health centers.

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The National Early Warning Alert and Response Sur-veillance (NEWARS) is ongoing systematic and ad-hoc collection of health related data on selected diseases of public health importance and their associated syndromes which is then collated, analyzed, interpreted and the rel-evant information are disseminated for action.

NEWARS has two main objectives:

1. Early warning to prevent or minimize morbidity and mortality through:• Monitoring trends of endemic diseases• Detecting outbreaks and events• Providing an adequate and timely response

2. Program monitoring for:• Planning, monitoring and evaluating disease

control programs• Resource mobilization and allocation

The NEWARS system is supplemented by additional laboratory sentinel based surveillance system such as the influenza-like illness (ILI) and severe acute re-spiratory infections (SARI) sentinel surveillance, diar-rhea disease sentinel surveillance, dengue sentinel surveillance, measles and rubella surveillance, acute encephalitis syndrome sentinel surveillance and drug resistance and multi-drug resistance tuberculosis (MDR-TB) surveillance which focuses on the collec-tion of more information on disease.

2. Objectives

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3. Features & attributes of NEWARS

NEWARS constitute both indicator-based surveillance (IBS) and event-based surveillance (EBS).

National Notifiable Disease Surveillance is an Indica-tor based Surveillance which is ongoing and system-atic. It involves reporting of cases and deaths of 21 priority diseases and conditions seen at health facili-ties as defined in pre-agreed case definitions. Data is collected in a systematic manner which usually in-volves collection of information using standard forms, aggregated and reported routinely by fax, web based online reporting system or Short Message Service (SMS). Data obtained are then analyzed, interpreted and disseminated by surveillance focal points at dif-ferent levels.

Event Based Surveillance is ad-hoc. It involves report-ing of any ‘unusual’ event, unusual cluster of cases or suspected outbreak. It is reported IMMEDIATELY by anyone i.e. health care workers, general public, me-dia, civil organizations, NGOs, etc to National Disease Surveillance and Epidemiology (NADSAE) Unit at PHL or health centers who in turn report to NADSAE. The main features of IBS and EBS are summarized and in Table 1.

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Table 1: The main features of IBS ad EBSFeatures Indicator Based

Surveillance Event Based Sur-veillanceDisease/Syndrome

Disease/Syndrome Selected notifiable diseases and pre-agreed case defi-nition

Any disease or event

Reporting Unit Health facilities Anyone: Health fa-cilities and commu-nities

Reporting frequency Weekly ( some disease require additional immedi-ate notification)

Immediate

Reporting formats Standard form Form or None

Reporting methods Web based, Email, SMS, Mo-bile Applications, Fax/phone

Web based and hot-line phone

All health professionals and health workers working in different health centers are responsible for implement-ing NEWARS including village health workers because they act as link between health centers and communi-ties. Therefore, it is important that every individuals un-derstand his/her roles and responsibilities are defined to implement NEWARS effectively.

4. Roles & responsibilities

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Village Health Workers

Village health workers are key contact persons in the communities for health related information and link be-tween communities and health centers.

• Identifying suspect cases of priority diseases and report them to the nearest health center.

• Reporting public health events to the health cent-er.

• Supporting district and national teams during in-vestigations by informing the community of the problem, and assist in case finding.

• Carrying out community health education.

Health Professionals

Clinicians including specialists and health workers working in clinics are the first contact of cases and main source of information for notifiable diseases or public health events at all level of health care facilities. All clinicians including specialists and health workers in every hospital and BHU should:

• Identify and collect information on notifiable dis-eases on daily basis according to the case defini-tions in the daily case reporting form (Annex 2).

• Hand over the duly filled forms (daily case report-ing forms) to the Surveillance focal points of BHU’s and hospital on daily basis.

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• Referring cases to laboratory for laboratory inves-tigation or diagnosis of priority notifiable diseases, if required by the guideline.

• Report public health events to National Disease Surveillance and Epidemiology (NADSAE), PHL.

Surveillance Focal Points

1. BHUs and Hospitals

To implement NEWARS effectively, two competent persons in each BHU, district hospital, regional referral hospital and national referral hospitals should be des-ignated as the Surveillance Focal Point (SFP). One of these officers has to be designated as main focal point and should be available at all times. In absence of the main focal point, he/she has to delegate this responsi-bility to other designated person.

Data collection and reporting

• Collecting routine notifiable diseases data record-ed by clinicians and health workers in clinics.

• Collate and send Weekly Reporting Form (An-nex 3) to District Health Office Surveillance Focal Points every Friday afternoon OR report by online reporting system in PHL website if health center has access to internet facility OR use SMS.

• Any unreported cases on Friday should be report-ed on Monday morning.

• Regional and national referrals hospitals should send directly to NADSAE, PHL every Monday OR

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report using web based online reporting in PHL website.

• Report immediately a single case of defined dis-eases such as vaccine preventable diseases (e.g. Acute Flaccid Paralysis, measles, rubella, and per-tussis), acute hemorrhagic fever, avian influenza, bacterial meningitis, cholera, pneumonic plague and suspected rabies, or suspected outbreaks/events to the DHO Surveillance Focal Points or NADSAE through online reporting system.

Analysis and Response

• Analyzing weekly report using paper-based or computer generated charts and graphs.

• Coordinate in collection of clinical specimens by laboratory technologist/technicians and transport to PHL for testing (if necessary).

Supervision and Validation

• Giving feedback to village health workers about out come of reported cases and prevention activi-ties.

• Monitoring quality of routine case detection of no-tifiable/priority diseases by clinicians, timeliness and completeness of reporting and report to DHO or NADSAE for taking action to improve reporting practices if required.

• Maintaining contact with communities and village health workers to conduct preparedness and pre-vention activities.

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2. District Health Office

District Health Office should also have two com-petent person designated as the DHO Surveil-lance Focal Point and part of the rapid response team. One of these officers has to be designated as main SFP and should be available at all times. In absence of the main SFP, he or she has to del-egate the responsibility to another person and in-form the BHUs and hospitals of the change.

Data collection and Reporting

• Collecting routine surveillance data in a timely and accurate manner and follow-up with BHUs and hospitals that are late in sending reports OR re-porting online.

• Reporting weekly report “Weekly Reporting Forms” received from health centers in online re-porting system every Monday on behalf of health centers OR sent reports to NADSAE every Mon-day. If health centers have reported online, check and verify the data.

• Immediate reporting to the NADSAE of any unu-sual event or outbreak of disease.

• Immediate reporting of single cases of defined dis-ease such as vaccine preventable diseases (e.g. acute flaccid paralysis, measles, rubella, and per-tussis), acute hemorrhagic fever, avian influenza, bacterial meningitis, cholera, pneumonic plague and suspected rabies, or suspected outbreaks or events to the NADSAE.

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• Reviewing the “Weekly Reporting Forms” or online data to check for possible outbreaks; i.e. where there are more than expected numbers of cases of a syndrome or disease. Report alerts to the NA-DSAE, PHL.

• Preparing and periodically updating graphs, tables and charts to describe time, place and person for reported diseases and syndromes of the district.

• Interpreting data and making conclusions about analyzed data.

Medical Laboratories of Referral Hospitals, Dis-trict Hospitals and BHUs.

Sample testing is critical in confirming etiology of dis-eases under surveillance including outbreak investi-gation. A laboratory should actively participate in the surveillance.

• Providing diagnostic services of notifiable diseas-es or events.

• Request assay kits for diagnosis of notifiable dis-eases.

• Shipment of samples from BHU’s and hospitals to laboratory units under PHL for confirmatory testing if a laboratory has no capacity for testing samples.

• Collaborate and seek technical assistance from PHL if required for sample collection and diagno-sis of notifiable diseases or events.

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Public Health Laboratory 1. NADSAE

NADSAE is the national focal point for disease surveil-lance in the country. It is also a part of national rapid response team. Surveillance officers at NADSAE should be available at all times.

Data collection and Reporting

• Ensuring that DHOs are providing timely and ac-curate reports and follow-up on those DHOs that are late reporting in the online system OR in send-ing their reports.

• Routinely validate data reported by district health office and health centers.

• Report a single case of defined disease or sus-pected outbreak to the head of the PHL and Na-tional IHR Focal Point (if required).

• Coordinating rapid dissemination of disease re-ports to other agencies and national programs when immediate action is required.

• Production and dissemination of surveillance bul-letins to all level of health centers and relevant stakeholders.

• Risk assessments of events reported to NADSAE and inform to relevant health centers and district health offices about the event and request them for further investigation and report.

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• Reviewing the weekly surveillance data and checking for possible outbreaks; i.e. more than ex-pected numbers of cases of a particular disease or syndrome reported.

• Preparing and periodically updating graphs, tables and charts to describe time, place and person for reported diseases and syndromes.

• Interpreting data and making conclusions about trends, thresholds and analysis results from na-tional perspective.

• Assisting the DHO to coordinate investigations of suspected outbreaks (if requested).

• Coordinating support for local, district and lead na-tional outbreak investigation.

• Responding to outbreaks of national and interna-tional public health importance.

• Collaborating with international authorities as needed during investigations.

Supervision and Validation

• Providing technical support to DHOs if required.

• Coordinating support for the surveillance and re-sponse system through regular trainings of staff at all level, and monitoring performance of surveil-lance.

• Coordinating periodic evaluation of surveillance system using standard evaluation methodologies for continuous quality improvement.

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• Conducting evaluation of outbreak investigated to improve outbreak investigation and response.

2. Laboratory Units• Providing confirmatory diagnosis for all notifiable

diseases and events.

• Providing technical assistance to peripheral labo-ratories in diagnosis of diseases and events.

• Mobilizing diagnostic supplies for all the district laboratories for diagnosis of notifiable diseases.

• Providing prompt result for all samples referred from referrals, district hospitals and BHU for inves-tigation and feedback.

• Referring samples to supranational reference laboratories for investigation if the Laboratories in PHL have no capacity to perform testing.

• Seeking technical and logistic assistance from rel-evant international agencies, if required.

3. Information Technology and Data management Unit

Information technology will play important role in:

• Maintaining and updating web based reporting system and data management.

• Development and maintenance of web based sys-tem and database.

• Upgrading of IT system as and when required

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• Providing data or assist District SFP in accessing the website.

• Assist NADSAE & District SFP in data analysis.

National IHR Focal Point• As per the IHR 2005 guideline, any disease or

events of international concern should be reported to WHO through National IHR focal Point.

• Assessing if an outbreak or event reported is a Public Health Event of International Con-cern (PHEIC) using the “IHR (2005) Decision Instrument”(Annex7).

• Notifying WHO an event which may constitute a PHEIC in the country and help implement re-sponse measures.

• Providing all relevant public health information to WHO if there is evidence of an unexpected or unu-sual public health event in the country which may constitute a PHEIC.

• Responding to WHO requests for verification of reports from sources other than notifications or consultations of events which may constitute a PHEIC allegedly occurring in the country.

• Serve as focal point for information sent by WHO, and consulting with WHO on IHR related matters.

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Department of Public Health (Communicable Disease Division)

Communicable Disease Division is the main stake-holder in infectious disease surveillance.

• Defining surveillance needs

• Supporting training of health personnel at various health levels.

• Setting policies and procedures for reporting of notifiable diseases and events.

• Setting policies and procedures for responding to cases and outbreaks or events of public health concern.

• Mobilization of resources to maintain and improve the quality of surveillance.

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National Notifiable Disease

SurveillanceSystem

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1. The Surveillance System

The Notifiable Diseases Surveillance is a nation-wide surveillance system involving patients who attend health care facilities (BHUs and hospitals including regional and national referral hospitals) in all districts. There are 21 diseases identified to be notifiable (as of 2014) based on priority of the country (Table 2). Each notifiable disease has surveillance case definition which is a set of criteria based on clinical signs and symptoms used for detection of cases for the purpose of disease surveillance.

These case definitions are used to ensure that every case is identified in the same way. This allows com-parison of the number of cases of the diseases and syndromes that occurs in one time or place with the number occurring in another time or place. The case definition are given in Table 3.

Table 2: List of notifiable diseases and syndromesSN Diseases/syndromes1 Anthrax (ANT)2 Acute Bloody Diarrhea (ABD)3 Acute Watery Diarrhea (AWD)4 Acute Encephalitis Syndrome (AES)5 Acute Flaccid Paralysis (AFP)6 Acute Haemorrhagic Fever Syndrome (AHF)7 Acute Jaundice Syndrome (AJS)8 Acute Respiratory Infection (ARI)9 Bacterial Meningitis (BMG)10 Dengue fever (DGF)11 Severe Dengue (SDG)

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2. Identification of the diseases or syndromes

12 Diphtheria (DPT)13 Fever with Rash (FWR)14 Food poisoning (FDP)15 Malaria (MAL)16 Pertussis (PTS)17 Rabies (human) (RBH)18 Congenital Rubella Syndrome (CRS)19 Multi-drug Resistance TB (MRT)20 Tetanus (TTN)21 Typhoid /Paratyphoid fever (TPF)22 Unusual Disease(s), Death(s) OR Event (UDE)

In Bhutan, national notifiable diseases have been identified as the diseases of public health priority for monitoring and control efforts by the Ministry of Health in consultation with the Department of Public Health and Department of Medical Services. The decision has been based on following criteria and also upon the recommendation of expert from World Health Organi-zation (WHO).

• Diseases of epidemic potential in the community.

• Vaccine preventable diseases.

• Diseases that are aimed for elimination.

• Disease with high morbidity and mortality.

• Diseases which are of potential threat to interna-tional community (Public Health Emergencies of

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3. Sources of data

4. How the surveillance sys-tem works

Source of data collection for 20 lists of national notifi-able diseases and syndromes are:

• Out Patient and observation Registers of 191 Basic Health Units.

• Out Patient and admitted patient Registers of 31 District Hospitals.

• Out Patient, admitted patient and Emergency Registers of 3 Referral Hospitals.

The national NDSS in Bhutan is carried out through a case-based reporting system (indicator-based, con-tinuous system, routine reporting and ad-hoc system, immediate reporting).

Cases of 21 notifiable diseases and syndromes and any other unusual case seen at health care facilities - Basic Health Units (BHUs) and hospitals are routinely

International Concerns).

The national notifiable diseases list is revised periodi-cally according to the status of the disease epidemiol-ogy in Bhutan.

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reported to District Health Office (DHO). The DHO in turn reports to National Disease Surveillance and Epidemiology (NADSAE) unit, PHL. The data (report) is transmitted every week to NADSAE through NDSS online reporting system (www.phls.gov.bt) from the District Health Offices (DHOs) and BHUs where inter-net facility is available and by fax or via phone (SMS) where internet facility is not available. Even if no cases occur, weekly zero reporting is done to the next higher level.

The data collated at BHU and hospital is analyzed by designated BHU and hospital SFPs for respective BHU and hospital and designated referral hospitals SFP for referral hospitals. The data received from BHUs and Hospitals under a district is analyzed by District Health Office SFP. The overall data obtained from all the BHUs and Hospitals including referral hospitals is ana-lyzed by NADSAE. Then a feedback report is prepared and disseminated to all the reporting units by NADSAE on weekly and yearly basis.

The structure and procedures of the NDSS ensures that all levels are actively involved in the collection of data, analysis and response to surveillance data col-lected by the system (Figure 1). The assistance for implementation of overall surveillance system is pro-vided by PHL. In the case of outbreak of major public health concern detected by the system, appropriate control measures are coordinated by relevant district and national authorities, with the support of the WHO and other international partners if required.

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Collect

Collate

Report

Analyze

Interprete

Feedback

SFPs to aggregate data on weekly basis from dialy case log form. DHO SFP to check status on number of Health Facilities that have reported, validate data and inform those under reporting or not reporting sites to report on time.

SFPs to report aggregated data to the NADSAE, PHL on FRIDAY using online system, SMS, phone or fax for correct epi week (Saturday‐Friday)

BHU’s, district hospitals, regional referral hospitals, and national referrals hospital, collect data on cases and death of 21 noti�able diseases using: OPD, Emergency and IPD log/record book, Case de�nition, Correct epi-week, daily log and weekly reporting Form.

All SFPs to create trend graphs (x‐axis week, y‐axis no. cases) for all diseases.‐ Take note of one or more cases of VPDs and severe conditions.‐ Use software to automatically compute the alert thresholds.

Report any event alerts to data provider, district health manager (for action), national programme manager, policy makers (for follow‐up including �nancial & technical support).Weekly & yearly surveillance reports produced by PHL should reach data providers at all levels of the system.

Interpret disease trend, threshold, possible outbreaks (increasing trend of an outbreak‐prone disease )

Figure 1: Flowchart explaining how NNDSS works

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Identifying diseases and syndromes

Data should be collected from health care facilities and hospitals including referrals hospitals. In each health care facility, a daily registration book of consultations should be used to collect important information/data (name, age, gender, Occupation, location, case symp-toms, diagnosis, treatment and outcome) about each person visiting health care facilities.

The table 3 below contains the Disease ID (column 1), names (column 2), the clinical case definitions (column 3) for the 20 priority diseases or syndromes and “Un-usual Disease(s), Death(s) OR Event” (ID 22). In col-umn 4 it describes diseases that need to be reported immediately. Information/data about the 21 priority dis-eases and syndromes, including zero-reporting should be collected on a weekly basis by BHU and hospitals including referral hospitals staff.

5. The operational components

Preparing Report (Data Collation)

Information collected for the 21 priority diseases or syndromes and “Unusual Disease(s), Death(s) by all health care facilities should be prepared for weekly reporting to next higher level. The “Weekly Reporting Form” collects information on new cases of the 21 pri-ority diseases and syndromes separated into outcome of illness – ‘cases’ and ‘deaths’.

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Public Health Laboratory

National & Regional Hospitals

Every Monday of next week

Every Monday of next week

Every Friday of the week

As & when required

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BHUs & Hospitals

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IHR National Focal Point

World Health Organization

Health Information & Management System

All BHUs and hospitals should:

• Collate data in a weekly report using “Weekly Re-porting Form” (Annex 3) and report to DHO every Friday. Only data about patients admitted during the correct epidemiological week calendar should be collected and reported (that is the reporting pe-riod from the previous Saturday to until Friday of present week).

• Record cases into two outcome categories: Num-

Figure 2: Operational components of NNDSS

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ber of cases and number of deaths (if case has died it should be recorded as both case and death) (Annex 3).

• Report according to the Epidemiological week: Saturday to Friday.

• Review both the ‘admission diagnosis’ and ‘symp-toms’ columns of the register to see if the patient meets the case definition for admitted cases.

• Mark (e.g. tick) those cases in the register that are included in the “Weekly Reporting Form” so that it can be validated if needed during evaluation and monitoring process.

• Mark (e.g. draw a line under) the last case in the register included in the weekly report. This way re-porters know where to start looking for cases in the register the following week.

• Do Zero-reporting using the same form for week-ly reporting form (Annex 3). Having a system of zero-reporting is important to prevent missing reports from being interpreted as no cases. If no cases occurred, fill up form with “0” (zero cases).

• Double check and validate data before sending to the next higher level (DHO & NADSAE).

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Please note:• Cases of immediately reportable diseases that

were reported to the next level by phone should still be reported in the “Weekly Reporting Form”.

• Only new cases that are related to one of the listed 21 notifiable diseases or syndromes should be recorded.

• The “Weekly Reporting Form” records cases of diseases or syndromes rather than patients. If two or more notifiable diseases and syndromes are identified in the same patient during a con-sultation, record each of them in the appropriate field of the form.

• Patients marked as referred to another health care facility should not be included in the record to avoid duplication but immediately reportable diseases should still be reported to next level.

• Each “Weekly Reporting Form” should only contain data from the relevant epidemiological week. If data is not recorded during a particular week (e.g. due to absence of responsible staff), that data should not be added to the “Weekly Reporting Form” of the subsequent week. How-ever, data reporting should be done even at the later date for which the system allows grace pe-riod of 7 days.

• Data in NDSS is different from the “Health Infor-mation and Management System” data as it is based on the admission diagnosis rather than the final diagnosis to allow for early warning.

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thro

ugh

a ve

sicu

lar s

tage

, to

a de

-pr

esse

d bl

ack

esch

ar in

varia

bly

acco

mpa

nied

by

oede

ma

that

may

be

mild

to e

xten

sive

.G

astro

inte

stin

al:

abdo

min

al d

istre

ss c

hara

cter

-iz

ed b

y na

usea

, vom

iting

, ano

rexi

a an

d fo

llow

ed

by fe

ver.

Pul

mon

ary

(inha

latio

n): b

rief a

cute

resp

irato

ry il

l-ne

ss,

follo

wed

by

rapi

d on

set

of h

ypox

ia,

dysp

-ne

a an

d hi

gh te

mpe

ratu

re (w

ith X

ray

evid

ence

of

med

iast

inal

wid

enin

g)

A si

ngle

cas

e of

sus

pect

ant

hrax

w

ith a

ny o

f the

clin

ical

form

s

2A

cute

Blo

ody

Dia

rrhe

a (A

BD

)A

ny p

erso

n w

ith a

cute

dia

rrhe

a w

ith v

isib

le b

lood

an

d/or

muc

us in

the

stoo

l.A

clus

ter (

>5 c

ases

) of a

cute

blo

ody

diar

rhea

Tabl

e 3:

Cas

e de

finiti

ons

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

3A

cute

Wat

ery

Di-

arrh

ea (A

WD

)A

ny p

erso

n w

ith a

cute

wat

ery

diar

rhea

(pas

sage

of

3 o

r mor

e lo

ose

or w

ater

y st

ools

in th

e pa

st 2

4 ho

urs)

with

or w

ithou

t deh

ydra

tion.

A cl

uste

r* o

f acu

te w

ater

y di

arrh

ea

A si

ngle

cas

e of

sus

pect

cho

lera

: a

pers

on >

5 y

ears

of a

ge w

ith s

ever

e de

hydr

atio

n or

dea

th fr

om a

cute

wa-

tery

dia

rrhe

a4

Acu

te E

ncep

halit

is

Syn

drom

e (A

ES

)A

cute

ons

et o

f fe

ver

AN

D a

cha

nge

in m

enta

l st

atus

(in

clud

ing

sym

ptom

s su

ch a

s co

nfus

ion,

di

sorie

ntat

ion,

com

a, o

r ina

bilit

y to

talk

) AN

D/O

R

new

ons

et o

f se

izur

es (

excl

udin

g si

mpl

e fe

brile

se

izur

es in

chi

ldre

n). M

ay a

lso

incl

ude:

incr

ease

d irr

itabi

lity,

so

mno

lenc

e or

ab

norm

al

beha

vior

gr

eate

r tha

n th

at s

een

with

usu

al fe

brile

illn

ess.

A si

ngle

of A

ES

5A

cute

Fla

ccid

Pa-

raly

sis

(AFP

)A

ny c

hild

und

er fi

fteen

yea

rs o

f ag

e w

ith a

cute

fla

ccid

par

alys

is (A

FP)*

whi

ch is

defi

ned

by s

ud-

den

onse

t of p

aral

ysis

occ

urrin

g in

all

parts

of t

he

body

and

is c

hara

cter

ized

by

:• D

roop

ing

of th

e af

fect

ed jo

int (

s),

• D

ecre

ase

or a

bsen

ce o

f re

sist

ance

of

the

af-

fect

ed m

uscl

es w

hen

push

ing

A si

ngle

cas

e of

AFP

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

6A

cute

H

aem

or-

rhag

ic F

ever

Syn

-dr

ome

Acu

te o

nset

of f

ever

in a

sev

erel

y ill

pat

ient

AN

D

any

two

of th

e fo

llow

ing:

• H

aem

orrh

agic

or p

urpu

ric ra

sh •

Epi

stax

is •

Hae

mat

emes

is •

Hae

mop

tysi

s •

Blo

od in

sto

ols

•

Oth

er h

aem

orrh

agic

sym

ptom

and

no

know

n pr

edis

posi

ng h

ost f

acto

rs fo

r hae

mor

rhag

icm

anife

stat

ions

A si

ngle

cas

e of

acu

te h

emor

rhag

ic

feve

r syn

drom

e

7A

cute

Ja

undi

ce

Syn

drom

eA

ny p

erso

n w

ith a

cute

ons

et o

f jau

ndic

e A

ND

ab-

senc

e of

any

kno

wn

pred

ispo

sing

fact

ors

A cl

uste

r of

ac

ute

jaun

dice

sy

n-dr

ome

8A

cute

Res

pira

tory

In

fect

ion

(AR

I)A

ny p

erso

n w

ith

• H

isto

ry o

f fev

er o

r m

easu

red

feve

r of

≥ 3

8°C

A

ND

• C

ough

AN

D •

Ons

et w

ithin

the

last

7 d

ays

A la

rge

clus

ter (

>10

case

s) o

f AR

IA

clus

ter*

of A

RI c

ases

that

req

uire

ho

spita

lizat

ion

(Sev

ere

Acu

te R

es-

pira

tory

Infe

ctio

n (S

AR

I))U

nusu

al d

eath

(s) d

ue to

AR

I (e.

g. in

<6

0 ye

ars

old)

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

A si

ngle

cas

e of

sus

pect

avi

an i

n-flu

enza

: a

pers

on h

ospi

taliz

ed w

ith

AR

I w

ho d

urin

g th

e pa

st 7

day

s pr

ior

to o

nset

of s

ympt

oms

had

ex-

posu

re to

sic

k/de

ad b

irds

OR

livi

ng

in a

vill

age

with

con

firm

ed a

vian

in

fluen

za in

bird

s O

R c

lose

con

tact

(w

ithin

one

met

er) w

ith a

con

firm

ed

hum

an H

5N1

case

A si

ngle

cas

e of

sus

pect

pne

umon

ic

plag

ue:

coug

h w

ith b

lood

sta

ined

sp

utum

, ch

est

pain

, or

di

fficu

lt br

eath

ing

9B

acte

rial

Men

in-

gitis

A pe

rson

pre

sent

ing

with

acu

te o

nset

of f

ever

(>

38.0

°C

) AN

D h

eada

che

AN

D a

t lea

st o

ne o

f the

fo

llow

ing

sign

s:

neck

stif

fnes

s, p

roje

ctile

vom

iting

, al

tere

d co

n-sc

ious

ness

(let

harg

y, d

eliri

um, c

oma)

For

infa

nts

(<1

year

): fe

ver

and

bulg

ing

font

a-ne

lle.

A si

ngle

cas

e of

sus

pect

bac

teria

l m

enin

gitis

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

10D

engu

e fe

ver

Any

per

son

with

acu

te fe

brile

illn

ess

of 2

-7 d

ays

dura

tion

with

two

or m

ore

of th

e fo

llow

ing:

• H

eada

che

• Ret

ro-o

rbita

l pai

n• M

yalg

ia• A

rthra

lgia

• Ras

h• H

aem

orrh

agic

man

ifest

atio

ns

A cl

uste

r* o

f sus

pect

den

gue

feve

r

11S

ever

e D

engu

eD

engu

e fe

ver

case

defi

nitio

n A

ND

Sev

ere

plas

-m

a le

akag

es le

adin

g to

:• S

hock

(DS

S)

• Flu

id a

ccum

ulat

ion

with

resp

irato

ry d

istre

ss O

RS

ever

e bl

eedi

ng a

s ev

alua

ted

by c

linic

ian

OR

• S

ever

e or

gan

invo

lvem

ent:

• Li

ver:

AS

T or

ALT

>=1

000

• C

NS

: im

paire

d co

nsci

ousn

ess

• H

eart

and

othe

r org

ans

A cl

uste

r* o

f sus

pect

sev

ere

deng

ue

12D

ipht

heria

Any

per

son

with

an

illne

ss c

hara

cter

ized

by

lar-

yngi

tis O

R p

hary

ngiti

s O

R to

nsill

itis,

AN

D a

n ad

-he

rent

mem

bran

e of

the

tons

ils, p

hary

nx a

nd/o

r no

se.

A cl

uste

r* o

f sus

pect

dip

hthe

ria

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

13Fe

ver w

ith R

ash

Any

per

son

pres

entin

g w

ith fe

ver A

ND

rash

A cl

uste

r* o

f fev

er w

ith ra

shA

sing

le c

ase

of s

uspe

ct m

easl

es:

Any

per

sons

pre

sent

ing

with

fev

er

AN

D m

acul

opap

ular

ras

h A

ND

any

of

the

fol

low

ing:

cou

gh,

cory

za O

R

conj

unct

iviti

s14

Food

poi

soni

ngA

ny p

atie

nt w

ith s

igns

and

sym

ptom

s of

the

di-

gest

ive

syst

em (

such

as

naus

ea,

vom

iting

, ab

-do

min

al p

ain,

dia

rrhe

a) a

nd/o

r ne

rvou

s sy

stem

(s

uch

as p

ares

thes

ia (t

ingl

ing)

aro

und

the

mou

th

and

extre

miti

es,

dizz

ines

s)

afte

r co

nsum

ing

food

s or

drin

ks s

uspe

cted

to

be c

onta

min

ated

w

ith b

acte

ria, c

hem

ical

sub

stan

ces

and

or to

xins

.

A cl

uste

r* o

f sus

pect

ed fo

od p

oiso

n-in

g

15P

ertu

ssis

Any

per

son

with

a c

ough

las

ting

for

at l

east

2

wee

ks w

ith a

t lea

st o

ne o

f the

follo

win

g:• P

arox

ysm

(i.e

. fits

of c

ough

ing)

• Ins

pira

tory

who

opin

g

A cl

uste

r* o

f sus

pect

per

tuss

is

16R

abie

s (h

uman

)A

ny p

erso

n w

ith e

ncep

halit

is d

omin

ated

by

form

s of

hyp

erac

tivity

follo

wed

by

para

lytic

syn

drom

es

that

pro

gres

s to

war

ds c

oma

and

deat

h

A si

ngle

cas

e of

sus

pect

rabi

es

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

17C

onge

nita

l R

u-be

lla

Syn

drom

e (C

RS

)

An

infa

nt w

ith a

t le

ast

two

of t

he c

ompl

icat

ions

lis

ted

in (a

) bel

ow o

r one

in (a

) and

one

in (b

):(a

) C

atar

act(s

), co

ngen

ital g

lauc

oma,

con

geni

tal

hear

t dis

ease

, los

s of

hea

ring,

pig

men

tary

ret

in-

opat

hy.

(b) P

urpu

ra, s

plen

omeg

aly,

mic

roce

phal

y, m

enta

l re

tard

atio

n, m

enin

goce

phal

itis,

rad

iolu

cent

bon

e di

seas

e, ja

undi

ce th

at b

egin

s w

ithin

24

hour

s af

-te

r birt

h.

A si

ngle

cas

e of

sus

pect

con

geni

tal

rube

lla s

yndr

ome

18M

alar

iaD

etec

tion

of P

lasm

odiu

m s

peci

es b

y ra

pid

di-

agno

stic

ant

igen

test

ing

with

out c

onfir

mat

ion

by

mic

rosc

opy

or n

ucle

ic a

cid

test

ing

in a

ny p

er-

son

(sym

ptom

atic

or

asym

ptom

atic

) di

agno

sed,

re

gard

less

of

whe

ther

the

per

son

expe

rienc

ed

prev

ious

epi

sode

s of

mal

aria

whi

le o

utsi

de t

he

coun

try

A cl

uste

r* o

f sus

pect

ed m

alar

ia

19M

ulti-

drug

R

esis

t-an

ce T

BM

ycob

acte

rium

Tu

berc

ulos

is

resi

stan

t ag

ains

t R

ifam

pici

n an

d Is

onia

zid

with

or

with

out r

esis

t-an

ce to

oth

er tw

o pr

imar

y dr

ugs

A si

ngle

con

firm

ed c

ase

of 88


SNSy

ndro

mes

/ D

is-

ease

sC

linic

al C

ase

Defi

nitio

nsFo

r Im

med

iate

Rep

ortin

g

20Te

tanu

sTe

tanu

s of

all

ages

: A

ny p

erso

n w

ith s

udde

n pa

infu

l mus

cula

r co

ntra

ctio

n (m

ajor

ity,

max

illar

y an

d ne

ck m

uscl

e pa

in) A

ND

gen

eral

ized

mus

cu-

lar

spas

ms

AN

D/O

R h

isto

ry o

r cu

rren

tly h

avin

g pu

nctu

red

or o

pen

wou

nd.

A si

ngle

cas

e of

sus

pect

teta

nus

Neo

nata

l te

tanu

s: A

ny n

ewbo

rn w

ith a

nor

mal

ab

ility

to s

uck

and

cry

durin

g th

e fir

st tw

o da

ys o

f lif

e, A

ND

who

can

not s

uck

norm

ally

and

bec

ome

stiff

AN

D/O

R h

as c

onvu

lsio

ns A

ND

/OR

die

d be

-tw

een

3 an

d 28

day

s of

age

.

A si

ngle

cas

e of

sus

pect

neo

nata

l te

tanu

s

21Ty

phoi

d /P

arat

y-ph

oid

feve

rA

n ill

ness

with

pro

long

ed f

ever

(>3

day

s),

con-

stitu

tiona

l sy

mpt

oms

(e.g

. m

alai

se,

head

ache

, an

orex

ia) A

ND

hep

atos

plen

omeg

aly.

A cl

uste

r* o

f su

spec

t ty

phoi

d/pa

ra-

typh

oid

feve

r

22U

nusu

al

Dis

ease

(s),

Dea

th(s

) OR

Eve

nt

Any

dis

ease

(s),

deat

h(s)

or

even

t th

at a

re c

on-

side

red

as u

nusu

al b

y th

e he

alth

wor

ker

(vill

age

heal

th w

orke

r, st

aff a

t BH

U o

r hos

pita

l).

Any

dis

ease

(s),

deat

h(s)

or

even

t th

at a

re c

onsi

dere

d as

unu

sual

by

the

heal

th w

orke

r

*Clu

ster

refe

rs to

a g

roup

ing

of h

ealth

rela

ted

even

ts th

at a

re re

late

d te

mpo

rally

and

in p

roxi

mity

(US

dep

artm

ent o

f H

ealth

and

Hum

an s

ervi

ces)

of 88


Reporting (Data Transfer and Frequency)

1. Routine reporting

A. BHUs and District hospitals Basic Health Units (BHUs) and hospitals SFP should report every week on Friday. The reports should be sent using SMS or internet to online system main-tained by NADSAE and ICT Unit. In case BHUs and hospitals cannot report using SMS and internet, then they should fax or telephone the report to DHO SFP within stipulated time frame (Friday). BHUs and hospi-tals SFP should also fill up ‘Weekly Reporting Form’ and file for monitoring and evaluation purpose and re-visiting the data if required.

The DHO should call the BHUs and hospitals that fail to report through online or SMS. BHUs and hospitals should be encourage to report even if it is late through ‘Late Reporting Request’ and ask them to report on time.

B. Distric Health Offices

The DHO should call the BHUs and hospitals that fail to report through online or SMS. BHUs and hospi-tals should be encouraged to report even if it is late through ‘Late Reporting Request’ and ask them to re-port on time.

of 88


C. Referral Hospitals and Airport Health Service

Referral Hospitals and Airport Health Service at Paro International Airport SFP should report directly to the NADSAE every week on Monday using online sys-tem or SMS method. The hospitals should also fill up Weekly Reporting Forms’ and retain it for future refer-ence.

D. District Health Offices

The DHO should monitor online reporting status and ensure all BHUs under its jurisdiction have reported by Friday. Those reports received by fax or phone should be entered into online system by Monday.

NADSAE

NADSAE should report to IHR National Focal Point (IHR NFP) if the reported information (priority diseas-es and syndromes, outbreak/event) is a Public Health Event of International Concern (PHEIC) after conduct-ing risk assessment within 24 hours for onward report-ing to WHO.

2. Immediate reporting

Basic Health Units (BHUs) and hospitals SFP should report immediately the diseases given in table 4 using SMS or internet to online system and inform DHO SFP. These diseases are of major public health importance as a single case may lead to an outbreak or public health threat that requires immediate action. In case

of 88


BHUs and hospitals cannot report using SMS and in-ternet, then they should fax or telephone the report to NADSAE immediately.

Table 4: Immediate reportable diseases ID Diseases Conditions for reporting

100 Anthrax Single case of suspected disease

101 Acute flaccid paraly-sis

(suspected poliomyelitis) in a child < 15 years old

102 Acute hemorrhagic fever syndrome

Single case of suspected disease

103 Avian influenza Single case of suspected disease

104 Bacterial meningitis Single case of suspected disease

105 Cholera Single case of suspected disease

106 Malaria Single confirmed case

107 Measles Single case of suspected disease

108 Pertusis Single case of suspected disease

109 Pneumonic plague Single case of suspected disease

110 Rabies Single case of suspected disease

111 Rubella Single case of suspected disease

112 (Neonatal) tetanus Single case of suspected disease

112 Unusual death(s) Single case of unusual death Hard copies of “Weekly Reporting Forms” & “Immediate Reporting form” should be stored in files in a safe place at BHU’s and hospitals and be accessible during monitoring and evaluation.

Quality Data management and quality is critical for the surveillance system in analyzing and interpretation. Therefore, consistency in data collection and reporting

6. Data Management

of 88


7. Data Analysis

To understand specific patterns of notifiable diseases occurrence and take necessary public health action at respective BHU’s, and hospitals, SFPs at DHO na-tional, BHUs, and hospitals should analyze and inter-pret the compiled data in their respective health facil-ity regularly. At district level, DHO should analyze and interpret compiled data obtained from all the health facilities under its jurisdiction and by NADSAE at na-tional level

as mentioned in preparing report is also important for quality data management.

During the data collection, respective BHUs, hospitals, DHO SFP should validate all the data by cross check-ing once again. The correction should be made imme-diately at respective level if any discrepancy is found in the “Weekly Reporting Forms” (data cleaning). One week time frame will be provided by the system to verify and correct the data from the date of online sub-mission. DHO SFP should seek clarification from BHU or hospital SFP in order to clarify information if neces-sary. NADSAE should also validate and cross-check data at national level and make necessary correction.

The NADSAE should manage all the data obtained from the online reporting system. The electronic data at ICT Unit should be backed up on a daily basis to avoid data loss.

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Case based analysis

Diseases and syndromes can be interpreted as a risk where a single suspected case is a trigger for action like:

• Diseases targeted for eradication or elimination

• Epidemic-prone diseases where a single case or cluster constitutes a suspected outbreak.

Therefore when one or more cases of Vaccine Pre-ventable Diseases (e.g. fever & rash, AFP, Tetanus), severe conditions (e.g. suspected AI, suspected Chol-era) and death are reported, detailed case analysis should be performed.

Analysing aggregated data by person, place and time

All the data obtained at each health facility should be analyzed by person (gender, age group, etc), place (vil-lage, geog, district, etc) and time (onset date).

Trend analysis

For every levels of health centers, the online system will analyze disease trend. If alerts are generated, the SFP of BHUs, Hospitals or DHO should consult with NADSAE to discuss further action. After receiving all reports, the data should be analyzed for the trend and screened again at the NADSAE for any unusual oc-currences.

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8. Laboratory testing

9. Feedback

Regular feedback to all the stakeholders of the surveil-lance system is crucial to keep them motivated and improve the system. The feedback is also to reinforce health staff’s effort to actively participate in the surveil-lance system. Informal feedback by phone and email should also be used regularly and especially during outbreaks and Public Health Events at all level.

At district level, DHO should report back summarized data to respective BHUs and hospitals. The purpose is to reinforce health workers efforts to raise awareness about certain diseases, condition and situation to im-prove their participation in the system.

At national level, NADSAE should provide feedback

Laboratory testing of specimens collected from sus-pected cases should be undertaken to identify the pathogens. This is an important part of the surveil-lance system to establish and understand disease eti-ology for clinical management. Some diseases or syn-dromes such as acute flaccid paralysis, fever and rash (suspected measles and rubella) require every case to be confirmed by laboratory testing. See Annex 1 for detailed information on specimen collection, storage, transport and laboratory testing for the 20 notifiable diseases or syndromes.

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10. Monitoring & evaluation

through “Weekly and Annual” report to all the stake-holders. Weekly feedback report should be descriptive analysis describing disease conditions and situation while annually feedback report should be comprehen-sive analysis of data reported to facilitate evidence-based planning and intervention at district and nation-al level. Additionally, a yearly surveillance workshop should be conducted by NADSAE to share surveil-lance information and discuss issues or problems re-lated to surveillance system among stakeholders. The findings from monitoring and evaluation (M&E) of the surveillance system should also be incorporated in the annual report.

For all immediately reportable diseases need to be verified and investigated by NADSAE. For investi-gation, Rapid Response and Outbreak Investigation Manual should be used.

Surveillance monitoring and evaluation is an important component of surveillance and response. In order to scale up response to notifiable disease, all the stake-holders need to constantly review their performance in detecting, reporting and responding to notifiable dis-eases. The key activities of health workers/profession-als for notifiable disease surveillance system at each administrative level are described under roles and re-sponsibilities section.

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Surveillance performance should be monitored & eval-uated at each administrative level with aim to improve and sustain existing surveillance system. The DHO and NADSAE should monitor surveillance system at least once a year with set of indicators.

Indicators for Monitoring Timeliness and completeness of reporting is important indicator of a surveillance system.

The timeliness reporting should be monitored based on reporting schedule set for health centers of each administrative level. If BHUs and hospitals under dis-trict administrative are sending data to DHO on Fri-day and DHO and Referral hospitals to NADSAE on Monday, it is consider as timely reporting. However, if health centers are sending report Tuesday consider as late report and if sending later than that considered as no report, but still need to keep report as record.

Completeness should also be monitored whether health centers provide complete information as require by reporting form.

The timeliness and completeness should be moni-tored on weekly basis as they reflect the effective-ness of data collection and transmission and annually to assess the overall performance of the surveillance system to identify gaps. In addition, annual indicators should also include indictors to assess sensitivity of the surveillance system.

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Weekly indicators

Weekly timeliness and completeness should be calcu-lated every week as follow:

1. Timeliness of report for a week

Total number of reporting units that have been on time during the specific week

Total number of reporting

2. Completeness of report for a week

Total number of reporting units that have been complete during the specific week

Total number of reporting

Annual indicators

Annual monitoring of timeliness, completeness, sen-sitivity and specificity should be calculated as follow.

1. Timeliness of report for the year

Total number of reporting units that have been on time during the specific year

Total number of reporting for the year

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2. Completeness of report for the year

Total number of reporting units that have been complete during the specific week

Total number of reporting for the year

3. Sensitivity of surveillance

Total number of true disease/epidemicsdetectedduring the specific year

Total number disease/epidemic reported during the year

4. Specificity of surveillance

Total number of false disease/epidemics detectedduring the specific year

Total number false disease/epidemic reported during the year

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Supervisory visit should aim to help the health staff to improve their knowledge and performance and not be a fault-finding exercise. Supervisors and health staff work together to review progress, identify problems, and develop feasible solution.

Supervisory visits should be conducted at least twice a year to help the Surveillance Focal Point to improve their performance. During the visit, (positive feed-back and improvements needed) should be provided to health workers. Gaps identified should be tackled on the spot if possible, or solved at a later stage. On-the-job training should also be provided to improve the quality of activities.

Finally, a report should be written-up after the visit, which could be used for future visits to follow up rec-ommended actions.

10. Supervisory Visit

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Event Based Surveillance

System

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Event-based surveillance is rapid gathering of infor-mation about events that are a potential risk to public health and responding to events based on information verification and risk assessment. This information can be rumors, or any ad hoc reports that are transmitted through formal and informal channels such as media, health workers, community leaders, community health workers and non-governmental organizations related to;

• The occurrence of disease in humans, such as clustered cases of a disease or syndromes,

• Unusual disease patterns or unexpected deaths,

• Potential exposure for humans to events related to diseases and deaths in animals,

• Contaminated food products or water, and envi-ronmental hazards including chemical and radio-nuclear events.

Event based surveillance basically complements in-dicator-based surveillance (notifiable diseases and syndrome surveillance) because indicator-based surveillance often fail to timely detect outbreaks and important public health events. Further, the indicator-based surveillance is not an ideal surveillance to detect rare, emerging, re-emerging or unknown diseases.

1. What is Even-based Surveillance (EBS)?

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2. What are events?

The following are events of potential public health sig-nificance:

• Events where the underlying agent, disease or mode of transmission is new, newly discovered or unknown at the time of notification;

• Events involving transmission or potential trans-mission through persons, vectors, cargo or goods (including food products) and environmental dis-persion;

• Events that carry potential future impact on public health and require immediate action to reduce the consequences;

• Events arising outside of their known usual occur-rence patterns

• Events, irrespective of their origin or source, in-cluding those caused by biological (of infectious or non-infectious in nature), chemical agents or radio nuclear materials.

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Sources of events Information

Event-based surveillance (EBS) requires a multi-sec-torial approach and relies on sources of information beyond conventional health system sources (e.g., in-dicator based surveillance). Events are most likely to be detected or suspected in the community, institutes (schools, monasteries), army barrack, public functions (religious rites, festivals) and health centers (Table 4).

Table 4: Events reporting SourcesMedical Setting

Health care facilities Hospitals and BHUs

Health Help center

Airport health service Unit

Allied Health care professionals and organizations

Veterinary services

BAFRA

Wildlife

Environmental Health (NEC)

Pharmacy sale counter

3. The operational aspects

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Community setting

Community group and services

Village health workers

Village animal health workers

MSTF

Community leaders

General public

Religious organizations

Schools, Institutes & universi-ties

Municipality

Media Media (print, radio, TV, inter-net)

Other organization

NGOs

Military (Army & Police)

International organizations

Border entry points and air-ports

Reporting an Event

In the community, Village Health Workers, Village Animal Health Workers, Community Group Lead-ers, NGO’s CSO’s and general public including allied health care professionals (see details in table 4) may detect and report events. In institutes, school health In-charges may detect and report events, in army and police barrack by army/police medical and health per-sonnel and by religious rite organizers during public functions. In health facilities, all medical and health professional at various point of contact may detect and report events. Media is one of the important reporting sources and any event reported in TV, radio and print

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including news internet should be considered as an event reported (Table 4). Any events as defined in Ta-ble 5 should directly report to the NADSAE under the Public Health Laboratory. However, event from com-munity, institutes and other setting may also report to the Basic Health Unit (BHU) and hospitals. Therefore, BHU and hospital staff should be alert and any event reported should be immediately collected and reported

NADSAE, PHL

Department of Public Health (MoH)

IHR NFP

WHO

District Health O�cesHospitals & BHUs

MediaGeneral PublicSchoolsHealthcare workers Allied Health Workers VolunteersNGOsCommunity Workers

Disaster Management Authority

if an Event is disaster

if an Event is public health event if an Event is PHEIC

Report any event

Report any eventReport any event

Figure 3: Event reporting

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in the online system in Event reporting form (Annex 5).

Any disease(s), death(s) or event that are considered as unusual by health staff (See Table 3 – Sl. No 22) should be immediately reported to NADSAE using web based online event reporting system by BHU and hospital. However, anyone can report using the same system.

An event that poses potential risk to public health re-ported to NADSAE should be immediately reported to DHO SFP for investigation while event that does pose risk to public health should be documented but require no further action. Those events which are considered Public Health Emergency of International Concerns (PHEIC) should be reported to WHO through IHR Na-tional Focal Point (NFP) in according to the decision chart (Annexure 6) by NADSAE. The events which have serious public health implication should be also reported to National Disaster Management Authority through Ministry of Health as per Disaster Manage-ment Act of Bhutan 2013.

Table 6: Reportable Events SN Events Definition1 Any outbreak A group people are sick with simi-

lar symptoms in one place (e.g. village, school, or health facility) at the same time.

2 Any cluster of death Two or more people die of unknown cause after suffering from similar symptoms in one place (e.g. vil-lage, school, or health facility) at the same time.

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3 Suspected food poi-soning

A group of people become sick or have another unusual reaction after consuming the same food or drinks from the same water source.

4 Possible exposure to chemicals

A group of people become sick or have another unusual reaction af-ter being exposed to any chemical agent.

5 Suspected emerging infectious disease

Any person with symptoms you have not seen before or not seen for a long time in a place.

6 Suspected zoonotic disease

Villager(s) and animal become sick or die at the same time in a locality.

7 Any other event that is unusual

Any disease(s), death(s) or events that a re considered as unusual.

Collection of event information

Systematic, structured data collection is a critical com-ponent of any surveillance system, including event based surveillance. For event-based surveillance, data collection should be rapid and capture enough information to allow for an initial assessment of the event. Information on each event reported should be captured in a database where the outcomes, assess-ment and subsequent responses are stored.

The following questionnaires answers are to be col-lected by the team or focal point receiving the infor-mation at NADSAE or SFP in hospital/BHU if events are reported to hospitals and BHU’s. As part of the assessment, other partners such as hospitals, local authorities, laboratory units under public health labo-ratorie, food safety authority, national environment fo-cal points may be consulted depending on the nature

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of the events.

During the information collection, NADSAE may con-tact BHU/hospitals through District Health Office or directly if in case information provided is inadequate. The information of event should be collected as per the questionnaire provided in the table 7 below.

Table 7: Questionnaires for event information collectionSN Questions Remarks1 Date of reporting

2 What do you want to report?3 When did this happen?4 Where did this happen?5 How many have been affected?6 Has anyone died?7 How many died?8 Do you have any other information?9 Can we have your name and contact

number?

4. Maintaining database

Information obtained through different sources on the event should be stored at NADSAE in electronic for-mats. NADSAE should maintain online database for easy accessibility, reporting and analysis. The data-base should be able to collect and store all the relevant information required in table 7.

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All events reported and information collected should be assessed immediately by NADSAE to determine whether events reported pose potential risk to public health. The risk assessment of all events should be done using assessment questionnaires in the Table 8.

Table 8: Criteria for assessment of public health risk on first report-ing of an event SN Assessment Question Yes* No

Human Health Events

1 Does the event involve a notifiable disease or syndrome (i.e. diphtheria, watery diar-rhea)?

2 Can the suspected disease cause out-breaks with a high potential for spread (i.e. cholera, measles)?

3 Is there a higher than expected mortality or morbidity from the disease?

4 Is the disease unusual/unexpected in the community

5 Is there a cluster of cases or deaths with similar symptoms (i.e. bloody diarrhea, hemorrhagic signs and symptoms

6 Could the disease be caused by a contami-nated, commercially available product (i.e. food product, water)?

7 Does the disease have possible conse-quences from trade or travel (i.e. SARS)?

8 Is there suspected nosocomial spread of the infection (i.e. is the infection being transmitted within a health care setting)?

5. Assessment of an event

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Non-human health events

1 Does the event have a known conse-quence for human health (i.e. chemical spill and biological event

2 Does the event have a possible conse-quence for human health (i.e. suspected zoonotic disease outbreak in animals, Avian Influenza, outbreak in animals, un-explained deaths in animals)?

*if assessment scores is one or more Yes, then investigate the event

6. Responding to an event

Responding to an event is an essential part of event-based surveillance. Once an event is considered to be a potential risk to public health; the response should be organized from either the local or national level. The level of response required should be determined af-ter conducting risk assessment by NADSAE. Not all events of public health risk will result to investigation or require full investigation during the initial response.

After an event has been assessed and if found to pose potential risk to public health, the NADSAE should im-mediately report to respective DHO for investigation. Subsequently, DHO should report event immediately to respective BHU or hospital for an event investiga-tion.

BHU and hospital staff should be involved in verify-ing and investigating event/outbreak. Event/outbreak investigation should be initiated or done by BHU and

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hospitals. However, if BHU or hospital does not have capacity or need assistance to investigate, concern DHO should be notified and DHO should then activate district RRT and sent for investigation. For investiga-tion and formation of RRT the “manual for outbreak investigation and rapid response” should be used. The Rapid response team must be deployed in the field within 24 hours from the first report of the assessment of the event.

Figure 4: Event assessment and response

7. Feedback

NADSAE Unit

Public Health Event?

Risk Assessment

Disaster Management Authority

District Health O�ces

Hospitals & BHUs

MediaGeneral PublicSchoolsHealthcare workers Allied Health Workers VolunteersNGOsCommunity Workers

Yes No

Disaster Response( if required)

Report events that needs investigation

Investigate events

Report events that need investigation to nearest health centres

Record event. No action required

Feedback on events reported, assessed and inves-tigated should be provided weekly by NADSAE in simple format adapted to the general population to encourage reporting an event. In addition, information and reports about events based surveillance should be

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shared with stakeholders along with notifiable disease surveillance reports during annually surveillance work-shop to discuss issues and problems to improve event based surveillance system. Informal feedback by phone and email should be shared regularly with health staff during event investi-gation. Any event investigated report should be made available as soon as possible to all health personnel in the field and also to the person or organization report-ing. Investigation reports are excellent tools for learn-ing.

8. Public Health Events of International Concern (National IHR Focal Point)

The International Health Regulations (2005) provide new notification requirements for State Parties. These provisions move away from the automatic notification and publication by WHO of cases of specific diseases to the notification to WHO of all events that are as-sessed as possibly constituting a Public Health Event of International Concern (PHEIC).

Notifications should be followed by ongoing commu-nication of detailed public health information on the event, including, where possible, case definition, labo-ratory results, source and type of the risk, number of

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cases and deaths, conditions affecting the spread of the disease and the health measures employed.

Any events of PHIC should be communicated to WHO through the National IHR Focal Point.

Notification to WHO should occur within 24 hours of the assessment if two of the four above questions were answered with “Yes”.

Always Noti�able Events

WHO must be immediately noti�ed of these, irrespective of the context in which they occur.A single case of: • Smallpox; • Poliomyelitis (via wild type poliovirus); • Human influenza caused by a new subtype; • Severe acute respiratory syndrome (SARS).

Potentially Noti�able Events

The decision instrument provided in Annex 2 of the IHR (2005) (See Annexure 7) identi�es four criteria that State Parties must follow in their assessment of events within their territories and their decision as to whether an event is noti�able to WHO:

1. Is the public health impact of the event serious? 2. Is the event unusual or unexpected? 3. Is there a signi�cant risk of international spread? 4. Is there a signi�cant risk of international restriction(s) to travel and trade?

Figure 5: Always Notifiable Events

Figure 6: Potential Notifiable Events

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5. References1. Operational manual for district surveillance unit,

Directorate General of Health Services, Ministry of Health and Family Welfare,New Delhi.

2. WHO recommended strategies for the preven-tion and control of communicable diseases, WHO/CDS/CPE/SMT/2001.13

3. Communicable diseases surveillance, Centre for Health protection, Hong Kong, Version 2.

4. Vaccine and immunization CDC website.

5. Diseases Surveillance, WHO website.

6. Kansas Department of health and Environment, Varicella reporting guidelines, 2004

7. Notifiable conditions, Washington State Depart-ment of Health website

8. Department of Public health and preventive Medi-cine, Government of Tamil Nadu website.

9. How to investigate an outbreak; National Center For Chronic Disease Prevention And Health Pro-motion, Centers For Disease Control And Preven-tion, 2006.*

10. Epidemiological investigation of outbreaks, Com-municable Disease

11. Management Protocol Manual, Communicable Disease Control Unit, Public Health, Manitoba Health. 2006*

12. Kane J Albert & Morley S. Paul, How to investigate

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a disease

13. Park, K. Textbook of Preventive & Social Medi-cine, 14th edition, M/s Banaras Bhanot, 1994.

14. CDC, principle of epidemiology. Unpublished, 1978

15. Conducting an Outbreak Investigation. The North Carolina Communicable Disease Control Manual, North Carolina Division of Public Health. Accessed at http://www.epi.state.nc/epi/gcdc/manual/out-breakinvest.pdf

16. http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01262.html

17. Bender AP, Williams AN, Johnson RA, Jagger HG. Appropriate public health

18. Responses to clusters: the art of being responsibly responsive. Am J Epidemiol, 1990;132:S48-52.

19. LAO EWARN manual, year 2012 by NCLE and WHO

20. A guideline to establishing Event Base Surveil-lance, World HealthOrganization Western Pacific Region (2008), ISBN 978 92 9061 321 3

21. International Health Regulation, World Health Or-ganization (2005), World Health Assembly 58, Ge-neva

22. Guideline for Evaluating Surveillance System, Bu-reau of Epidemiology, Ministry of health, Thailand; ISBN 974 297 264 8

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od s

ampl

eA

t 2-8

°C

for 7

da

ys.

Sto

re a

t -2

0°C

de

ep

freez

er. i

f de

laye

d

At 2

-8 ºC

Den

gue

rapi

d te

st in

end

emic

ar

eas

and

deng

ue a

ntib

ody

dete

ctio

n (E

LIS

A).

Lept

ospi

ro-

sis

rapi

d te

st.

6

Acu

te

Jaun

dice

S

yndr

ome

1. H

epat

itis

A,

B, C

, D,

E v

iruse

s,

Lept

ospi

ra

Blo

od s

ampl

eA

t 2-8

°C

for 7

da

ys.

Sto

re a

t -2

0°C

de

ep

freez

er. i

f de

laye

d

At 2

-8 ºC

Hep

atiti

s B

and

C ra

pid

test

s in

dis

trict

s. A

nti-H

epat

itis

B

and

C a

ntib

ody

dete

ctio

n (E

LIS

A) a

t PH

L: A

cute

Hep

a-tit

is B

if H

BsA

g or

IgM

ant

i-HB

co

re- p

ositi

ve a

nd H

epat

itis

C

if A

nti-H

CV

pos

itive

. Lep

tosp

i-ro

sis

rapi

d te

st.

IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

7

Acu

te R

es-

pira

tory

Infe

c-tio

n (A

RI)

Stre

pto-

cocc

us

pneu

mon

ia,

R

espi

ra-

tory

syn

cy-

tial v

irus,

P

arai

nflue

nza

viru

s, In

flu-

enza

viru

s,

Av

ian

influ

-en

za v

irus,

H

aem

ophi

lus

influ

enza

B,

Le

gion

ella

pn

eum

oph-

ila, Y

ersi

nia

pest

is

Sam

ple

colle

c-tio

n de

pend

ent

on s

uspe

ct

culp

rit: n

asal

, th

roat

and

/or

bloo

d sa

mpl

es.

Viru

ses

sus-

pect

ed: A

t 2-

8°C

for

48 h

rs. I

n ca

se o

f de

lay

in

trans

-po

rtatio

n st

ore

at

-70°

C.

Bac

teria

su

s-pe

cted

: cu

lture

is

olat

es a

t -2

0 ºC

.

Viru

ses

susp

ecte

d:

At 2

-8°C

, sw

abs

in

VTM

. Bac

teria

su

spec

ted:

im

med

iate

ly

in tr

ansp

ort

med

ia a

t 2-8

ºC

.

Test

ing

depe

nden

t on

susp

ect

culp

rit: m

ultip

lex

test

ing

for

viru

ses,

cul

ture

for b

acte

ria?

of 88


IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

One

nas

al

and

one

thro

at

swab

sam

ples

fro

m a

ll S

AR

I ca

ses

usin

g ap

prop

riate

P

PE

.

At 2

-8°C

fo

r 48

hrs.

In

cas

e of

de

lay

in

trans

-po

rtatio

n st

ore

at

-70°

C.

At 2

-8°C

, sw

abs

in V

TMIn

fluen

za te

stin

g by

PC

R/

Rea

l-tim

e P

CR

test

ing.

One

nas

al

and

one

thro

at

swab

sam

ples

fro

m a

ll su

s-pe

cted

avi

an

influ

enza

cas

es

usin

g ap

prop

ri-at

e P

PE

(with

in

72 h

ours

of

onse

t of f

ever

)

2-8°

C fo

r 5

days

. S

tore

in

-70°

C

deep

fre

ezer

if

dela

yed

At 2

-8°C

, sw

abs

in V

TMIn

fluen

za te

stin

g by

PC

R/

Rea

l-tim

e P

CR

test

ing.

Blo

od o

r spu

-tu

m s

ampl

e C

ultu

re

isol

ates

at

-20

ºC

Imm

edia

tely

in

trans

port

me-

dia

at 2

-8 ºC

Isol

atio

n of

Yer

sini

a pe

stis

at

refe

renc

e la

bora

tory

out

side

B

huta

n.

of 88


IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

8

Den

gue

feve

rD

engu

e vi

-ru

ses

type

1,

2, 3

and

4

Blo

od s

ampl

eA

t 2-8

°C

for 7

da

ys.

Sto

re a

t -2

0°C

de

ep

freez

er if

de

laye

d

At 2

-8 ºC

Den

gue

rapi

d te

st in

end

emic

ar

eas

and

deng

ue a

ntib

ody

dete

ctio

n (E

LIS

A) a

t PH

L:

Det

ectio

n of

den

gue

IgM

/IgG

fro

m s

erum

or d

emon

stra

tion

of a

four

fold

or g

reat

er ri

se in

re

cipr

ocal

IgG

/IgM

ant

ibod

y tit

res

to o

ne o

r mor

e de

ngue

vi

rus

antig

ens

in p

aire

d se

rum

sa

mpl

es

9

Dip

hthe

riaC

oryn

ebac

te-

rium

diph

the-

riae

Nas

al s

wab

, th

roat

sw

ab

and/

or p

iece

s of

pse

udo-

mem

bran

e

Cul

ture

is

olat

es

at -2

0 ºC

Imm

edia

tely

in

trans

port

me-

dia

at 2

-8 ºC

Isol

atio

n of

Cor

yneb

acte

ri-um

diph

ther

iae

from

a c

linic

al

spec

imen

.

of 88


IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

10

Feve

r with

R

ash

Mea

sles

vi

rus,

Rub

ella

vi

rus,

Den

-gu

e vi

rus,

O

rient

iats

ut-

suga

mus

, E

nter

ovi-

rus7

1, C

ox-

sack

ievi

rus

A16

, oth

ers,

Gro

up A

st

rept

ococ

-cu

s &

Oth

er

viru

ses

Sam

ple

colle

c-tio

n de

pend

ent

on c

linic

ally

su

spec

t cul

prit:

bl

ood

or s

tool

sa

mpl

e/re

ctal

sw

ab, t

hroa

t an

d ve

sicl

e sw

ab

Con

-se

rvea

t +4

°C.E

n-te

rovi

rus

71 a

nd

Cox

sack

i-ev

irus

A16

: sw

ab

sam

ples

in

VTM

. re

st a

t 2-4

ºC

and

-2

0 ºC

if

dela

yed

At 2

-8 ºC

Test

ing

stra

tegy

dep

ende

nt

of c

linci

ally

sus

pect

ed c

ulpr

it:

Det

ectio

n of

mea

sles

and

ru

bella

-spe

cific

ant

ibod

ies

by

ELI

SA

. Det

ectio

n of

Orie

ntia

t-su

tsug

amus

hi b

y ra

pid

test

or

PC

R in

the

futu

re. I

sola

tion

of

Ent

erov

irus

71 o

r Cox

sack

i-ev

irus

A16

and

PC

R te

stin

g.

Blo

od s

ampl

e2-

8°C

for

7 da

ys.

Sto

re in

-2

0°C

if

dela

yed

.

At 2

-8 ºC

Pre

senc

e of

mea

sles

-spe

cific

Ig

M a

ntib

odie

s in

ser

um

(ELI

SA

)..

of 88


IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

Blo

od s

ampl

e2-

8°C

for

7 da

ys.

Sto

re in

-2

0°C

if

dela

yed

.

Imm

edia

tely

at

2-8°

CP

rese

nce

of ru

bella

-spe

cific

Ig

M a

ntib

odie

s in

ser

um

(ELI

SA

).

11

Bac

teria

l M

enin

gitis

N. m

en-

ingi

tidis

,

S

. pne

u-m

onia

e,

H

.influ

enza

e B

Cer

ebro

spin

al

fluid

and

/or

bloo

d sa

mpl

e

Cul

ture

is

olat

es

at -2

0 ºC

Imm

edia

tely

in

trans

port

me-

dia

at 2

-8 ºC

Pos

itive

cer

ebro

spin

al fl

uid

cultu

re o

r pos

itive

blo

od c

ul-

ture

.

12

Acu

te

Enc

epha

litis

S

yndr

ome

(AE

S)

1. J

apan

ese

ence

phal

itis

(JE

) viru

s, 2

. R

abie

s vi

rus,

3.

Oth

er

viru

ses

Blo

od s

ampl

e an

d/or

cer

-eb

rosp

inal

flui

d (C

SF,

whe

n po

ssib

le)

At 2

-8°C

S

tore

at

-20°

C if

de

laye

d

At 2

-8 ºC

Japa

nese

enc

epha

litis

(JE

) vi

rus:

• F

ourfo

ld o

r gre

ater

rise

in

the

JE v

irus-

spec

ific

antib

ody

in p

aire

d se

ra (a

cute

and

co

nval

esen

t pha

ses)

thro

ugh

IgM

/IgG

, ELI

SA

• Det

ectio

n of

the

JE v

irus

or

antig

en in

blo

od b

y P

CR

• J

E

viru

s-sp

ecifi

c Ig

M in

the

CS

F

of 88


IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

13M

alar

iaP

lasm

odiu

m

spB

lood

Spe

ci-

men

N

ot a

p-pl

icab

le

Not

app

licab

leC

onfir

m b

y M

icro

scop

ic

exam

inat

ion

of b

oth

thic

k an

d th

in b

lood

sm

ears

.

14

MD

R-T

BM

. tub

ercu

-lo

sis

Spu

tum

At 2

-8°C

fo

r 7

days

. S

tore

at

-20°

C if

de

laye

d

At 2

-8 ºC

isol

atio

n o

f M. t

uber

culo

sis

and

Dru

g R

esis

tant

pat

tern

of

MD

R

15P

ertu

ssis

Bor

dete

llap-

ertu

ssi

Nas

opha

ryn-

geal

spe

cim

enC

ultu

re

isol

ates

at

-20

ºC

Imm

edia

tely

in

trans

port

me-

dia

at 2

-8 ºC

Isol

atio

n of

B. p

ertu

ssis

from

cl

inic

al s

peci

men

s

16

Rab

ies

(hu-

man

)R

abie

s vi

rus

Blo

od s

ampl

e,

CS

F an

d/or

sa

liva

At -

20

ºC if

im-

med

iate

sh

ipm

ent

is n

ot

poss

ible

Imm

edia

tely

at

2-8°

CTe

st c

an b

e pe

rform

ed a

t N

atio

nal C

entre

for A

nim

al

Hea

lth. I

sola

tion

of ra

bies

vi

rus

from

clin

ical

spe

cim

ens

and

confi

rmat

ion

of ra

bies

vi

ral a

ntig

ens

by d

irect

fluo

-re

scen

t ant

ibod

y te

stin

g.

of 88


IDS

yndr

omes

/ D

isea

ses

Res

pons

ible

Pa

thog

ens

Wha

t to

colle

ctS

tora

geTr

ansp

orta

-tio

n To

Con

firm

Cas

e(s)

17

Con

geni

tal

Rub

ella

Syn

-dr

ome

(CR

S)

Rub

ella

viru

sB

lood

sam

ple

At 2

-8°C

fo

r 7

days

. S

tore

at

-20°

C if

de

laye

d

At 2

-8 ºC

Test

ing

of s

erum

sam

ple

from

the

infa

nt: P

rese

nce

of

rube

lla-s

peci

fic Ig

M in

ser

um

(ELI

SA

)..

18Te

tanu

sC

lost

ridiu

m

teta

niN

o sa

mpl

e re

quire

d!N

ot a

p-pl

icab

leN

ot a

pplic

able

The

diag

nosi

s is

ent

irely

clin

i-ca

l and

doe

s no

t dep

end

on

bact

erio

logi

cal c

onfir

mat

ion.

19

Typh

oid

/P

arat

ypho

id

feve

r

Sal

mon

ella

ty

phi /

par

a-ty

phi

Blo

od a

nd/o

r st

ool s

ampl

e/re

ctal

sw

ab

Cul

ture

is

olat

es

at -2

0 ºC

Imm

edia

tely

in

trans

port

me-

dia

at 2

-8 C

Rap

id te

sts

in h

ospi

tals

. Iso

la-

tion

and

cultu

re o

f Sal

mon

ella

ty

phi/

para

typh

i fro

m b

lood

or

stoo

l.

20

Unu

sual

D

isea

se(s

), D

eath

(s) O

R

Eve

nt

Bio

logi

cal,

chem

ical

or

radi

olog

ical

ev

ents

Sam

ple

depe

nden

t on

clin

ical

sym

p-to

ms

Test

ing

depe

nds

on s

uspe

ct

culrp

it.

of 88


Daily Case Record Log(To be filled by Clinicians in OPD)

Reporting Site:____________________Date :_________________

ID Case of diseases/syndromes No. of Cases

No. of Death

1 Anthrax 2 Acute Bloody Diarrhea3 Acute Watery Diarrhea 4 Acute Encephalitis Syndrome5 Acute Flaccid Paralysis 6 Acute Haemorrhagic Fever Syndrome7 Acute Jaundice Syndrome8 Acute Respiratory Infection 9 Acute Encephalitis Syndrome 10 Dengue fever11 Severe Dengue12 Diphtheria13 Fever with Rash14 Food poisoning 15 Malaria 16 Pertussis17 Rabies (human)18 Congenital Rubella Syndrome 19 Multi-drug Resistance Tuberculosis20 Tetanus21 Typhoid /Paratyphoid fever22 Unusual Disease(s), Death(s) OR Event

Reported by: _________________Dated Initial : _______

Annex 2

of 88


Annex 3Weekly Case Reporting Form

(To be filled by SFP)

Reporting Site:________________Reporting Week: ____________

ID Case of diseases/syndromes No. of Cases

No. of Cases

1 Anthrax 2 Acute Bloody Diarrhea3 Acute Watery Diarrhea 4 Acute Encephalitis Syndrome5 Acute Flaccid Paralysis 6 Acute Haemorrhagic Fever Syndrome7 Acute Jaundice Syndrome8 Acute Respiratory Infection 9 Acute Encephalitis Syndrome 10 Dengue fever11 Severe Dengue12 Diphtheria13 Fever with Rash14 Food poisoning 15 Malaria 16 Pertussis17 Rabies (human)18 Congenital Rubella Syndrome 19 Multi-drug Resistance Tuberculosis20 Tetanus21 Typhoid /Paratyphoid fever22 Unusual Disease(s), Death(s) OR Event

Reported by: ________________Dated Initial : __________

of 88


Annex 4Immediate Disease Reporting Form

Reporting Site: __________Date of Reporting: __________

ID Case of diseases/syndromes No. of cases

No. of Deaths

100 Anthrax (Suspected)

101 Acute Flaccid Paralysis

102 Acute Haemorrhagic Fever Syn-drome

103 Avian Influenza

104 Bacterial Meningitis

105 Cholera

106 Malaria

107 Measles

108 Pertussis

109 Pneumonic plaque

110 Rabies (human)

111 Rubella

112 Neonatal Tetanus

113 Unusual Death (s)

Reported by: _______________Dated Initial: ___________

Note: Copy must be sent to PHL immediately.

of 88


Annex 5

Report Receiver @ NADSAE

Date & Time of Reporting

What do you want to report?

When did this happen? (Time of Event)

Where did this happen? (Location of Event)

Number of people affected

Number of death due to the event

Other Information (if any)

Event Reporting Form

of 88


Ann

ex 6

SN

Attr

ibut

esTa

rget

Tim

e el

apse

d in

day

s

1 T

ime

take

n fo

r re

ach

wee

kly

data

fro

m

sent

inel

site

to P

HL

Rep

ort r

each

es/e

nter

into

onl

ine

syst

em

late

st b

y M

onda

y of

eve

ry n

ext w

eek

2Ti

me

take

n fo

r sp

ecim

en fr

om s

ite to

ar-

rive

at P

HL

With

in 3

-4 d

ays

of s

ampl

e co

llect

ion

3Ti

me

take

n to

pro

cess

, tes

t and

gen

erat

e re

sults

by

PH

LW

ithin

1 w

eek

of s

ampl

e re

ciep

t

4Ti

me

take

n to

not

ify S

FP a

fter r

esul

t gen

-er

atio

nw

ithin

1 d

ay o

f rep

ort

5Ti

me

take

n to

gen

erat

e re

port

by P

HL

Eve

ry T

uesd

ay o

f nex

t wee

k

6Ti

me

take

n to

dis

sem

inat

e re

port

to t

he

sent

inel

site

s by

PH

LE

very

Tue

sday

of n

ext w

eek

1. T

imel

ines

s

Mon

itorin

g &

Eva

luat

ion

Form

of 88


SN

Attr

ibut

esTa

rget

Per

cent

age

1P

erce

ntag

e of

form

s re

ceiv

ed w

ith c

ompl

ete

info

rmat

ion

from

site

sA

t le

ast

80%

of

the

repo

rts h

ave

all d

ata

field

s co

mpl

eted

2P

erce

ntag

e of

site

s re

porti

ngA

t le

ast

80%

of

all

sent

inel

site

s de

liver

ev

ery

repo

rting

inte

rval

3P

erce

ntag

e of

dat

a fo

rms

ente

red

from

the

fo

rms

into

the

data

base

.A

t le

ast

80%

of

case

s fro

m w

hich

spe

ci-

men

s ar

e co

llect

ed h

ave

data

col

lect

ed

2. C

ompl

eten

ess

3. C

onsi

sten

cy

SN

Attr

ibut

esTa

rget

Per

cent

age

1U

nexp

ecte

d or

sud

den

incr

ease

or

decr

ease

in

num

ber o

f not

ifiab

le d

isea

ses

repo

rted

--

2U

nexp

ecte

d or

sud

den

chan

ge in

the

perc

enta

ge o

f sp

ecim

ens

test

ing

posi

tive

for a

not

ifiab

le d

isea

se--

3U

nexp

ecte

d or

sud

den

shift

in th

e ty

pe o

r sub

type

of

etio

logi

c ag

ent

dete

cted

--

4C

hang

es in

the

dist

ribut

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of ri

sk fa

ctor

s re

porte

d--

5C

hang

e in

the

age

dist

ribut

ion

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ases

repo

rted

--

of 88


4. O

utbr

eaks

and

Eve

nts

SN

Attr

ibut

esTa

rget

Num

ber

1N

umbe

r of o

utbr

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to th

at

of th

e pr

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ear

--

2N

umbe

r of o

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inve

stig

ated

and

con

firm

ed b

y la

bora

tory

--

3N

umbe

r of

out

brea

ks t

hat

have

bee

n in

terv

ened

an

d co

ntro

lled

--

Any

oth

er C

omm

ents

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Eval

uate

d by

:___

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Dat

ed In

itial

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newars - rcdc.gov.bt · pdf fileevent based surveillance is being incorporated to sup-plement...

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