Communicable disease Surveillance Programme

What is surveillance?

Why surveillance?

• Integrated Disease Surveillance Project (IDSP) is a decentralized, state based surveillance programme in the country. It is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. It is also expected to provide essential data to monitor progress of on-going disease control programmes and help allocate health resources more efficiently.

1 Syndromes under Surveillance:

• Fever• Less than seven days duration without any localizing signs• With Rash• With altered sensorium or convulsions• Bleeding from skin or mucus membrane• Fever more than seven days with or without localizing signs

• Cough more than three weeks duration• Acute Flaccid Paralysis• Diarrhoea• Jaundice• Unusual Events causing death or hospitalization

Types of surveillance under IDSP:

• Syndromic:

• Presumptive:

• Confirmed:

Symptoms, signs and syndrome

• Symptom is complaint perceived by the patient or identified by the examiner (e.g. fever, loose motions, headache, vomiting, cough etc.)

• Signs are findings on examination of patients e.g. skin rash, yellow discoloration (jaundice).

• • Syndrome is group of symptoms and/or signs

attributable to particular disease condition (e.g. fever with skin rash indicative of measles).

Which are the reporting units?

Reporting units for disease surveillance

• Public health sector• Private health sector• RuralSub-centers, PHCs, CHCs, District

HospitalsSentinel Private practitioners (SPPs) and Sentinel hospitals.UrbanUrban Hospitals, ESI / Railway / Medical college hospitalsSentinel Private nursing homes, sentinel hospitals, Medical colleges, Private and NGO laboratories

Data collection Flow of information:

Weekly Information Flow under IDSP

Sub-Centres

P.H.C.s

C.H.C.s

Dist.Hosp.

ProgrammeOfficers

Pvt. Practioners

D.S.U.

P.H.LabOther Hospitals: ESI, Municipal Rly., Army etc.

S.S.U.

C.S.U.

Nursing Homes

Private Labs.

Corporate Hospitals

Med.Col.

Private Hospitals

Transmission of data

Feedback

Laboratory confirmation

Syndrome Action

Only Fever Blood Smear for all patients

Acute Flaccid Paralysis

Inform PHC MO immediately to arrange for collection of stool samplesTwo samples of stools taken at interval of 24 hours and transported to the

MO PHC in reverse cold chain

Loose watery stools with dehydration in an adult

Take sample of stools in a filter paper or in a sterile bottle and send it by reverse cold chain to the nearest District Laboratory (within two hours) or use Cary-Blair medium for transport of the sample

Fever with rash

Referred to the MO PHC for specific lab action

Fever with altered sensorium

Fever with bleeding

Fever more than 7 days

Cough for more than three weeks

Unusual severe syndromes

COLLECTION, STORAGE & TRANSPORT OF SPECIMENS

INTEGRATED DISEASE SURVEILLANCE PROJECT- TRAINING

FOR STATE AND DISTRICT SURVEILLANCE OFFICERS

Methods of Collection:

a) Venepuncture b) Finger prick

For serum & For peripheral blood

Blood culture smear

PERFORMING VENE PUNCTURE

Label the collection container before commencement of venepuncture.

Gloves should be worn.

Use sterilized/sterile disposable syringes and needles.

Clean the site well with spirit.

Tighten tourniquet.

- Perform venepuncture,and collect 5 ml of blood.

- After blood collection, remove tourniquet and

withdraw

the needle .

- Remove the needle from the syringe.

- Carefully transfer blood from the syringe without

squirting, into a sterile screw capped plastic leak

proof

specimen container.

- Any blood spill is wiped with 70% ethanol.

- All the swabs are placed in plastic bags for

disposal.

- If the outside of the vial is visibly

contaminated with blood, it should be

cleaned with 10% freshly prepared

sodium hypochlorite solution.

EXTRACTION OF SERUM

5ml of venous blood is collected remove the needle before transferring to sterile dry test tube.

Let the specimen clot for 30 mins. at ambient temperature. Do not shake.

Then place in a cool box for clot retraction at 4-8o C, for a minimum of 1-2 hours.

If facilities for separation of serum are not available, then it should be refrigerated at 4o C. (NOT FROZEN).

Otherwise centrifuge @ 1000 G for 10 mins.

Separate the serum from the clot. Sera should be transported at 4-8o C and

can last at this temperature for upto 10 days.

SERUM………

Required for the diagnosis of the following diseases:

1) Typhoid- Paired sera

2) Leptospirosis- Paired sera

3) Measles- Paired sera

4) Dengue- Paired sera

5) Japanese encephalitis- Paired sera

6) Hepatitis – Single sample

7) Plague- Paired sera

Ideally blood should be collected within 5-7 days of the start of illness. The second sample should be collected with a gap of 10 days.(for paired sera)

BLOOD FOR CULTUREHow much?

Venous blood0.5 – 2 ml for infants2-5 ml for children5-10 ml for adults

When?

As early as possible and before starting antibiotics

Transport:

-Collect into blood culture bottles (with Glucose broth Or Bile salt broth). --Should be transported at ambient temperature.

Preparation for collecting blood for culture:

Blood culture contd….

After palpating the vein, clean the site for venepuncture with 70% alchol for at least 30 secs

Next clean with iodine (tincture iodine ) in concentric circles away from the puncture site covering an area of 1-2” in diameter

SKIN PREPARATION (Very important)

Blood culture contd….

Collect required amount of blood with a sterile needle and syringe.

Transfer with the needle into the blood culture bottle.

Shake the bottle properly to prevent clotting.

Can be kept at room temperature.

Always label the bottle and with the patient details mention time & date of collection

Blood can also be collected in an anticoagulant solution e.g. EDTA.

A second person wearing gloves should help in shaking the vial for mixing the blood well with the anticoagulants.

Usually collected for detection of malarial antigen.

FINGER PRICK – Examination of bloodsmear

for malaria

# Peripheral blood smears are prepared for the diagnosis of malaria.# Collect blood either during or 2-3 hours after the peak oftemperature.# Sample should be taken before administration of antimalarial drugs.# Both thick and thin films should be made.# Thick film is used to detect the parasite and thin film to determinethe species of the parasite.

Thick Films:

Take 3-4 drops of blood and spread over a 1 cm square area or in a 1cm diameter circle. Allow to dry,

Thin Films:

These are prepared by taking a drop of blood on one edge of the slide and spreading it evenly over the surface with another slide.

Examination of blood samples for leptospirosis, Dengue and chikun

gunya

• Serum from blood sample is prepared.• Antibody detection – IgM ELISA method.

– Microplates precoated with inactivated antigen.– Patient’s serum sample is added.– Incubation at 37º C for a definite period.– Addition of conjugates followed by aspiration and

washing many times.– Results read by colorimetric method using

spectrometer.

RESPIRATORY TRACT SPECIMEN COLLECTION

Specimens are collected from the upper or lower respiratory tract, depending on the site of infection. Upper respiratory tract pathogens (viral and bacterial): a) Throat swab.b) Nasopharyngeal swab.

Lower respiratory tract pathogens:

a) Sputum specimens.

MATERIALS REQUIRED :

Transport media – bacterial and viral.

Throat swabs (Dacron and cotton swabs).

Tongue depressor Nasal speculum

20-50 ml syringeSterile screw-cap test tubes and wide-mouthed clean sterile containers (minimum volume 25 ml.)

METHOD OF COLLECTING A THROAT SWAB :

* Hold the tongue down with the tongue depressor.

* Use a strong light source to locate areas of

inflammation and exudate.(posterior pharynx and

the tonsillar region of the throat behind the uvula) .

* Rub the area back and forth with a sterile cotton

swab.

* Sample the posterior pharyngeal wall at the end to

avoid gagging by the patient.

•Withdraw the swab without touching

cheeks, teeth or gums and insert into

a sterile screw-cap test tube

containing appropriate transport

medium required.

- Seat the patient comfortably, tilt the head back and insert the nasal speculum.-Insert a flexible cotton swab through the speculum parallel to the floor of nose. - Alternately, bend the wire and insert it into the throat and move the swab upwards into the nasopharyngeal space.- Rotate the swab on the nasopharyngeal membrane a few times, remove it carefully and insert it into a screw-cap tube containing transport medium.- Break off the top part of the stick without touching the tube and tighten the screw cap firmly.- Label the specimen tube.

METHOD OF COLLECTING PER-NASAL AND POST-NASAL SWABS :

- Have the patient sit with the head tilted slightly backward.- Flush a plastic catheter or tubing with 2-3 ml of VTM/sterile normal saline.- Instill 1-1.5 ml of VTM (viral transport medium)/sterile normal saline into one nostril.- Insert the tubing into the nostril parallel to the palate and aspirate nasopharyngeal secretions.- Repeat this procedure with the othe nostril.- Collect 1-2 ml in a sterile VTM and transport in cold chain at 2-8o C

METHOD OF COLLECTING NASOPHARNGEAL WASH/ASPIRATE :

Materials required :Select a good wide-mouthed sputum container, which is disposable, made of clear thin plastic, unbreakable and leak proof material.

Method of collection :Collect an early morning sample after rinsing the mouth with water.Instruct the patient to inhale deeply 2-3 times, cough up deeply from the chest and spit in the sputum container by bringing it closer to the mouth.This should be done in the open or away from other people.Make sure the sputum sample is of good quality. A good sputum sample is thick purulent and sufficient in amount.

COLLECTION OF SPUTUM SAMPLE

HANDLING AND TRANSPORT

- If the specimen is collected in the field and cannot be immediately processed, it should be transported to the laboratory within 3-4 days of collection. - The specimen should be properly labelled and kept away from the sun and heat. These can be placed in a special box, which can withstand leakage of contents, shocks and other conditions incident to ordinary handling practices.-These boxes should be kept & transported in cool conditions. - If delay is unavoidable, the specimens should be refrigerated.

ACUTE (WATERY) DIARRHOEA

Causative Agents : Bacteria(eg.Cholera,Salmonella,Shigella, E.coli) Viruses (eg Rota virus) and Parasites.

Which sample should be collected? Stool sample is preferred incase of infants rectal swabs can be collected.

COLLECTION OF FAECES

When should it be collected?

Collect soon after onset of diarrhoea

For viruses : < 48hrs of onset,

For bacteria : < 4days after onset

of illness.

PREFERABLY BEFORE STARTING ANTIBIOTICS

If required two or three samples can be collected

on consecutive/alternate days.

In which container?

Clean dry leak proof container Container with spatula

CONTAINERS SHOULD NOT BE WASHED

WITH

DISINFECTANT SOLUTION

INSTRUCTIONS FOR COLLECTING FAECES

# Label the specimen container clearly with patients name and date of collection. ( If a specimen container is not available, a clean jar with a screw-top lid may be used.)

# Pass faeces directly into the container. Do not contaminate the faeces with urine/Or place a separate clean container with a wide opening (for example, an ice-cream container), or plastic wrap or newspaper in the toilet bowl.Transfer enough faeces with spatula to at least half fill the specimen container.

# Screw the lid on the specimen container firmly. Place it in a sealed plastic bag.

COLLECTION OF RECTAL SWAB

This method of sampling is less satisfactory than collecting faeces. It is not appropriate for parasitology.

•Moisten a cotton swab with sterile saline.

•Insert it inside the anal sphincter and go

upto 2-4 cm inside the rectum .

•Gently rotate upto 90 degrees, so that faeces covers the swab.

•Withdraw the swab

•Place it in transport medium, break off the top portion of swab stick and discard

•Label the specimen and place it in a plastic bag with the appropriate request slip attached

• If delay of more than two hours is anticipated, inoculate the specimen in a transport medium

• Cary Blair medium : for bacterial pathogens(Salmonella , Shigella, Esch coli and Vibrio). Should reach laboratory in 2-3 days time.Can keep at room temperature.

V.R. Fluid :For Cholera should reach laboratory in 2-3 days time.Can keep at room temperature.

For viruses keep in fridge (4ºC-8ºC)DO NOT FREEZE.

Rectal swab in Cary Blair medium

Rice water stool in V.R. Fluid

HANDLING AND TRANSPORT

When do we collect?

The specimen must be taken by a physician experienced in the procedure. CSF is used in the diagnosis of viral, bacterial, parasitic, and fungal meningitis.Also Dengue and Japanese Encephalitis.Collect as early in the disease as possible, before antibiotics

MATERIALS REQUIRED:

Lumbar puncture tray which includes :Sterile materials : gloves, cotton, towels or drapes.Local anaesthetic, sterilized needle, syringe.Skin disinfectants : 10% providone iodine or 70% alcoholTwo lumbar puncture needles, small bore with stylet (sterilized)Six externally threaded sterile screw-cap tubes and tube rack.

Gloves

Drapes

METHOD OF COLLECTION :

Only experienced clinicians should be involved in performingA lumbar puncture. CSF is collected directly into the separate screw-cap sterile tubes. Separate tubes should be used for bacterial and viral processing.Step 1. Make the patient lie on the bed in left lateral position. Ask the patient to flex the neck (so that the chin touches the chest) hip and the knee joint.

Step2: Using the iliac crest as the reference point, palpate the joint space between the 4th and the 5th lumbar vertebrae and identify the surface anatomy.Step3; Disinfect the site meticulously with 10% povidone iodine or 70% isopropyl alcoholby swabbing the skin concentrically from the centre of the site outwards. Let the disinfectant evaporate.- Do not repalpate the site again.Step 4: Infiltrate the local area with the local anaesthetic and wait for 4-5 mins for the effect to appear before performing lumbar puncture.

L4

L5

Step5: Insert the sterile lumbar

puncture needle between the 4th

and 5th lumbar vertebrae to a depth

of 4-5 cm, withdraw the stylet. Fluid

flows freely through the needle.

Step 6: Between 1 and 2 ml of CSF is

collected in each of the 3 tubes,

a) one for culture,

b) one for biochemical analysis and

c) one for cytology.

HANDLING AND TRANSPORTATION :

In general send the specimens to the laboratory

and process as soon as possible.

Transport CSF specimens for bacteriology at

ambient temperature, generally without transport

media. Never refrigerate the CSF, as many of the

bacterial pathogens do not survive well at low

temperatures.

CSF specimens for virology do not need transport

medium. They should be transported at 4-8o C.

POST MORTEM SPECIMEN COLLECTION

When, why & how?# Need to be collected during outbreak situation when causative agent is not known. # Strict precautions, including respiratory protection from aerosolized particles, must be taken when carrying out post-mortem specimen collection during outbreaks. # Collect the specimens as soon as possible, preferably within 24 hour since viral titres decline while bacteria multiply rapidly after death..

Materials Required :- Barrier precautions : double gloves, sterile gown, eye goggles, mask.- Blood and other fluids, should be collected as mentioned before.- Aseptic surgical and biopsy instruments for collecting tissue specimens.- For histology :saline formalin.- For culture:Sterile saline/appropriate viral and bacterial transport media. - Sterile containers, sterile screw cap tubes or vials, glass slides and slide box.- Disinfectant such as household bleach diluted 1:10 in water.

Method of collection :

- Use a separate sterile instrument for each tissue

specimen from affected sites (several fragments with

1-2 grams of each is sufficient).

- Smaller, but adequate, specimens may be taken with

a biopsy needle.

- Place different tissues in separate sterile containers

containing the relevant medium

- Label all containers and tighten the screw caps

firmly.* Blood may be taken from the heart cavities.* If cerebral malaria is suspected, make several smears from the cerebral cortex on glass slides to detect Plasmodium falciparum. Label the slides and transport in a slide box.

Handling and Transportation :- Fixed specimens can be stored and transported at ambient temperature.- Tissue specimens for isolation of bacterial pathogens can be transported at ambient temperature in transport media for upto 24 hours.- Transport tissue specimens for isolation of viral pathogens in viral transport medium or sterile saline at 3-8o C for 24-48 hours. For longer periods, freeze and store at –70o C.- If rabies is suspected and brain samples are collected, freeze unfixed specimens immediately after collection. Formalin-fixed samples are also useful and may be transported at ambient temperature.

Some general principles

Effective diagnostic microbiology depends upon the correct collection and timing of clinical specimens and their proper transport to the laboratory under optimal conditions. - Specimen should be in adequate quantity.- Must be collected before the administration of antimicrobial agents. - Contamination of specimen with externally present organisms of normal flora of body must be prevented. - Specimen must be collected at appropriate stage of the diseases.- Specimen should not get contaminated during storage.- Specimen handling should not be risky to individual.

GENERAL RULES FOR COLLECTION AND TRANSPORTATION OF SPECIMENS FOR CULTUTRE:

• Apply strict aseptic techniques.• Wash hands before and after the collection.• Collect or place the specimen in a sterile container.• Ensure that the outside of the specimen container is clean.• Tightly close the container.• Appropriately label and date the container and complete the requisition form.• Arrange for immediate transportation to the laboratory.

UNIVERSAL PRECAUTIONS• BARRIER PROTECTION• HAND WASHING• SAFE TECHNIQUE• SAFE HANDLING OF SHARP• SAFE HANDLING OF SPECIMEN• SAFE HANDLING OF SPILLS• USE OF DISPOSIBLE• IMMUNISATION WITH HEP-B VACCINE

BARRIER PROTECTION

Gloves-• Use well fitting, disposable / autoclaved

Change if visibly contaminated / breachedRemove before handling telephones, performing office work, leaving workplace

BARRIER PROTECTION

• Facial protection – When splashing or spraying of blood / blood fluids expected

• Gowns/Special uniforms – in high risk areas

• Occlusive bandage – breach of skin

All skin defects must be covered with water proof dressing.

HAND WASHING

An ideal safety precaution

Washing with soap and water

Hands must be washed-

• Immediately after contamination

• Before eating, drinking, leaving the workshop

• After removing gloves

• At completion of days work

Hand wash

Sharps policy

• Reduce use

• Selection of devices

• Care in use

• Disposal

Handling of sharps• Dispose your own sharps yourself. • Never pass used sharps to another person. • During exposure-prone procedures, minimize

the risk of injury by ensuring that the operator has the best possible visibility. E.g. by positioning the patient, adjusting good light source and controlling bleeding.

Handling of sharps

• Protect fingers from injury by using forceps instead of fingers for guiding suturing.

• Never recap, bend or break disposable needles.

• Place used needles and syringes in a rigid puncture resistant container

• Destroy using needle destroyer.

Chemical disinfectants effective in inactivating HIV

• Ethanol 70% 3-5 min

• Povidone iodine 2% 15 min

• Formaline 4% 30min

• Gluteraldehyde 2%(cidex)30min

• Hydrogen peroxide 6% 30min

SAFE HANDLING OF SPECIMEN

MANAGEMENT OF BLOOD SPILLS

• Spill on floor/ work surface should be covered with paper towel / blotting paper / newspaper / absorbent cotton.

• 1% Bleach solution should be poured on an the spill and covered with paper for 30 minutes

• All the paper / cotton should be removed with gloved hands

Occupational Exposure

• Contact of blood with skin

• mucous membrane

• non intact skin

• Percutaneous injury

On Exposure

• Wash needle stick injuries and cuts with soap and water

• Flush splashes to nose, mouth or skin with water

• Irrigate eyes with clean water, saline or sterile irrigates

POST EXPOSURE PROPHYLAXIS

• Assess risk of infection versus toxic side effects of drugs

• PEP decision to be based on:

• (1) Degree of exposure to HIV

• (2) HIV status of the source of exposure

Standard Precautions

• All patients to be treated as potential carriers of blood borne pathogens

• Use of appropriate personal protective equipments

• Careful handling of sharps and avoiding sharp injury

• Proper disposal of sharps and infectious waste.

Thank You