Operational guideline for ARI, ILI & SARI surveillance · ARI/ILI/SARI Surveillance Guideline 1...
Transcript of Operational guideline for ARI, ILI & SARI surveillance · ARI/ILI/SARI Surveillance Guideline 1...
Operational guideline for
ARI, ILI & SARI surveillance
First Edition 2012
Public Health LaboratoryDepartment of Public Health
Ministry of HealthThimphu: Bhutan
ARI/ILI/SARI Surveillance Guideline
iii Pages
Table of Contents
Acronyms..............................................................................................................iv
1. Background................................................................................................1
2. Objectives...................................................................................................2
3. OperationalaspectsofARI/ILI/SARIsurveillance.....................................2
4. Figure1:ARISurveillanceOverview.........................................................4
5. Figure2:ILI/SARISurveillanceoverview.................................................5
6. RolesandResponsibilitiesofHealthcenters............................................6
7. CaseDefinitions........................................................................................8
8. Reportingsystem......................................................................................9
9. DataCollectionTool...................................................................................10
10. DataAnalysisandFeedback.....................................................................11
11. Samplecollection,storageandtransportation..........................................11
12. ARI/ILIoutbreakandrapidresponse.......................................................12
13. ARI/ILI/SARIMonitoring&Evaluation.......................................................14
14. References.................................................................................................16
15. Annexure1:FormA:ARIreportingformfromBHUs/Hospitals
toDistrictHealthAuthority.........................................................................17
16. Annexure2:FormB:ARIreportingformfromDistricttoARI
Program......................................................................................................18
17. Annexure3:FormC:WeeklyILIandSARIreportingform......................19
18. Annexure4:FormD:ILIcaseInvestigationandSample
collectionform............................................................................................20
19. Annexure5:FormE:SARIcaseinvestigationandsample
collectionform...........................................................................................21
20. Annexure6:Proceduresforsamplecollection.........................................22
21. Annexure7:Samplestorage....................................................................24
22. Annexure8:SpecimenTransportationProcedures.................................25
23. Annexure9:ColdChainMaintenanceTable............................................28
iv Pages
Acronyms
AHB AnnualHealthBulletinARI AcuteRespiratoryIllnessBHU BasicHealthUnitCDD ControlofDiarrheaDiseasesCMO ChiefMedicalOfficerDHO DistrictHealthOfficerDMO DistrictMedicalOfficerH1N1 Hemeagglutinin1Neuraminidase1H5N1 Hemeagglutinin5Neuraminidase1HIMS HealthInformationandManagementIEC InformationEducationandCommunicationILI InfluenzaLikeIllnessIMCI IntegratedManagementofChildhoodIllnessMS MedicalSuperintendentMT MedicalTechnician/TechnologistNRRT NationalRapidResponseTeamOPD OutPatientDepartmentPCR PolymeraseChainReactionPHL PublicHealthLaboratoryRRT RapidResponseTeamRSV RespiratorySyncytialVirusSARI SevereAcuteRespiratoryIllnessVTM ViralTransportMediaWHO WorldHealthOrganization
Public Health Laboratory
ARI/ILI/SARI Surveillance Guideline
v Pages
Acronyms
AHB AnnualHealthBulletinARI AcuteRespiratoryIllnessBHU BasicHealthUnitCDD ControlofDiarrheaDiseasesCMO ChiefMedicalOfficerDHO DistrictHealthOfficerDMO DistrictMedicalOfficerH1N1 Hemeagglutinin1Neuraminidase1H5N1 Hemeagglutinin5Neuraminidase1HIMS HealthInformationandManagementIEC InformationEducationandCommunicationILI InfluenzaLikeIllnessIMCI IntegratedManagementofChildhoodIllnessMS MedicalSuperintendentMT MedicalTechnician/TechnologistNRRT NationalRapidResponseTeamOPD OutPatientDepartmentPCR PolymeraseChainReactionPHL PublicHealthLaboratoryRRT RapidResponseTeamRSV RespiratorySyncytialVirusSARI SevereAcuteRespiratoryIllnessVTM ViralTransportMediaWHO WorldHealthOrganization
Developed by:SonamWangchuk,M.Sc.Microbiology. Head&Microbiologist PublicHealthLaboratory
Contributors:BinayThapa,M.Sc.Med.Microbiology. MicrobiologistPublicHealthLaboratory
SangayZangmo,B.Sc.AlliedHealthSciences.MedicalTechnologist
PublicHealthLaboratory
TsheringDorji,B.Sc.Medical(Laboratory)Technology.MedicalTechnologist
PublicHealthLaboratory
ARI/ILI/SARI Surveillance Guideline
1 Pages
1. Background
Respiratoryillnessduetoinfluenzavirusinfectionandotherrespiratorypathogensisamajorcauseofmorbidityandmortalityworldwide.Annualinfluenzaepidemicsareestimatedtoresultinbetween3-5millioncasesofsevereillnessandbetween250,000and500,000deathseveryyeararound the world. Additionally, lower respiratory infections are theleadingcauseofdeath in low incomecountriesandthethird leadingcauseofdeathworldwide.
In Bhutan,AcuteRespiratory Infection Illness(ARI) is amajor publichealthconcernandaffectsmajorityof thepopulation inBhutan.(ARIrankednumberonepublichealthdisease in thecountry for thepastfive years and it has dominated the morbidity among public healthdiseases (Annual Health Bulletin-2010). The rate of pneumonia isveryhighamongchildrenlessthan5yearsbutthecommoncausativeagentcausingthepneumoniaisunknown.Moreover,thecountryhasnowbecomeendemictoavianinfluenza,therebyposingasignificantthreat to thepeopleof thecountry.So far, thespreadofH5N1virusfromperson-to-personhasbeenvery rare, limitedandun-sustained.However,thisepizooticdiseasecontinuestoposeanimportantpublichealth risk because of its severity with high mortality. Influenza (A/H1N1)2009pandemichastakeneverycountrybysurpriseandmostdevelopingcountrieswereneverpreparedtosuchscaleofpandemic.However,itisfortunatethatthe2009pandemichasbeenrelativelymildbutthenextpandemicmighttakeadifferentcourseintermsofseverity.
As of now the country does not have systematicARI/Influenza LikeIllness/Severe Acute Respiratory Infection(ILI/SARI) surveillancetomonitor the trend of respiratory illnesses and also to find out thecausativeagentsof respiratory infection.Therefore,Bhutanneeds toestablishanefficientARI/ILI/SARIsurveillancesystem formonitoringinfluenza illness to understand the true burden, epidemiology ofinfluenza and other respiratory pathogens, the social and climaticfactors that influence community transmission to help in planning ofinterventionandpreventivemeasures.
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2. Objectives
1. Todeterminetheburdenofrespiratorydiseasesinthecountry;
2. Monitorepidemiologyandseverityofinfluenzaandotherrespiratorypathogens(e.g.Respiratorysyncytialvirus(RSV),adenovirus,para-influenzavirus,andrhinovirus);
3. Provideinformationongroupsathighriskforsevereoutcomes,includinghospitalizationanddeathtoinstitutepreventionandcontrolmeasures.
3. Operational aspects of ARI/ILI/SARI surveillance
3.1 ARI surveillance
ARIwillbeexclusivelyaclinicalbasedsurveillanceandwillbecarriedoutinallhealthcenters.Itwillbeoperationalizedatthreelevels(BHU’s,district/referralhospitalandnationallevel)withtheDistrictHealthOfficerasthenodalofficerinthedistricthospitalsandMedicalSuperintendentin referral hospitals.ARI cases fromhealth facilitieswill be reportedto district health authority and then to nationalARI/CDDprogrammeincluding referral hospitals. The district health officers/medicalsuperintendents will coordinate the overall ARI surveillance in thedistrictandreferralhospitals.Thekeypersoncoordinatingsurveillanceat BHU and hospitalswill be a nodal officer identified by respectiveBHUor hospitalmanagement forARI surveillance in health centers.The national programofficer ofARI/CDDprogrammewill coordinatetheactivityatnationallevel.DatacollectedonARIsurveillancewillbecollatedandanalyzedbyARI/CDDprogrammeandfeedbackprovidedtodistricthealthauthorityforfurtherdisseminationtothehealthcenters(Figure 1).
3.2 ILI/ SARI surveillance
ILIandSARIwillbebothclinicalaswellaslaboratorybasedsurveillanceandthesesurveillanceswillbecarriedoutexclusivelyintheidentifiedsentinel sites (TableNo.1) selected based on geographical location,climaticcondition,populationandpatientreferral.TheCMOorMSwillcoordinate the overall surveillance activities in their respective site.ThereportsfromthesentinelsiteswillbecommunicatedtoPHLbyanidentifiedfocalpersoninsentinelsitesbyhospitalmanagement.
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Table No. 1: Sentinel sites for ILI/SARI surveillanceSelected sentinel sites
Western region Code C e n t r a l
region Code Eastern region Code
Parohospital PAR Trongsa
hospital TON Trashiganghospital TGA
Punakhahospital PUN Damphu
hospital DAM MongarRRhospital MON
P/linghospital PHU
G e l e p h uRRhospital
GAY SamdrupJongkharhospital SZK
Samtsehospital SAM
PHLwillcoordinatetheactivityatnationallevel.DatacollectedforILI/SARIsurveillancewillbecollatedandanalyzedbyPHLandfeedbackprovidedtoCMOofrespectivesentinelsites(Figure 2).PHLwillsendsamplestoreference lab ifdeemednecessaryfor further testingandstudy.
Eachidentifiedsentinelsites(hospitals)forILI will register 3-5 ILI cases randomly for sample collection every week (15-20 per month).Criteria for those ILI cases registered for sample collection should have fever or history of onset of fever within the last 72 hours.A patientmeeting the criteria for sample collection fromOPD/Ward/EmergencyshouldbereferredorreportedtoLaboratorybyconcernedclinicians/nursesforILIcaseregistrationandsamplecollection.Similarlyeach identifiedsite forSARIwill registerallSARIcasesandcollect samples from every SARI case.AllILI/SARIsentinelsiteswillcollectonenasalandonethroatswabsamplesfromILIselectedcasesandallSARIfortestingbyrapidtestkitandreferraltoPHLforPCR/RealTimePCRtesting. Throatswabcollected forPCR/RealTimePCRshouldbeshippedtoPHLonaweeklybasis.Allsentinelsiteswilltestnasalsamples for influenzavirusand inaddition, the sentinel siteshavingbacteriology culture facilities will collect sputum sample/appropriaterespiratory specimen from all SARI cases to carry out culture andidentificationofbacterialrespiratorypathogens(namely Haemophilus influenza B and streptococcus pneumoniae).ThebacteriologyreportsshouldbesharedtoPHLeverymonth.
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1. Figure 1: ARI Surveillance Overview
2. Figure 2: ILI/ SARI Surveillance overview
ARI/ILI/SARI surveillance guideline 15 | P a g e
13. Figure 1: ARI Surveillance Overview
ARI case detection and reporting
Health centers (BHUs/BHU-1s/hospitals/referral hospitals
Weekly reporting
Data collation, analysis and monthly reporting
District Health Authority
National ARI Programme
Monthly feedback
Monthly feedback
HIMS
Monthly reporting
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Mon
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rep
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Figure 2: ILI/ SARI Surveillance Overview
ILI/SARI case detection and reporting
ILI/SARI case selection for samples collection
One nasal swab for rapid test
Two throat swabs sample in VTM
ILI/SARI case registration and samples collection
Public Health Laboratory
Sentinel sites (hospitals/referral hospitals)
Testing by real time PCR
Data analysis
WHO HIMS Sputum/appr. samples culture for SARI where facilities are available
Wee
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rep
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Weekly shipment
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4. Roles and Responsibilities of Health centers
4.1. Roles of BHUs/hospitals including referral hospitals on ARI surveillance
Eachhealthfacilityshouldhavea focal point responsiblefortheroutinesurveillanceoperations.Thehealthfacilityfocalpoint(s)/managementshouldensurethat:
• Casedefinitionsareknownandadheredto;• Alldatacollectionformsarefilledoutcompletelyandaccurately;• Epidemiologicdataareappropriatelymanagedandtransmitted
fromallheathcenterstoARI/CDDprogramme;• Datareportingareoccurringinatimelywayandaccordingto
theindicatorsoutlinedinthesystemmonitoringsection.
4.2. Roles of ILI/SARI surveillance sentinel sites (hospitals including referral)
Eachsentinelsiteshouldhavea focal point responsiblefortheroutinesurveillanceoperations.Thehealthfacilityfocalpoint(s)/managementshouldensurethat:
• Casedefinitionsareknownandadheredto;• AlldatacollectionformsincludingILI/SARIcaseinvestigation
and samples collection forms are filled out completely andaccurately;
• EpidemiologicdataareappropriatelymanagedandtransmittedtoPHL;
• Respiratoryspecimensarecollectedfromappropriatepatientsmeetingthecasedefinitionsandareproperlylabeled,packaged,stored,andtransportedtoPHLaccordingtotheguidelines;
• Datareporting,specimencollection,andspecimentransportatthesentinelsitesareoccurringinatimelywayandaccordingtotheindicatorsoutlinedinthesystemmonitoringsection.
4.3. Roles of ILI and SARI sentinel sites laboratories• Ensureallrespiratoryspecimensandcorrespondingformsare
assignedauniqueIDnumber• Ensurerespiratoryspecimensarecollectedfromappropriate
patientsmeetingthecasedefinitionsandareproperlylabeled,packed, stored, and transported to the PHL according toguidelines
• Performrapidflutest(Rapid flu test kit has limitation in terms
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of sensitivity and identifying influenza subtype).• Ensurerapidflutestresultsarereportedtothetreatingclinician
assoonastestiscompletedandsimultaneouslyrecordedintherelevantform(ILI/SARI).
• Ensure there is adequate stock of test kits, VTM, barcodesandrelevantformsinthelaboratory.
• Referralhospital laboratorieswill, inaddition,collectsputumsamples from same patients enrolled for SARI surveillanceandperformbacteriological tests.ReportsshouldbesharedtoPHLeverymonth.
4.4. Roles of Public Health Laboratory• PHLwill serveas the technical and scientific focal point for
activitiespertainingtoILIandSARIsurveillance• Providetrainingonpropercaseselection,specimencollection,
storageandtransport• Receiving,archivingandstoringoriginalclinicalspecimensat
-70°CforILI/SARIforatleastoneyear.• TestingsamplesusingrealtimePCR/conventionalPCR• Managingcomputerdatabaseanddisseminatingthemonthly
andannualinfluenzasurveillancereports• ReportingtoIHRanycasesofinfluenzanovelstrainsasper
theIHRrequirements• Sharing with WHO collaborating centres a representative
clinicalsampleofseasonalandpandemicinfluenza,• Sharing of samples that react poorly with the WHO CDC
reagentskit,andallnovelvirusesdetected.• Communicating theresultsofall individualconfirmatory tests
forILI/SARIcasesbacktothesentinelsitefocalpointsassoonastheyareknown
• Reportingweeklynationalsurveillancedata intoregionalandglobalinfluenzasurveillanceplatforms
• ParticipatingintheWHOGlobalExternalQualityAssessmentProjectforthemoleculardetectionofinfluenzavirusesaswellasinregionalprogrammes
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5. Case Definitions Therearethreecasedefinitionsinthisguideline;ARI(outpatient),ILI(outpatient)andSARI(Inpatient).TheSARIcasedefinitionisfurtherbrokendown intocasedefinitionsusedforperson≥5yearsoldandchildren<5yearsold.ThecombinationofILIsurveillancewithSARIsurveillancewill provide a description of a broad range ofmedicallyattendedinfluenza.
5.1 Case definition for ARIAnypersonwithsuddenonsetofat leastoneof the four respiratorysymptoms;
• cough,• sorethroat,• coryza,• shortnessofbreath OR• clinician’sjudgmentthattheillnessisduetoaninfection
(Note:ARI may present with or without fever)
5.2 Case definition of ILIAnypersonwithsuddenonsetoffever>38°Candcoughorsorethroatintheabsenceofotherdiagnosis
(Note:Consider sample collection from ILI patients only if onset of fever is within the past 72 hours/3 days)
5.3Case definition for SARI in persons ≥ 5 years oldOnsetofthefollowingsignsandsymptomsduringtheprevious7daysthatresultinhospitalization
• Fever>38ºC;AND• coughorsorethroat;AND• Shortnessofbreathordifficultyinbreathing
(Note:In adult, SARI is not equivalent to classic pneumonia and would not always present as pneumonia).
5.4 Case definition for SARI in children < 5 years oldFor children < 5 years old, theWHO case definition for pneumoniaandseverepneumoniafromtheIntegratedManagementofChildhood
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Illness(IMCI)programmeshouldbeused.TheIMCIcasedefinitionforpneumoniaisanychildaged2monthsto5yearswithcoughordifficultybreathingand:
• breathingfasterthan40breaths/minute(ages1–5years);• breathingfasterthan50breaths/minute(ages2–12months)
(Note:Infants less than 2 months of age with fast breathing of 60 breaths or more per minute should be referred for serious bacterial infection).
The IMCI case definition for severe pneumonia is any child aged2months to5 yearswith coughordifficult breathingandanyof thefollowinggeneraldangersigns:
• unabletodrinkorbreastfeed,or• vomitseverything,or• convulsions,or• lethargicorunconscious,orchestindrawingorstridorinacalm
child
6. Reporting system
ARIsurveillancewillbereportedatthreelevels(BHU’s,district,regional/nationalreferralhospitals)whileILI/SARIsurveillancewillbereportedfromselectedsentinelsites.
6.1. ARI reporting from BHU levelBHUwillreportnumberofARIcasestoDistrictHealthOffice(DHO)weeklyinARIreportingFormA(Annexure 1)byfaxorphone/mobile(with availability of mobile network across the country, reporting by mobile can also be considered as formal reporting from any BHU’s to respective District Health Office and accordingly documenting the data in appropriate form/format).TheDHOofficewillcompiledatafromallBHUsindistrictARIreportingForm B (Annexure 2) and submit to ARI/CDD programme everymonth.CopyofthereportmustberetainedbyDHOoffice.
6.2 ARI reporting from District Hospitals/BHU-I levelRegionalreferral/Districthospital/BHU-1willreportARIcasestoDHOOfficeweeklyinARIreportingFormA(Annexure 1)byfax/post/e-mail/webbased.TheDHOofficewillcompilereportsinARIreportingForm
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B(Annexure 2)fromallhospitalsandsubmittoARI/CDDprogrammeeverymonth.CopyofreportmustberetainedinDHOoffice.
6.3 ARI reporting from Regional/National Referral hospitalsReferralhospitalwillsubmitARIreporttoARI/CDDprogrammeeveryweekinweeklyARIreportingFormA(Annexure 1)byfax/email.Copyofreportmustberetainedbythehospital.
6.4 ILI/SARI reporting from sentinel sitesSentinel sites identified for ILI/SARI surveillancewill collect ILI/SARIdata inFormC (Annexure 3) andsend toPublicHealthLaboratoryweeklyfax/email/webbased.
7. Data Collection Tool
TherearetworeportingformsforARIsurveillanceandonereportingform for ILI/SARI surveillancewith an additional of two case-baseddatacollectionformsforILI/SARIsurveillance.
7.1 Weekly ARI reporting form from health centers (Form A):All focal persons in BHU’s and hospitals BHU’s including referralhospitalsshouldprovideweeklyARIdataintheformA.
7.2 Monthly ARI reporting form from district health office (Form B):DHOofficeshouldcompileandprovidemonthlyARIdatainformB.
7.3 Weekly ILI/SARI reporting form from sentinel sites (Form C):AllILI/SARIsentinelsitesshouldprovideILI/SARIdatainformC.
7.4 ILI sample registration/investigation and sample collection (Form D): All ILI/SARIsentinelsitesshouldprovide information fromILIpatientsselectedforthroat/nasalswabsamplecollectioninformD(Annexure 4).TheformDshouldbefilledoutbylaboratorystaffinthefollowingorder;(seeBox-1)
• assignuniqueILIidentificationnumberintheforms• filluptherelevantinformationasrequiredbytheform• assignthesameuniqueILIidentificationnumbertothesample• shippedsampletoPHLonaweeklybasis
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Acopyoftheformshouldremainatthesentinelsite.
7.5 SARI sample registration/investigation and collection (Form E): AllILI/SARIsentinelsitesshouldprovideinformationofSARIpatientsandcollect throat/nasalswabsample for laboratory testing in formE(Annexure 5). The formEshouldbefilledoutbyclinicians/nursesand sent/reported to the laboratory for sample collection. LaboratorywillassignuniqueSARIidentificationnumberintheforms(seeBox-1),sameuniqueSARI identification number to the sample and shippedsampletoPHLonaweeklybasis.Acopyoftheformshouldremainatthesentinelsite.
Box-1: Assigning Identification Unique number
8. Data Analysis and Feedback DatacollectedfromdistrictswillbemaintainedandanalyzedmonthlyinMicrosoft spread sheet.Monthly feedbackwill be brief descriptive(time,placeandperson)analysisfollowedbycomprehensiveannually.ARI/CDDprogrammewill sharemonthly feedback todistrictsonARIandPHLonILI/SARI(FluView)whichwillbeavailableinPHLwebsite.
9. Sample collection, Storage and TransportationSpecimens for the direct detection of viral antigens or nucleic acidsshould be taken no later than seven days after the onset of clinicalsymptoms, and preferably within three days. Specimens should
The first three alphabets specify the sentinel site. Thesentinel site code is followed by a two digit number thatindicatestheyearofsymptomonset/samplecollection.Thelast digits are the case number.The case number shouldbeginatthenumber1atthestartofeachinfluenzaseasonateachsentinelsite.(Sentinel Site) (Year) (Case Number) An Example: MON/11 /0001 means the sentinel site isMonggar, year of collection is 2011 from the first caseassignedonILIinvestigationform.SameappliestoSARI.
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preferablybetakenbeforecommencementofanti-viralchemotherapy.ProcedureforcollectionofspecimensisprovidedinAnnexure 6.
Typesofspecimentocollect:• nasalswab(forrapidinfluenzatesting)• throatswab(forPCR)• nasopharyngealswab(forPCR/culture)• sputum(bacterialisolation)
Allsamplesshouldbeaccompaniedbytherelevantsurveillanceformsdulyfilledbytheconcernedhealthworker.AnythroatswabcollectedinVTMshouldbe immediatelystoredgiven inAnnexure 7 and latertransportedtoPHLasgiveninAnnexure 8.
10. ARI/ILI Outbreak and Rapid Response
10.1. ARI/ILI OutbreakARI/ILIoutbreakisdefinedasan‘abnormalincrease’ofcasescomparedwithnormalcasesor trend inagivenperiod.An ‘abnormal increase’shouldbedefinedasanincreaseaboveandbeyondthenormalrangeofseasonalvariationofreportedcaseswhichcanonlybedeterminedifprevalenceisknown.However,abnormalincreasewilldifferfromplacetoplaceanddistrict todistrict.Toconfirmanoutbreak,at least5-10samples fromARI/ILIcasesshould tobecollectedandconfirmedbyPHL.Theoutbreakshouldbeinvestigatedatthelocallevelbyadistrictrapidresponse team. The Rapid Response Team from national level willonlycometositeifdistrictcannotconductoutbreakinvestigationoranoutbreakhasmajorprogrammatic implications.ThecompositionandresponsibilitiesoftheRRTareasfollows:
10.2. National Rapid Response Team (NRRT)• Epidemiologist• Microbiologist• Pediatrician/Physician
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10.3. Responsibilities of NRRT at national level• Provide technical expertise for any outbreak and provide all
technicalassistancetotheRRTatdistrictlevel.• Visit outbreak sites to investigate outbreak at the request of
districtRRT.• Provide all logistic support including drugs, PPE and other
necessarysupplies• Recommend appropriate interventions to be undertaken
by DoPH/ MoH based on findings and/ or outbreak reportssubmittedbydistrictRRTtopreventfutureoutbreaks.
10.4. Rapid response team (RRT) at district level• DistrictMedicalOfficer(DMO)/ChiefMedicalOfficer(CMO)• DistrictHealthOfficer(DHO)• MedicalTechnologist/Technician(MT)
10.5. Responsibilities of RRT in district • In ARI/ILI outbreak, the RRT team from district should
immediatelyvisittheaffectedsite.• Ascertain cases based on clinical case definition and send
appropriatesamplesfrom5–10casestothePHLforlaboratoryconfirmation.
• InformtheNationalRRTforanyassistanceifrequired.• Informthelocalauthorityaboutthesituationandpossiblerisks.• Ensure logistics support including drugs, PPE and other
necessarysupplies• Immediately implement interventionmeasures to contain the
outbreak.
10.6. Rapid Response to ARI/ILI outbreakOnceanoutbreakisbelievedtohaveoccurred,theRRTindistrictshouldimmediatelyconductarapid investigationand implementappropriateinterventionmeasures. A national Rapid Response Teammay visitthesitetoconductoutbreakinvestigationifdistrictlackscapacityandrequest national RRT to intervene.A detailed outbreak investigationwill be conducted to establish outbreak epidemiology, etiology, andrecommendbothshortand long term interventions to respond to theoutbreakandpreventfutureoutbreaks.Anoutbreakresponseshouldincludethefollowingsteps/actions:
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Investigationstoconfirmtheoutbreak• Establishthatthe‘suspectcases’fitthecasedefinitionofARI/
ILI byobtaining information regarding signandsymptomsofdisease, onset of illness, placeof residence, etc.The casesmustbelinelisted.
• Conduct a rapid search for additional cases that may haveoccurredinthelocalitybutnotreportedtothehealthfacilities.
• Deaths, if any, should be determined that have not beenreportedorforwhichnocausehasbeenknown.
Information,EducationandCommunication• IECcampaignshouldbeplannedonceoutbreakisconfirmed
and launched forgeneralpublic toensureARI/ILI casesaretakentothenearesthealthfacilityforcheckupandsupportivecare.
• IECmustprovidetheinformationtothecommunityregardingthediseaseanditspossiblethreats.
• IECshouldbecommunicatedthoughlocalmediaifavailabletilloutbreakiscontained.
11. ARI/ILI/SARI Monitoring & Evaluation
Theoverallusefulnessofasentinelsurveillancesystemwilldependonwhetheritcontributestothepreventionandcontrolofadversehealthevents. A surveillance system should undergo regular monitoringto routinely assesswhether it is functioning efficiently and providingquality data. Additionally, routine assessment will indicate areas inwhich personnelmay need technical or logistical support and/or re-training.Indicatorstoassesssurveillancesystemaredescribedbelow:
Table No. 2. Indicators for Monitoring and Evaluation
Indicators Frequency of monitoring
Source of information
Timelinessofreporting Weekly Routinedata
Completenessofdatacollected Weekly Routinedata
Numberofsamplescollected Weekly Routinedata
NumberofARI/ILIoutbreaksdetected Quarterly Routinedata
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11.1. Timeliness of reporting Timelinessreferstothespeedbetweenstepsinasurveillancesystem.Data must be timely, if it is to be useful to clinicians, public healthauthorities,andthecommunity.Indicatorsoftimelinessinclude:
Expected dates of data reporting from sentinel site to PHL ascomparedtoactualdatesofreporting;
TimeelapsedfromspecimencollectionatsitetoarrivalatPHLfortesting;
Time elapsed from receipt of specimens at PHL to processing,testingandgeneratingresults;
Timeelapsedfromreceiptoflaboratoryresultsforindividualcasesbythesentinelsitefocalpointtonotificationofthepatient’sdoctor;
11.2. Completeness of data collected Completenessreferstothedatacollectedwithcompleteinformationandcanbemeasuredbyassessingthefollowing:
Percentageofformsreceivedfromeachsitewithcompletedata;Percentageofformsthatarereceivedascomparedtothe
expectedforms;
11.3. Number of samples collected Number of samples collected in each site can be used to monitorsurveillanceandcanbeassessedby:
ComparingnumberofILI/SARIsamplescollectedascomparedtothatofrequirednumberofsamples.
11.4. Number of ARI/ILI outbreaks detected
Thesurveillancecanbemonitoredbyassessingtheoutbreaksthatweredetected.Theindicatorsusedcan:Numberofoutbreaksreportedascomparedtothatoftheprevious
year;Numberofoutbreaksinvestigatedandconfirmedbylaboratory;Numberofoutbreaksthathavebeenintervenedandcontrolled.
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12. References
1. WHO regional office for Europe Guidance for Influenza
SurveillanceinHumans.
2. AnnualHealthBulletin,2010,MinistryofHealth,Bhutan
3. OperationalManualforNationalNotifiableDiseaseSurveillance,
PublicHealthLaboratory,Bhutan
4. Protocolfortheevaluationofthequalityofclinicaldatawithin
theEuropeanInfluenzaSurveillanceScheme.www.euroflu.org
5. CoreTermsofReferenceforWHOCollaboratingCentres for
ReferenceandResearchonInfluenza
http://www.who.int/csr/disease/influenza/whocccoretor2006.pdf
6. IndicatorsofInfluenzaActivity.www.ecdc.europa.eu
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13. Figure 1: ARI Surveillance Overview
14. Figure 2: ILI/ SARI Surveillance overview
15. A
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Public Health Laboratory
18 Pages
15. Annexure 1: Form A:ARIreportingformfromBHUs/HospitalstoDistrictHealthAuthority
16. Annexure 2: Form B:ARIreportingformfromDistricttoARIProgram
16. Annexure 2: Form B: ARI reporting form from District to ARI Program
WEEKLY ARI & PNEUMONIA SURVEILLANCE REPORTING FORM (From District to ARI program)
Reporting Center Name Month Year
From………./……/…….…
To…………/……….../………
Type of cases
Age group
0-11 Mths 1-4 years 5-14 years 15-29 years 30-64 years 65+ years
Male Female Male Female Male Female Male Female Male Female Male Female
Week: ² 1. No. of ARI cases 2. No of Pneumonia cases
3. Death due to ARDS/ Pneumonia
4. Total OPD cases
Week: ²
1. No. of ARI cases 2. No of Pneumonia cases
3. Death due to ARDS/ Pneumonia
4. Total OPD cases
Week: 3
1. No. of ARI cases 2. No of Pneumonia cases
3. Death due to ARDS/ Pneumonia
4. Total OPD cases
Week: 4
1. No. of ARI cases 2. No of Pneumonia cases
3. Death due to ARDS/ Pneumonia
4. Total OPD cases Reported By: Signature: Mobile No.: Date:
ARI/ILI/SARI Surveillance Guideline
19 Pages
17. Annexure 3: FormC:WeeklyILIandSARIreportingform
ARI/ILI/SARI surveillance guideline 19 | P a g e
17. Annexure 3: FormC:WeeklyILIandSARIreportingform
WEEKLY ILI & SARI SURVEILLANCE REPORTING FORM
SENTINEL ILI & SARI SURVEILLANCE AGGREGRATE DATA
WEEK _____________ From: …../……./…… To …../……/…..… Year………
Site Name:
Aggregate cases
Age group (Years)
0-1 2-4 5-14 15-29 30-64
65+
Number of ILI cases during the week
Number of SARI cases during the week
Number of deaths due to SARI/Pneumonia during the week*
Total OPD cases ** during the week
*Death cases details:
Name Age/ Sex Sample collected for testing (Influenza/ other viral agents)? (Yes/ No)
**The OPD cases includes patients seen with and without ILI in the OPDs (total OPD registration)
Reported By: Signature:
Mobile No.: Date:
Public Health Laboratory
20 Pages
18. Annexure 4: Form D:ILIcaseInvestigationandSamplecollectionform
20 | P a g e PUBLIC HEALTH LABORATORY
18. Annexure 4: Form D:ILIcaseInvestigationandSamplecollectionform
Influenza –Like Illness Case investigation/sample collection form Patient ID number * Site: Month/Year Sample #
Name of Patient:
Age: Sex:
Date of onset of illness:
Sign and Symptoms: Fever ≥0C: Cough: Sore throat:
Others:
Travel history prior illness: □No □Yes, travel to ___________duration____________(weeks/month)
Direct exposure to animal: □No □Yes, poultry □ Yes, swine □Yes other (specify)_________
Date of specimen collection:
Specimen type Throat swab: Nasal swab: Others:
Laboratory use only
Rapid Test Result
Influenza A: Influenza B: Influenza A+B: Negative:
Analyzed by: Date:
* Patient ID number example: if the sample is the first specimen collected in January 2012 from a patient in Mongar, the patient ID number would be: MON/Jan/12 /0001.
ID#:
/Sex: Occupation:
20 | P a g e PUBLIC HEALTH LABORATORY
18. Annexure 4: Form D:ILIcaseInvestigationandSamplecollectionform
Influenza –Like Illness Case investigation/sample collection form Patient ID number * Site: Month/Year Sample #
Name of Patient:
Age: Sex:
Date of onset of illness:
Sign and Symptoms: Fever ≥0C: Cough: Sore throat:
Others:
Travel history prior illness: □No □Yes, travel to ___________duration____________(weeks/month)
Direct exposure to animal: □No □Yes, poultry □ Yes, swine □Yes other (specify)_________
Date of specimen collection:
Specimen type Throat swab: Nasal swab: Others:
Laboratory use only
Rapid Test Result
Influenza A: Influenza B: Influenza A+B: Negative:
Analyzed by: Date:
* Patient ID number example: if the sample is the first specimen collected in January 2012 from a patient in Mongar, the patient ID number would be: MON/Jan/12 /0001.
ARI/ILI/SARI Surveillance Guideline
21 Pages
19. Annexure 5: Form E: SARI case investigation and samplecollectionform
ARI/ILI/SARI surveillance guideline 21 | P a g e 19. Annexure 5: Form E: SARIcaseinvestigationandsamplecollectionform
SARI CASE INVESTIGATION AND SAMPLE COLELCTION FORM(Send one copy of this form to PHL along with the sample. The original form should be kept at the
surveillance site)SAMPLE COLLECTION INFORMATION
Health Centre:
Date of onset of symptoms
Date of specimen collection:
Specimen ID:
PATIENT IDENTIFICATION Patient name: Age/Sex: Occupation:
Address:
Date of reporting to the health worker/Health facility:
CLINCIAL INFORMATION SARI Case Criteria Fever measured >38 degrees? � Yes � No �Unknown Cough? � Yes � No � Unknown Sore throat? �Yes � No � Unknown Shortness of breath or difficulty breathing? �Yes �No � Unknown Requiring hospitalization? � Yes � No � Unknown Clinical Signs of Pneumonia: � Yes � No � Unknown Others (specify):________________________________________________________________________ Pre-Existing Medical Conditions � Heart Disease � Asthma � Chronic Lung Disease � Liver Disease � Pregnant � Diabetes � Neuromuscular Dysfunction � Immune compromised � Others (specify) ________________________ � Unknown Antiviral and Vaccine Exposure to influenza virus drugs during last 14 days: : � None � Yes � Unknown If Yes, Name of antiviral: ___________________________ Vaccination for influenza: � Yes � No � Unknown EPIDEMIOLOGY INFORMATION Travel History: History of Travel within the last 7 days: Area and Location: ___________ Exposure History Direct exposure to animals: � No � Poultry Yes, � Swine Yes, � Other(specify)__________________________
Reporting Physician/Clinician: Telephone/Mobile No: Signature:
Rapid Test Result (For Laboratory Purpose only)
Influenza A: Influenza B: Influenza A+B: Negative:
Analyzed by: Date:
Public Health Laboratory
22 Pages
20.
20.1. Throat swab: • LabelVTMtubewithLabIDnumber.• Askpatient (adults) to sit comfortably
on chair or lay down the patient(infants/young children) in a supineposition on bed with extendedpositioningofthepatient’sarmsabovethehead(Figure1&2)(Note:throatswab from infants/young childrenshouldbecollectedbyPediatricianoronlytrainedpersonnelonly).
• Holdthetongueoutofthewaywithatonguedepressor(Fig3).
• Use a sweeping motion to swab theposteriorpharyngealwalland tonsilarpillars.Havethesubjectsay“aahh”toelevatetheuvula.Avoidswabbingthesoftpalateanddonottouchthetonguewiththeswabtip(Figure4).(Note.Thisprocedurecaninducethegagreflex).
• OpenandputtheswabintoVTM.• Immediately close the VTM tube
and store in 2-4°C till the sample isprocessed or transported to PHL/referencelab.
FIGURE 1
FIGURE 2
FIGURE 3
Annexure 6: Procedures for sample collection
FIGURE 4
ARI/ILI/SARI Surveillance Guideline
23 Pages
20.2. Nasopharyngeal swab: • LabelVTMtubewithLabIDnumber,• Askpatient(adults)tositcomfortablyon
chair• Holdpatient’sheadslightlybackbyleft
hand.• Insert a flexible,fine-shafted polyester
swab into the nostril and back to thenasopharynx(Fig5and6).Theswabisinsertedfollowingthebaseofthenostriltowards the auditory pit till resistanceismet. (Need to insert at least 5–6 cmin adults to ensure that it reaches theposterior pharynx). (DO NOT use rigid shafted swabs for this sampling method).
• Leavetheswabinplaceforafewsecondsandwithdrawslowlywitharotatingmotion
• OpenandputtheswabintoVTM• A second swab should be used for the
othernostrilandput intoasecondtube.This can serve as the second samplefromthepatient.
• Immediately close the VTM tube andstorein2-4°CtillthesampleisprocessedortransportedtoPHL.
20.3. Nasal swab: • Askpatienttositcomfortablyonchair• Holdpatient’sheadslightlybackbyleft
hand• Use the same type of rigid swab as for
samplingfromthethroat.• Advance theswab tippast thevestibule
FIGURE 5
FIGURE 6
FIGURE 7
Public Health Laboratory
24 Pages
(anterior nares) to thenasalmucosa (approximately 2–3 cmfromthenostrilsinadults)
• Store in 2-4°C till the sample is processedor transported toPHL/reference lab. Gently rotate to collect nasal secretionsfromtheanteriorportionsoftheturbinateandseptalmucosa(Fig7).
• OpenandputtheswabintoVTM• Asecondswabshouldbeusedfortheothernostrilandputinto
asametube.ImmediatelyclosetheVTMtubeand
21. Annexure 7: Sample storage
21.1. Sample Storage Procedure (for sentinel sites)
• Wearanapron,glovesandotherprotectivebarriers.• SealallVTMtubescontainingspecimenswithparafilmairtight.• ArrangespecimensinserialorderbasedonsampleIDnumber
instoragerack.• Labelstoragerackswithdetailed informationofspecimens it
contain.• Placethespecimenracksinarefrigeratorat2-8°Cuntilready
totransporttoPHL.
21.2. Sample Storage Procedure (for PHL)
• Wearanapron,glovesandotherprotectivebarriers.• CheckwhetherallVTMtubescontainingspecimensaresealed
withparafilmairtight.• ArrangespecimensinserialorderbasedonsampleIDnumber
instoragerack.• Arrange surveillance specimen from sentinel sites serially in
differentstorageracks.• Label storage rack with detailed information of specimens it
contain• Store the specimens in -70°C until ready to be shipped to
referencelass.
ARI/ILI/SARI Surveillance Guideline
25 Pages
22. Annexure 8: Specimen Transportation Procedures
22.1. Domestic transport (district labs to Referral labs/PHL)• Placethespecimeninaprimarycontainer(polysterelynescrew
cappedvials)containingVTM.Theprimarycontainermustbeleak-proofunbreakableandairtight.
• Aftertighteningthecap,applysealingtape(para-film)overthecapand topof thecontainerandwrap inabsorbentmaterial(e.g.absorbentcottonortissuepaper)toabsorbtheaccidentalleakage.
• The sealed specimen container with a small amount ofabsorbent material must be placed in a suitably sized selfsealingplasticbag.
• Sealthebag.Twoormoresealedspecimensfromthesamesourcemaybeplaced ina largerplasticbag inbatchesandsealed.Specimenfromadifferentsourcemustnotbeplacedinthesamebag.
• Place the sealed bags containing the specimens inside asecondaryselfsealingplasticcontainerandsealit.Specimensfromseveralsourcesmaybepackedinsidethesamesecondaryplasticcontainer.
• Place additional absorbent material inside the secondarycontainer to cushion and to absorb any leakage that mayoccur.
• Tapethelaboratoryrequestformsealedinaplasticbagtotheoutsideofthissecondarycontainer.
• Place thesecondarybagcontaining thespecimen inwizard/coolboxcontainingice/icepacks.
• Sealthecoolboxproperlywiththehelpofbrowntaperunningaroundfulllengthandbreadthoftheboxsothataplusorcrosssignismade.
Public Health Laboratory
26 Pages
• Label the box with appropriate addresses and a biohazardsymbol.
22.2. Transportation from PHL to Reference lab
• Aftercollectingthesampleinsamplevialsprovided,makesurethatthevialiscappedverytightlyandsealedwithparafilm.
• Wrap the sample vial(s) in absorbent (tissue paper can beused)usingrubberband.
• Placethesampleinprimaryreceptacle(sealedplasticbag).• Batch the sample according to the size of the secondary
receptacleandplaceinit.Useadditionalabsorbentandsealthesecondaryreceptacle.Fore.g.fiveprimaryreceptaclescanbebatchedtogetherandplacedinsidethesecondaryreceptacle.
• Put the secondary receptacle in transport container/shippingcontainerfortransportingtoadesignatedlaboratory.
• Place specimen data forms, letters and other relevantdocuments in a water proof bag (preferably sealed plasticbag) carefully tapped either to the outside of the secondaryreceptacleorinsideofthetransportationcontainer.
• Placedryicebetweenthesecondaryandtransportcontainerto keep the sample at the required temperature duringtransportation.
• The outer shipping or transportation container should belabelled with the name of the receiver, indication of storageconditions requiredduring transport,andbearanyadditionallabels or stickers (biohazard sign) as per the national/internationalregulations.
ARI/ILI/SARI Surveillance Guideline
27 Pages
Figure 8: Triple packaging system
Public Health Laboratory
28 Pages
FIGURE 4
23. A
nnex
ure
9: C
old
Cha
in M
aint
enan
ce T
able
Site
:___
____
____
____
____
____
____
____
____
__
Year
: __
____
____
____
____
_Sl
. N
o.Sp
ecim
en #
Col
lect
ion
date
at
site
2-80 C
sto
rage
dur
atio
n at
site
-70
0 C s
tora
ge
at P
HL
Rem
arks
Ship
ped
by: _
____
____
____
____
____
____
____
Dat
e of
shi
pmen
t:
___/
____
_/__
___