A Field Manual Second Edition EWARN Guidelines · Field Manual Second Edition 3 Foreword The guidelines serve as a general reference for surveillance activities across all levels,

EWARN Guidelines 2017

Field Manual - Second Edition 1

A Field Manual

EWARN Guidelines

Early Warning Alert and Response Network

Roles and responsibilitiesfor surveillance and response teams in Syria

Second Edition


2 Assistance Coordination Unit - EWARN

EWARN TEAM

This guideline is dedicated in honor of an exceptional colleagues

Zakaria Hijazi and Alaa Nahhas , who gave their bodies and souls

doing their duty in caring the health of the Syrian people...



Foreword

The guidelines serve as a general reference for surveillance activities across all levels, as a guide for improving early detection and preparedness activities; The guidelines also serves to improve timely investigation of events of concern and related response activities. It also is a good resource of information for training, supervision and outbreak communication. It also touches on ways of evaluation of surveillance activities.During the last 5 years, many changes have occurred in the demographic components, health infrastructure , WASH system .The emergence and re-emergence of diseases such as poliomyelitis resulted into the need to review the recommendations for evolving public health priorities for disease surveillance and response.

The guidelines are intended for use as:

• A general reference for surveillance activities at all levels.

• A set of definitions for threshold levels that trigger some action for responding to specific

diseases.

• A resource for developing training, supervision and evaluation of surveillance activities.

• A guide for improving early detection, preparedness for outbreak response and case

management.

This document are intended to be used by Health workers at all levels, Surveillance officers , Rapid response team , Health Authority, WASH inspectors , as well as

other public health experts, including NGOs.



Contents

Acronyms

Definition of terms

List of tables and figures

Introduction 1

Objectives 1

Content of the guidelines 2

Section 1: General Overview 3

Background and Purpose 4

Priority Diseases/Conditions under Surveillance 4

Types of Alerts for EWARN priority diseases 5

Data Flow 6

Routine analysis of surveillance information 8

Analyze data by time, place and person 9

Inclusion Criteria for Health Facilities 14

EWARN Staffing 14

Reporting Schedule 16

Monitoring and Evaluation 16

Section 2: Roles and responsibilities 18

Health Facility staff / Field Level Surveillance Office (FLO) 19

District Level Surveillance Officer (DLO) 24

Central Level Surveillance Officer (CLO) 25

Section 3: Alerts and Outbreaks 26

Alert Notification 27

Alert Verification 27

Outbreak Investigation 31

Roles and responsibilities of Outbreak Control Team (OCT) 32

Laboratory support 33

Response and control measures 34

Feedback and Dissemination 35



Contents

Appendix 1 : Weekly Reporting Form , Case Definition and Alert Thresholds 37

Appendix 2 : Sample Patient Register 41

Appendix 3 : Monitoring Checklist 42

Appendix 4 : Contact List of Alert Notification Team and Outbreak Investigation Team. 43

Appendix 5 : Sample Alert Notification Form 45

Appendix 6 : Alert Verification and Investigation Register 46

Appendix 7 : Sample Outbreak Investigation Form and Line List 47

Appendix 8 : Steps to Conduct an Outbreak Investigation 49

Appendix 9 : Checklist of Materials and Supplies 50

Appendix 10 : Referral Laboratory and Diagnostic Testing 51

Appendix 11 : Outbreak Response Plans for Priority Diseases / Conditions 52

Appendix 12 : Recommended List of Personal Protective Equipment (PPE) by Suspected Priority Disease 55

Appendix 13a : Acute Bloody Diarrhea (Suspected Shigellosis) 56

Appendix13b : Acute Watery Diarrhea (Suspected Cholera ) 59

Appendix 13c : Other Acute Diarrhea (OAD) 64

Appendix 13d : Acute Jaundice Syndrome (Hepatitis A , E) 66

Appendix 13e : Influenza Like Illness (ILI) and Acute Sever Acute Respiratory Illness (SARI) 68

Appendix 13 f : Acute Flaccid Paralysis (Suspected Poliomyelitis) 73

Appendix 13 g : Suspected Measles 74

Appendix 13 h : Suspected Meningitis 75

Appendix 13 i : Suspected Typhoid Fever 77

Appendix 13 j : Cutaneous Leishmaniais 81

Appendix 14 : Water Quality guidelines 84

Appendix 15 : Vaccination Response 86

Appendix 16 : References 87

Section 4: Appendices 36



Acute Bloody Diarrhea

Acute Flaccid Paralysis

Acute Jaundice Syndrome

Acute Watery diarrhea

Case Fatality Rate

Central Level Officer

Cerebral Spinal Fluid

District Level Officer

Expanded Program on Immunizations

Field Level Officer

Influenza Like Illness

Leishmaniasis

Measles

Meningitis

Neonatal Tetanus

Non-Governmental Organization

Other Acute Diarrhea

Outbreak Control Team

Oral Rehydration Solution

Personal Protective Equipment

Rapid Diagnostic Test

Rapid Response Team

Severe Acute Respiratory Illness

Syrian Immunization Group

Suspected Typhoid Fever

Tuberculosis

Unusual Cluster of Event

Unusual Cluster of Death

Water-Sanitation - Hygiene

World Health Organization

The United Nations International Children's Emergency Fund

ABD

AEFI

AJS

AWD

CFR

CLO

CSF

DLO

EPI

FLO

ILI

Leish

Meas

Men

NNT

NGO

OAD

OCT

ORS

PPE

RDT

RRT

SARI

SIG

STF

TB

UCE

UCD

WASH

WHO

UNICEF

Acronyms



Acute: Any disease having a rapid (sudden) onset and following a short course.

Chronic: Any health condition that develops slowly or of long duration and tends to result in some functional limitation and need for ongoing medical care.

Cluster: A closely grouped series of events or cases of a disease or health-related condition in relation to time or place or both.

Disease: An illness or medical condition, irrespective of origin or source, which presents or could present significant harm to humans.

Elimination: The interruption of disease transmission in country, region or locality.

Endemic: A disease or condition regularly found among particular people or in a certain area.

Epidemic: Refers to an increase in the number of cases of a disease above what is normally expected in that population in that area.

Epidemiological link: When a patient has or had exposure to a probable or confirmed case of a certain infectious condition or disease.

Epidemiology: The study of the distribution and determinants of health related states and the application of this information to controlling public health problems.

Eradication: The purposeful reduction of specific disease prevalence to the point of continued absence of transmission in the world.

Etiology: Refers to the cause, a set of causes, or manner of causation of a disease or condition.

Event: A manifestation of disease or an occurrence that creates a potential for disease.

Outbreak: The occurrence of more cases than expected in a limited geographic area.

Pandemic: An epidemic occurring worldwide, or over a very wide area, crossing international borders and usually affecting a large number of people.

Definition of terms



List of tables and figures

Section 1: 03

Table 1.1: Priority Diseases/Conditions under Surveillance 04

Table 1.2: Analyze Data by Time, Place and Person 09

Table 1.3: Example to calculate the Incidence Rate 12

Table 1.4: Example to calculate Case Fatality Rate 13

Figure 1.1: EWARN Data Flow 07

Figure 1.2: Leishmaniasis cases number in 2015 by week 10

Figure 1.3: Number of Suspected Measles Cases within the Last 3 Years 10

Figure 1.4: Number of AFP Cases in 2016 11

Figure 1.5: Measles Cases Distribution up to week 2016 _ 22 11

Figure 1.6: EWARN Staff Roles and Responsibilities 15

Figure 1.7: EWARN Reporting Schedule 17

Section 2: 18

Table 2.1 : Weekly Zero Report Form 20

Table 2.2 : Case Definition and Alert Threshold 23

Section 3: 26

Table 3.1 : List of laboratories testing capability 33

Table 3.2 : Summary of recommended sample collection media, use, storage and transport

33

Figure 3.1: Importance of Case Definition 28

Figure 3.2: Alert Verification Process Chart 29

Figure 3.3: Delayed Response VS Rapid Response 31

Figure 3.4 : Schematic of early warning alert and response 35

Section 4: 36

Figure 4.1 : The steps in management of a communicable disease outbreak 54

Figure 4.2 : Signs of Severe Dehydration 60

Figure 4.3 : Cholera investigation form 63

Figure 4.4 : SARI cases Line List 71

Figure 4.5 : Algorithm of Suspected Case of H1N1 influenza approaches 72

Figure 4.6 : STF investigation form 80

Figure 4.7 : Status of endemicity of Cutaneous Leishmaniasis , World Wide 2012. 81



Surveillance is the ongoing, timely, systematic collection, analysis, interpretation and dissemination of health information for public health action. Surveillance systems are essential for planning, implementation, and evaluation of public

health practice.

The Specific objectives of disease surveillance are :

• Strengthen the capacity to conduct effective surveillance activities: train personnel at all levels; develop and carry out plans of action; and advocate and mobilize resources.

• Integrate multiple surveillance systems so that resources can be used more efficiently.

• Improve the use of information to: enable rapid detection, analysis and response to suspect epidemics and outbreaks; monitor the impact of interventions; and facilitate evidence-informed public health policy, planning and action.

• Improve the flow of surveillance information across levels of the health system.

• Strengthen laboratory capacity for pathogen detection and monitoring of drug resistance.

• Increase involvement of clinicians in the surveillance system.

• Emphasize community participation in detection and response to public health problems.

• Trigger epidemiological investigations to detect and respond to public health threats.

These guidelines is a revision of previous edition in order to address surveillance requirements and building capacities for disease surveillance and response.These guidelines reflect national priorities, set policies and standards and public health intervention.The various surveillance tasks and procedures outlined here must take into account the changing and challenging country context within Syria.This manual will be updated as the system continues to improve and strengthen.

Introduction

Objectives of EWARN

For comments and feedback

Please Contact EWARN

[email protected]

www.acu-sy.org/ewarn



Content of the Guidelines

Section 1 – General overviewSection 2 – Roles and responsibilities by levelSection 3 – Alert and outbreaksSection 4 – Appendices (forms, charts, references)



Section

General Overview 1


EWARN FRAMEWORK



The conflict in Syria has displaced millions of people, disrupted basic health services, destroyed water and sanitation infrastructure, and greatly increased the risk of disease outbreaks among the affected populations. Those affected by war settled in temporary locations with high population densities, inadequate food and shelter, unsafe water, poor sanitation and lack of health infrastructure.These circumstances can increase the risk of transmission of communicable diseases and other conditions. In particular, epidemic-prone diseases can be a major cause of morbidity and mortality. The Early Warning and Alert Response Network (EWARN) is a simplified system for disease surveillance which can be quickly set up in the affected areas during the acute phase of an emergency.It is designed as a temporary stopgap measure when public health information systems are disrupted or non-functional.EWARN should be integrated into this larger system once the acute phase of the emergency is over. The primary purpose of EWARN is rapid detection of communication diseases and prompt response to epidemics among the affected population. After three years of establishing the EWARN system, the program has gained a great deal of specialized expertise and is starting to move towards a more stabilized system.

Priority Diseases/Conditions under Surveillance:

A limited number of priority diseases/conditions were selected based on certain criteria: 1) their potential to cause epidemics, 2) their association with high morbidity and mortality, 3) the existence of interventions in Syria.See Appendix 1 for reporting form, case definitions, and alert thresholds.

Other Acute diarrhea

Acute Bloody Diarrhea(Suspected Shigellosis)

Acute Watery Diarrhea(Suspected Cholera)

Acute Jaundice Syndrome (Hepatitis A & E )

Influenza Like Illness


Acute Flaccid Paralysis(Suspected Poliomyelitis)

Suspected Measles

Suspected Meningitis

Unusual cluster of health events

Unusual cluster of deaths

Suspected Typhoid Fever

Cutaneous Leishmaniasis

Background and Purpose:

Table 1.1 : Priority Diseases/Conditions under Surveillance



Types of Alerts for EWARN priority diseases:

An alert threshold suggests to health staff that further investigation is needed. Depending on the disease, an alert threshold is reached when there is a determined number of suspected case or when there is an unexplained increase seen over a period of time in monthly summary reporting.

EWARN works on two main types of alerts

Type A alert of Immediate notification

-Acute Watery Diarrhea (Suspected Cholera) -Acute Flaccid Paralysis (Suspected Poliomy-elitis)-Suspected Measles -Unusual cluster of health events-Unusual cluster of deaths -Acute Bloody Diarrhea (Suspected Shigello-sis) in camps .

-Other Acute diarrhea-Acute Bloody Diarrhea(Suspected Shigellosis) not in the camps-Acute Jaundice Syndrome(Hepatitis A & E )-Influenza Like illness (ILI)-Severe Acute Respiratory Illness (SARI)-Suspected Meningitis-Suspected Typhoid Fever

-Cutaneous Leishmaniasis

Type B alert of Weekly reporting

It depends on trend analysis of aggregated data from selected health facilities (senti-nel surveillance).



Organizing and analyzing data is an important function of surveillance. Analyzing data provides the information that is used to take relevant, timely and appropriate public health action.It is important that data analysis is undertaken at all levels of the surveillance

system.

The following procedures should take place:

• Receive, handle and store data from reporting sites

• Enter and clean the data

• Analyze data by time, place and person

• Draw conclusions from analysis

• Summarize results to guide public health action

Aggregated weekly data from patient registers must be submitted to the next reporting level, i.e., health center level (field level) district level central level for analysis, interpretation, and dissemination.If current situation (security, resources, etc.) prohibits reporting to the next level, data can continue up to the reporting level by alternate methods (i.e., non-government organizations [NGO]).Surveillance officers at all reporting levels should be informed of this alternative method so EWARN records and database may be updated at the various levels accordingly (Figure 1.1).Involving health facilities is essential, in order to use the patient registers for recording consultations. See Appendix 2 for sample patient register.

Immediate alerts can signal the early stages of an outbreak in the community or health facility.The information is shared from health facilities with the higher levels, the district or the central level, with no delays, it usually relays on the team capacity and the current situation.

Data Flow



Figure 1.1 : EWARN Data Flow



1- Calculate completeness and timeliness of reporting : Monitoring whether surveillance reports are received on time or not and if all reporting sites have reported is an essential first step in the routine analysis of the surveillance system. This assists district surveillance team in identifying silent areas (areas where health events may be occurring but not being reported) or reporting sites that need assistance in transmitting their reports.

2- Calculate district totals by week (or by month). Update the total number of reported cases for the whole year. This is an information summary that helps to describe what has happened in the a particular reporting period.

3- Prepare cumulative totals of cases, deaths and case fatality rates since the beginning of the reporting period.

4- Use geographic variables (such as hospitals, residence, reporting site, neighborhoods, village and so on) to analyze the distribution of cases by geographic location. This is information that will help to identify high risk areas.

5- Analyze disease trends for at least the diseases of highest priority in your district.

Routine analysis of surveillance information:



Findings from data analysis may trigger investigations and subsequent response to an outbreak, condition, or public health event.Data should be analyzed by time, place and person (refer to Table 1.2)

Type ofanalysis Objective Tools Method

Time Detect abrupt or long-term changes in disease or unusual event occurrence, how many occurred, and the period of time from exposure to onset of symptoms.

Record summary totals in a table or on a line graph or histogram.

Compare the number of case reported received for the current period with the number received in a previous period (weeks, months, seasons or years)

Place Determine where cases are occurring (for example, to identify high risk area or locations of populations at risk for the disease)

Plot cases on a spot map of the district or area affect-ed by an outbreak.

Plot cases on a map and look for clusters or relationships between the location of the cases and the health event being.investigated

Person Describe reasons for changes in disease occurrence, how it occurred, who is at greatest risk for the disease, and poten-tial risk factors

Extract specific data about the population affected and summarize in a table.

Depending on the disease, characterize cases accordingto the data reported for case- based surveillance such as age, sex, place of work, immunization status, school attendance, and other known risk factors for the.diseases

Analyze data by time, place and person:

Table 1.2 : Analyze Data By Time , Place And Person



Analyze Data by time

Figure 1.2 : Leishmaniasis cases number in 2015 by week

Figure 1.3 : Number of Suspected Measles Cases within the Last 3 Years

Data about time is usually shown on a graph. The number or rate of cases or deaths is placed on the vertical or y-axis. The time period being evaluated is place along the horizontal or x-axis. It is easier to see changes in the number of cases and deaths by using a graph, especially for large numbers of cases or showing cases over a period of time.



AFP cases distributionAFP Case

Pending Class

District Boundary

Governorate Boundary

Distribution of AFP cases - 2016

Analyze data by place

Analyzing data according to place gives information about where a disease is occurring. Mapping the cases of selected diseases regularly can give ideas as to where, how, and why the disease is spreading, in addition to understanding the population distribution, density and variety of the area.

Figure 1.4 : Number of AFP Cases in 2016

Figure 1.5 : Measles Cases Distribution up to week 22 _ 2016



Analyze data by person:

Analysis by person is recommended for describing the population at risk for epidemic-prone diseases.Analysis by person is not routinely recommended forsummarizing data.A simple count of cases does not provide all of the information needed to understand the impact of a disease on a community, health facility.Simple percentages and rates are useful for comparing information reported to the central level.The first step in analyzing person data is to identify the numerator and

denominator for calculating percentages and rates.

Calculate the incidence rate :

the number of new cases per population at risk in a given time period.

Example :

1- The numerator is the number of measles cases that occurred over one year. 2- The denominator is the number of school aged children at risk in each catchment area.

- In this example, the incidence rate is higher in health facility B than in A.

Table 1.3 : Example to calculate the Incidence Rate

Health facility Number of measles cases this year in children less

than 5 years of age

Number of children less than 5 years livingin the catchment area

Percentage of Measles in children lessthan 5 years during last 12 months

A 42 11,550(42/11,550)*1000 = 3.6 per 1000

population

B 30 6000(30/6000)*1000 = 5 per 1000

population



Calculate a case fatality rate :

Indicates any problems with case-management once the disease has been diagnosed, poor quality of care or no medical care.

Example :

1- Calculate the total number of deaths.(In the example of the measles data, there are 5 deaths).

2- Divide the total number of deaths into the total number of reported cases.(For example, the total number of reported cases is 78. The number of deaths is 5So divide 5 by 78 5 ÷ 78 is 0.06).

3- Multiply the answer by 100. (0.06 X 100 equals 6%).

Table 1.4 : Example to calculate Case Fatality Rate

Age group Number of reported cases Number of deaths Case fatality rate

0-4 years 40 4 10%

5-14 years 9 1 11%

15 years and older 1 0 0

Age unknown 28 0 0%

Total 78 5 6%



Due to the volatile situation in Syria, only selected health facilities will be included in the weekly aggregation of data for sentinel surveillance. Efforts will be made to ensure representativeness; however, priority will be given to the following health facilities:

EWARN Staffing

Sentinel sites will be evaluated periodically to determine the addition/removal of health facilities based on performance indicators (timeliness, completeness, regularity of reporting).Temporary institutions will not be included.Note: all sources are included for alert notification.

• Adequate resources o Staff – physician, surveillance officer or focal point o Resources – patient registers, method of communication• Stability and security• Accessibility

Health and surveillance staff play an important role in the timely and accurate transfer of EWARN data. Data will be transmitted by an identified Field Level Surveillance Officer (FLO) from the health facility to the district level on a weekly basis.

The District Level Surveillance Officer (DLO) will then transfer data from the health facilities in their province to the Central Level Surveillance Officer (CLO). The number of DLOs per province will depend on population size, access, and geography.

Health facility staff and NGOs will also assist EWARN surveillance officers with alert verification and outbreak investigations.

Rapid Response team (RRT) has been added to EWARN staff , to ensure optimum preparedness for outbreaks response by provision of detailed outbreak control plans, supplies, training, supervision and all needed capacities.

Inclusion Criteria for Health Facilities:



- Analyze, interpret, and disseminate weekly health data received from all provinces.

- Ensure the capacities for surveillance, outbreak investigation, laboratory confirmation and outbreak response are in place within the system.

- Conduct preliminary analysis of field level health data and submit to central level

- Share aggregated data and health alerts with local partners- Assist with alert verification and outbreak investigation

- Identify cases of diseases under surveillance based on EWARN case definitions

- Aggregate weekly health data and submit to District Level Surveillance Officers

- Detect and immediately report notifiable diseases- Assist with alert verification and outbreak investigation.

Central Level (CLO)

Health Facility/Field Level (FLO)

Rapid Response Team (RRT)-Provide technical experience in surveillance, outbreak investigation and response to facilitate in achieving the objectives of the project.

-Ensure optimum preparedness for outbreaks by provision of detailed outbreak control plans, supplies, training, supervision and all needed capacities.

Figure 1.6: EWARN Staff Roles and Responsibilities

District Level (DLO)



The epidemiological week is from Sunday to Saturday. Data must be submitted according to the predetermined schedule in order to ensure timely dissemination of information.

(See Figure 1.7)

Analysis and Interpretation:

Notification of alerts and simple trend analysis at the health facility and district levels can detect early changes in disease.These analyses occur at the most peripheral level, the level closest to the field where immediate action can take place. More detailed analysis and interpretation

of the findings occurs at the central level.

Dissemination:

Feedback is critical for ensuring full engagement. Surveillance data must be shared with partners, stakeholders, and the community for decision-making, advocacy, and to inform public health workers.The epidemiological bulletin is published weekly with current findings, interpretations, and recommendations.

Monitoring and Evaluation:

Data from EWARN must be regularly reviewed to ensure integrity and accuracy of the information collected. Every effort must be made to trace missing or incomplete data to the original source.These efforts are carried out by the FLO/health facility focal point, then the DLOs ,in their turn, take part in it, and eventually the CLOs involved in the process to finalize it .Monitoring via routine data-quality checks and internal evaluations will be conducted at all reporting levels Once establishing the system is done and it started to function.A formal external evaluation occurs once the emergency is over or approximately every 12-18 months in protracted situations.See Appendix 3 for Monitoring Checklist form in field and district level.

Reporting Schedule:



Figure 1.7: EWARN Reporting Schedule



Section

ROLES ANDRESPONSIBILITIESBY LEVEL2




Health facility staff / Field Level Surveillance Officer (FLO)

Data collection procedures:

Key principles when recording diseases:

• Strictly adhere to the EWARN case definitions. These may differ from previous surveillance case definitions and from clinical case definitions. For example, acute diarrhoea should not be confused with suspected cholera.

Note: EWARN case definitions are not to be used for case management and are not an indication of intention to treat

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

• Only record new cases during weekly aggregation of data.

- If a patient presents to the health facility for the same condition multiple times, this is considered a repeat visit and should only be counted once. - If a patient is transferred from another health facility, only count as a new case if the referring health facility is not part of EWARN (not a sentinel site).

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

How to complete the EWARN reporting form for weekly reporting: Weekly aggregated data must be recorded on the EWARN weekly reporting form and transmitted to the district level. This could be done as a hard copy or a soft copy depending on the health facility and its capacity.The top section of the reporting form is for general information (location, date, name of responsible person, etc.). The next section is for case counts disaggregated by age and sex. For each section, complete each space on the reporting form.Do not leave any spaces blank.See Table 2.1 and Appendix 1

1. Basic information for each health facility, indicate:

a. Name of reporter

b. Job title

c. Governorate

d. District , sub district and community.

e. Health center name

f. Catchment population, if known

g. Reporting period: From the start date of the epidemiological week being reported (Sunday of the previous week) to the end date of the epidemiological week being reported (Saturday of the current

week )

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

i. Date the reporting form was submitted to the DLO

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



2. Reporting of cases : Add up all the cases of the reportable conditions from the patient registers and write down (or type) these numbers into the corresponding boxes on the reporting form.Case counts should be disaggregated by age (4-0 and ≥ 5 years), and sex (male, female):

3. Only the 13 priority conditions under surveillance should be aggregated and reported (rows 13-1); all other conditions should be grouped under the ‘all other diseases’ category (row 14).

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

5. Total number of consultations is the number of top-priority conditions plus ‘others’.Make sure to calculate this number correctly.This information will help estimate the proportional morbidity, or the burden of a specific disease from the total number of patient visits, and will be used to monitor trends.

6. The last section is to further explain all unusual cluster of events, unusual cluster of deaths reported for that week.

7. All efforts should be made to ensure conditions are not counted more than once (i.e., registers should be cross-checked to avoid duplications).

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

Basic Information | معلومات أساسية

Epi Weekاألسبوع الوبائي Month الشهر

Governorate املحافظة District املنطقة Subdistrict الناحية

Communityقرية / بلدة / حي

Select village/town/neighborhood if it were not in the drop-down menuحدد قرية / بلدة / حي اذا لم تكن يف القائمة املنسدلة

Health Center Nameاسم املرفق الصحي

Catchment Populationعدد السكان املستفيدين

Report Period فترة اإلبالغFrom من

Report Period فترة اإلبالغTo الى

Name of reporter اسم املبلغ

Job title املسمى الوظيفي

Date Received by DLO* تاريخ التسليم الى منسقاملنطقة

Entered to system by DLO onتاريخ ادخال املعلومات من قبل منسق املنطقة

Table 2.1 : Weekly Zero Report Form



Reporting of cases | الحاالت املبلغة

DISEASEاملرض

Code الرمز

Typeالنمط

Alert threshold عتبة اإلنذار

0 - 4 years ≥ 5 yearsAlerts

االنذاراتMaleذكر

Femaleأنثى

Maleذكر

Femaleأنثى

1. Acute bloody diarrhea (suspect-ed shigellosis)اإلسهال الدموي الحاد )االشتباه بداء الشيغال (

ABD B 5 0

2. Acute watery diarrhea (suspect-ed cholera) اإلسهال املائي الحاد)االشتباه الكوليرا(

AWD A 1 0

3. Acute jaundice syndrome AJS متالزمة اليرقان الحاد B 5 0

4. Severe Acute Respiratory Illness املرض التنفسي الحاد الوخيم SARI B 5 0

5. Acute flaccid paralysis الشلل الرخو الحاد AFP A 1 0

6. Suspected Measles االشتباه بمرض الحصبة Meas A 1 0

7. Suspected Meningitis االشتباه بمرض التهاب السحايا Men B 5 0

8. Unusual cluster of health events مجموعة عنقودية من األحداث الصحيةغير االعتيادية

UCE A 3 0

9. Unusual cluster of death مجموعة عنقودية من الوفيات غيراالعتيادية

UCD A 3 0

10. Suspected Typhoid Feverاشتباه الحمى التيفية STF B 5 0

11. Cutaneous Leishmaniasis الليشمانيا الجلدية Leish B 50 0

12. Other Acute diarrheaإسهال حاد ألسباب أخرى OAD B - -

13. Influenza Like Illnessمرض الشبيه باالنفلونزا ILI B - -

14. Other Diseasesجميع الحاالت األخرى املسجلة other - -

15. Total consultations مجموع االستشارات الكلي Total 0 0 0 0 0



Notes مالحظات عامة

Mumps نكاف Tuberculosis سل Lice قمل

Varicella جدري املاء Pertussis سعال ديكي Scabies جرب

Others حاالت أخرى

District level officer evaluation تقييم منسق املنطقة :

The report have been sent on time )befor monday 05:30 PM

هل تم تسليم االبالغ بالوقت املناسب )قبل االثنين الخامسة)مساء

Any empty cells in the zero report

هل يوجد أي حقول فارغة يف االبالغاالسبوعي

Do the written dates are compatible with the Epi week range? هل التواريخ املكتوبة صحيحة ومتوافقة معاالسبوع الوبائي؟

The total of consultations and all the other cases have been added to the report in the correct method هل تم إضافة مجموع االستشارات و جميع الحاالت األخرى الى البالغبشكل صحيح؟

any unusual or unexpected numbers

هل هناك أي ارقام غير طبيعية أو غيرمتوقعة

How many alerts have not been notified within 24 H كم عدد اإلنذارات التي لميتم رفعها خالل 24 ساعة

DLO Name منسق املنطقة* : FLO Name منسق امليداني* :

Please note: مالحظات مهمة

-Type (A) alert diseases should be notified immediately

-Only report the new cases during the first visit

Write ‘0’ (zero) if no case has been reported for any of the above listed diseases. Do not leave any spaces blankالرجاء عدم ترك أية فراغات وكتابة صفر )0( يف حال عدم وجود حاالت مسجلة

-يجب اإلبالغ عن األمراض التي تتبع النمط A من اإلنذار بشكل فوري

-أبلغ فقط عن الحاالت الجديدة املسجلة خالل األسبوع الحالي (الزيارة األولى)

Table 2.2 : Case Definition and Alert Threshold



CASE DEFINITIONS

Alert Threshold Definition Code Disease / Syndrome

Other Acute diarrhea OAD Any person with acute diarrhea (three or more loose stools in the past 24 hours), not due to bloody diarrheal or suspected cholera.

Double the average of the last 3 weeks in a given location

Acute bloodydiarrhea (suspectedshigellosis)

ABD

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

≥ 5 cases in 1 locationin 1 week or

Acute waterydiarrhea (suspectedcholera)

AWDAny person aged 5 years or more with severe dehydration OR death from acute watery diarrhea in the past 24 hours , with or without vomiting.

One case

Acute jaundice syndrome (Hepatitis A & E )

AJS

Acute onset of jaundice ( yellowing of sclera ofeyes or skin or dark urine),ANDSevere illness (Fatigue, nausea, vomiting and abdominal pain) ANDThe absence of any known precipitating factors


Influenza Like Illness ILI

Acute respiratory illness with: - measured fever (≥ 38°C)- Cough - Onset within the last 7 days

Double the average of the last 3 weeks in 1 health facility


SARI

Acute respiratory illness with: - History of fever or measured fever (≥ 38°C)- Cough - Onset within the last 7 days - Requires hospitalization (whether possible or not )

≥ 5 cases in 1 health facility or hospital

in 1 week or

1 death due to influenza like illness

Acute flaccidparalysis (suspectedpoliomyelitis)

AFP

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

One case

Suspected Measles Meas

Any person with fever ≥ 38°C, AND;maculopapular (non vesicular) generalized rash,

AND ONE of the following:- Cough - Runny nose (coryza) - Red eyes (conjunctivitis),OR;Any person in whom a clinician suspects measles

Double the average of the last 3 weeks

Suspected Meningitis Men

Any person with sudden onset of fever ≥ 38°C,AND ONE of the following signs:- Neck stiffness.- bulging fontanel (in a child < 1 year).- Altered consciousness.- Petechial or purpuric rash OR other meningeal sign.

1 case in a crowdedcamp setting

or ≤ 30,000: 2 cases per week in the

same communityOR

Population ≥30,000: 5 cases per week in the same community


UCE

Any emerging disease or event of an unknown or unidentifiable causeresulted in suffering of many people from similar symptomsin the same location in given short period of time.

3 or more cases in same week in the same community or health facility

Unusual cluster of deaths UCDPersons who die suddenly of unknown, non-injury causewith same signs or symptoms and do NOT have any of the diseases or syndromes listed above.

3 or more deaths in same week in the same community or health

facility

Suspected Typhoid Fever STF

Any person with acute illness and fever of at least 38°C for 3 or more days with abdominal symptoms (diarrhea or constipation or abdominal tenderness progressing to prostration)and relative bradycardia.ORsymptomatic case contacted with confirmed case


Cutaneous Leishmaniasis Leish

Any person having skin lesions on the face, neck, arms, and legs (exposed body parts)which began as nodules and turned into skin ulcers, eventually healing but leaving a depressed scar.

≥ 50 of new cases in one area or health facility

The highlighted cells are Type A alert diseases

Table 2.2 : Case Definition and Alert Threshold



Ensure all reporting forms for the prior epidemiological week have been received on time. District Level Surveillance Officers enter the data reported weekly into the District EWARN database.

District Level Officers to send data to Central Level in between 5 pm Saturday - 5 pm Monday

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

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

See Appendix 5 for Alert verification and investigation register.

Immediate alerts Weekly data

• Conduct data quality checks on all submitted reporting forms for the following:- Completeness - All fields on the weekly forms are completed (no blank spaces).

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

- Screen for alert notification – Check the reporting forms if any criteria meet immediate alert notification are present and have not already been reported.

• On a weekly basis, submit the EWARN reports database and the alerts register by email to the central level.

It is the responsibility of all District Level Surveillance Officers to ensure timely and complete submission of their EWARN databases.

Did you...

- Collect all weekly reporting forms?

- Send updated weekly reports database and alerts register to central office?

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

- Identify any unreported alerts?

- Follow-up any problems?


District Level Surveillance Officer (DLO)



Central Level Surveillance Officer (CLO)

Ensure all district EWARN data have been submitted before 5:00 on Monday, and compile it into the consolidated database

• Conduct data analysis for indicated disease parameters by province: - Timeliness - Completeness - Proportional Morbidity - Summary of all health events under surveillance• Meet with all Central Level staff for technical review and interpretation of data by 10:00 am Thursday• Finalize and disseminate weekly health bulletin to partners, stakeholders, community by 4:00 pm Friday• Monitor status of outbreak investigations and maintain updated alerts/outbreaks database

The CLO is responsible for documenting and addressing challenges discussed in meeting surveillance expectations. Follow-up any discrepancies or outstanding issues with field staff.

Did you...

- Follow-up any alerts/outbreaks and update the central level alerts database?

- Review health bulletin for technical and editorial content?

- Follow-up any problems?




Section

3Section 1 – General overviewSection 2 – Roles and responsibilities by levelSection 3 – Alert and outbreaksSection 4 – Appendices (forms, charts, references)

ALERTS ANDOUTBREAKSALERT NOTIFICATION, VERIFICATION AND OUTBREAK INVESTIGATION PROCEDURES



Alert Notification

An alert is an unusual health event that can signal the early stages of an outbreak. It is triggered when a critical number, level, or point has been crossed. It is an essential step in making decisions to report an outbreak.

An alert is used to:• Sound an early warning• Launch a verification and possible investigation• Implement control measures to contain or prevent an epidemic

Alerts can be triggered from:• Surveillance data• Health facilities• Community informants or leaders, religious leaders, traditional healers• Media rumors• The affected population

Alerts are recorded in the patient registry, similar to other morbidity data. In addition, an alert form must also be completed and must be immediately reported to the DLO in charge in the region.and the CLO (if respective DLO is not reachable, alert should be reported to the adjacent-area DLO or directly to the CLO). Alerts must be reported using the fastest means possible (phone, SMS, etc.).See Appendix 5 for sample alert notification form.

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

- Potential outbreaks can be recognized by:

• Clever observation of a single event or cluster of events by health staff• Report of one or more cases with similar signs and symptoms from the same area• Routine surveillance activities

The trigger for an outbreak investigation is a verified alert, i.e. a valid number of cases crossing the alert threshold.When an alert has been received, the DLO should immediately try to verify the alert and details of the patient location systematically, using a standard list of questions, and record the information about the alert in a log.

This process should be conducted by the DLO, under the supervision of the Central Level in collaboration with the health provider.

Alert Verification



The standard list of questions is below and template for alert log format is in the ( Figure 3.2 ) :

1. Who is reporting the alert (is the source reliable?) and what are their contact details? (may be needed for further action)

2. Number of cases and their symptoms and signs? Number of deaths, if reported, and whether the cause of death determined by health personnel?

a. Do the cases fit the case definition? For example, did a health provider confirm that the rash was typical of measles?

b. What is the age and sex of the patients and their vaccination status, if relevant?

c. What was the onset date of the first case's symptoms, if more than one case, and of the most recently detected case?

d. What was the case address as the onset occured?

3. When were the cases seen? Were they hospitalized or have they returned to their home or other location? Where are they now? What is the patient contact information?

4. Any other information available about the cases, their exposure to risks, their presence in an IDP camp or hostel, or their travel history?

5. Any other information about family and health personnel who may have been exposed?

All alerts and information obtained during verification should be recorded in an alert log. The alert log can

also form the basis for a digitized system to track related outbreak investigations, lab specimens, environ-

ment sampling, and outbreak control activities.

The DLO should report all verified alerts, and any alerts which cannot be immediately verified or rejected

for whatever reason, immediately to the intermediate and central levels. Sharing the verified alert with

the other levels puts the relevant departments also on alert regarding lab sampling, essential meds, and

logistic arrangements, as well as the technical team who may need to advise or assist in the outbreak

response. Logs of the verified alerts are also kept at the intermediate and central levels to assist with lab

sample tracking and reporting results of outbreak investigation.

Figure 3.1 : Importance of Case Definition



1- Characterize the epidemiology : line listing , descriptive epidemiology , epidemic curve, case fatality rate, hypothesis regarding transmission.

2- Laboratory confirmation : control measures should not await laboratory results, antibiotic sensitivity should support case management.

3- Prevention : e.g community prevention messages , immunization prophylaxis for contacts , social mobilization.

4- Control : interrupt transmission , isolate , manage cases.

Outbreak response components :

Figure 3.2 : Alert Verification Process Chart



1- No Alert reported : E.g : alert seen in a weekly report but not reported immediately as expected, this can also known as regular supervision.Possible actions : orientation / training on alert notification and alert threshold , check communication lines to ensure non- reports can be communicated to EWARN focal points.

2- False alert on verification:E.g : alert is received from community health worker for a suspected measles case , verification process reveals isolated case of skin disease and it is not a measles case.Possible actions : re- orientation on case definition as a part of supportive supervision , positive feedback on use of EWARN.

3- Alert confirmed but no outbreak:E.g : health facility reports a meningitis case , then confirmed on verification , and field investigation suggested no ongoing transmission. Possible actions : probably a sporadic case of meningitis, emphasises the optimal treatment of the case and immediate notification of any new cases , positive feedback on use of EWARN.

4- Alert verified and outbreak confirmed:E.g : health facility reports unusual numbers of acute watery diarrhea among adults with sever dehydration.Verification and field investigation confirm an outbreak of sever diarrheal disease, possibly cholera.Possible actions : outbreak response measures initiated ,laboratory samples taken for confirmation and antibiotic sensitivity.

Four possible Alert scenarios :

Field investigation:

• On site visit , preferably within 24 hours

• Review the cases with physician

• Assessment clustering of the cases by place and time

• Household visit

• Examination of the cases , interviews case contacts .

• Interview to determine the medical history , review of vaccination record.

• Performance of the rapid test as indicated.

• Collection samples in relevant media.

• Line listing of cases.

• Expansion of surveillance coverage and enhancement of reporting as required.

Alert verification :

By telephone , find out about :

• Who is reporting the alert / rumor (and their contact details)

• Person / Place /Time :

Number of cases / deaths

Age , sex, origin of cases / deaths

Date of onset or consultation

• Treatment and outcome

• Check case definition used and symptoms / signs.

• Any healthcare staff affected

• Any cluster ? ( by families or contacts, geographically )

• Measures taken so far.

• Community reactions.



Outbreak Preparations:

Thorough investigation will require several resources including transportation, specimen collection materials, a multi-sectorial outbreak control team (OCT), outbreak response plans, standard treatment protocols, identification of isolation sites, and pre-positioned stockpiles of essential treatment supplies.It is critical to have these resources identified beforehand to ensure a timely and effective response.It is the responsibility of the DLO to maintain an updated checklist of required materials, supplies, and tools. See Appendix 9 for sample checklist of required materials and supplies.

Outbreak Investigation:

Outbreaks can spread very quickly.Once an alert has been verified, an outbreak investigation must be conducted.An outbreak investigation determines the cause of the outbreak in order to implement con-trol measures and ultimately reduce morbidity and mortality.Standardized case investigation forms and line lists should be used during an investigation. See Appendix 7 for sample case investigation form and line list.

Details on how to conduct an investigation are presented elsewhere, See Appendix 8 for a summary of key steps.The main objectives of an outbreak investigation are:

1. Identify the causative agent

2. Identify persons at risk

3. Identify mode of transmission and vehicle

4. Identify source of contamination

5. Identify additional risk factors

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

Figure 3.3: Delayed Response VS Rapid Response

Delayed Response

Rapid Response



Roles and responsibilities of Outbreak Control Team (OCT) :

For an effective response, outbreak investigations require a range of skills and expertise and coordination of many sectors.These include, but are not limited to:

• Team leader or Central Level Surveillance Coordinator

• District Level Surveillance Officer

• Rapid Response member

• Clinician

• Sector specialist (for example, WASH or nutrition)

• Laboratory personnel

• NGO health officer

• Logistician

• Health educatorSee Appendix 4 for sample OCT contact list. This list must be updated regularly consider-ing the revolving partners and staff during an acute phase of an emergency.

Primary functions of an OCT are to:

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

• Strengthen surveillance (staff training, updated line list, daily review of indicators such as attack rates and case-fatality ratios)

• Implement and evaluate control measures/interventions

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

• Communicate findings, disseminate results



Laboratory support:

Routine reporting of diseases/conditions that do not reach an alert threshold do not re-quire laboratory confirmation. However, laboratory confirmation of cases is important when an outbreak is suspected. Therefore, a reference laboratory with varying capacity should be identified beforehand and all samples sent for testing must be documented.

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

Table 3.1: List of laboratories testing capability

Name of labora-tory

Governorate district location Testing capability

Table 3.2 : Summary of recommended sample collection media, use, storage and transport

S/N Diseases Media for the sample

Collection

SampleRequired

TransportationTemperature &

Mechanism

1Other Acute Diarrhea Acute Bloody Diarrhea Acute Watery Diarrhea

1. Carry Blair Media2. Stool Containers3. Disposable Stick swabs

Approx.5 gram Stool

RefrigeratedCold box (2-80 C)

2

Suspected Measles Suspected Influenza H1N1 & H5N1Hemorrhagic Fever Acute Jaundice Syndrome

1. Blood Serum Tubes (Plain or with clot activator) 2.Throat Swabs in VTM(if H1N1/H5N1 or Measles Sample)

Blood (5- 10 cc in adults and 2 -5 in children) Serum (2-3 cc) Throat Swab

RefrigeratedCold box (2-80 C)VTMs (Pink Bottle)Must be refrigeratedOther VTMs at Room Temperature

3 Diphtheria / Pertussis Amies Charcoal Medium Throat / Nasal Swab

Cold box (2-80 C)

4 Meningitis Trans-Isolate Medium CSF (1-2 cc) Warm (370 C) or Room temperature

5 Acute Flaccid Paralysis Stool Container Approx.8 gram Stool

Cold box (2-80 C) (two Samples 24 hrs diff)

See Appendix 10 for general overview of diagnostics testing, and proper specimen collection, packag-ing, and transportation . For more details , please read the EWARN laboratory guidelines:

http://www.acu-sy.org/wp-content/uploads/2017/02/EWARNGuidelines_Laboratory_2016_AR.pdf



Response and control measures :

Control measures should be initiated as soon as possible. It is not necessary to wait for the results of the outbreak investigation. Some common control measures are:

- Interruption of environmental sources (e.g. provision of safe water)

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

- Isolation of infected people

- Improved hygiene and/or sanitation practices (ex., health education and messaging, provision of soap)

See Appendix 11 for outbreak response plans for selected priority diseases/conditions.



Feedback and Dissemination:

Findings and feedback must be shared with partners, stakeholders, and the community to monitor the progress of the outbreak and tosupport public health efforts.if the facility does not receive information on how the data was interpreted or what the data meant, health workers may think that their re-porting is not important.As a result, future reporting may not be as it should, because the health workers will not be aware of the importance of the information submitted to higher levels was important or necessary.They will have a good understanding of the health situation at their own level, but they will not have the information they need for charac-terizing the situation.

The purpose of the feedback is to rein-force health workers’ efforts to partici-pate in the surveillance system.Another purpose is to raise awareness about certain diseases and any achieve-ments of disease control and prevention projects in the area.Feedback may be written, such as in-formation summary sheets or it may be given orally through a telephone call or periodic meetings.This section focuses on district level feedback.But the information can also be applied in health facility .

Figure 3.4: Schematic of early warning alert and response



Section

4Section 1 – General overviewSection 2 – Roles and responsibilities by levelSection 3 – Alert and outbreaksSection 4 – Appendices (forms, charts, references)

APPENDICES



APPENDIX 1Weekly Reporting Form, Case Definitions, and Alert Thresholds:

Basic Information | معلومات أساسية

Epi Weekاألسبوع الوبائي Month الشهر

Governorate املحافظة District املنطقة Subdistrict الناحية

Communityقرية / بلدة / حي

Select village/town/neighborhood if it were not in the drop-down menu حدد قرية / بلدة / حي اذا لم تكن يف القائمةاملنسدلة

Health Center Nameاسم املرفق الصحي

Catchment Populationعدد السكان املستفيدين

Report Period فترة اإلبالغFrom من

Report Period فترة اإلبالغTo الى

Name of reporter اسم املبلغ

Job title املسمى الوظيفي

Date Received by DLO* تاريخ التسليم الى منسقاملنطقة

Entered to system by DLO on تاريخ ادخال املعلومات من قبل منسقاملنطقة

Weekly Zero Report form



Reporting of cases | الحاالت املبلغة

DISEASEاملرض

Code الرمز

Typeالنمط

Alert threshold عتبة اإلنذار

0 - 4 years ≥ 5 yearsAlerts االنذارات

Maleذكر

Femaleأنثى

Maleذكر

Femaleأنثى

1. Acute bloody diarrhea (suspect-ed shigellosis)

اإلسهال الدموي الحاد )االشتباه بداء الشيغال (

ABD B 5 0

2. Acute watery diarrhea (suspect-ed cholera)

اإلسهال املائي الحاد)االشتباه الكوليرا(AWD A 1 0

3. Acute jaundice syndrome AJS متالزمة اليرقان الحاد B 5 0

4. Severe Acute Respiratory Illness املرض التنفسي الحاد الوخيم SARI B 5 0

5. Acute flaccid paralysis الشلل الرخو الحاد AFP A 1 0

6. Suspected Measles االشتباه بمرض الحصبة Meas A 1 0

7. Suspected Meningitis االشتباه بمرض التهاب السحايا Men B 5 0

8. Unusual cluster of health events مجموعة عنقودية من األحداث الصحيةغير االعتيادية

UCE A 3 0

9. Unusual cluster of death مجموعة عنقودية من الوفيات غيراالعتيادية

UCD A 3 0

10. Suspected Typhoid Feverاشتباه الحمى التيفية STF B 5 0

11. Cutaneous Leishmaniasis الليشمانيا الجلدية Leish B 50 0

12. Other Acute diarrheaإسهال حاد ألسباب أخرى OAD B - -

13. Influenza Like Illnessمرض الشبيه باالنفلونزا ILI B - -

14. Other Diseasesجميع الحاالت األخرى املسجلة other - -

15. Total consultations مجموع االستشارات الكلي Total 0 0 0 0 0



Notes| مالحظات عامة

Mumps نكاف Tuberculosis سل Lice قمل

Varicella جدري املاء Pertussis سعال ديكي Scabies جرب

Others حاالت أخرى

District level officer evaluation | تقييم منسق املنطقة :

The report have been sent on time (befor monday 05:30 PM

هل تم تسليم االبالغ بالوقت املناسب )قبل االثنين الخامسة مساء(

Any empty cells in the zero report

هل يوجد أي حقول فارغة يف االبالغ االسبوعي

Do the written dates are compatible with the Epi week range? هل التواريخ املكتوبة صحيحةومتوافقة مع االسبوع الوبائي؟

The total of consultations and all the other cases have been added to the report in the correct method هل تم إضافة مجموع االستشارات و جميعالحاالت األخرى الى البالغ بشكل صحيح؟

any unusual or unexpected numbers

هل هناك أي ارقام غير طبيعية أو غير متوقعة

How many alerts have not been notified within 24 H كم عدد اإلنذارات التي لم يتمرفعها خالل 24 ساعة

DLO Name منسق املنطقة* : FLO Name منسق امليداني* :

Please note: مالحظات مهمة

Type (A) alert diseases should be notified immediately

Only report the new cases during the first visit أبلغ فقط عن الحاالت الجديدة املسجلة خالل األسبوع الحالي (الزيارة األولى)

Write ‘0’ (zero) if no case has been reported for any of the above listed diseases. Do not leave any spaces blankالرجاء عدم ترك أية فراغات وكتابة صفر )0( يف حال عدم وجود حاالت مسجلة

Weekly Zero Report Form



The highlighted cells are Type A alert disease

Alert Threshold Definition Code Disease / Syndrome

Other Acute diarrhea OAD Any person with acute diarrhea (three or more loose stools in the past 24 hours), not due to bloody diarrheal or suspected cholera.

Double the average of the last 3 weeks in a given location

Acute bloodydiarrhea (suspectedshigellosis)

ABD

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


Acute waterydiarrhea (suspectedcholera)

AWDAny person aged 5 years or more with severe dehydration OR death from acute watery diarrhea in the past 24 hours , with or without vomiting.

One case

Acute jaundice syndrome (Hepatitis A & E )

AJS

Acute onset of jaundice ( yellowing of sclera ofeyes or skin or dark urine),ANDSevere illness (Fatigue, nausea, vomiting and abdominal pain) ANDThe absence of any known precipitating factors


Influenza Like Illness ILI

Acute respiratory illness with: - measured fever (≥ 38°C)- Cough - Onset within the last 7 days

Double the average of the last 3 weeks in 1 health facility


SARI

Acute respiratory illness with: - History of fever or measured fever (≥ 38°C)- Cough - Onset within the last 7 days - Requires hospitalization (whether possible or not )

≥ 5 cases in 1 health facility or hospital in 1 week or

1 death due to influenza like illness

Acute flaccidparalysis (suspectedpoliomyelitis)

AFP

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

One case

Suspected Measles Meas

Any person with fever ≥ 38°C, AND;maculopapular (non vesicular) generalized rash,

AND ONE of the following:- Cough - Runny nose (coryza) - Red eyes (conjunctivitis),OR;Any person in whom a clinician suspects measles

Double the average of the last 3 weeks

Suspected Meningitis Men

Any person with sudden onset of fever ≥ 38°C,AND ONE of the following signs:- Neck stiffness.- bulging fontanel (in a child < 1 year).- Altered consciousness.- Petechial or purpuric rash OR other meningeal sign.

1 case in a crowdedcamp setting

or ≤ 30,000: 2 cases per week in the

same communityOR

Population ≥30,000: 5 cases per week in the same community


UCE

Any emerging disease or event of an unknown or unidentifiable causeresulted in suffering of many people from similar symptomsin the same location in given short period of time.

3 or more cases in same week in the same community or health facility

Unusual cluster of deaths UCDPersons who die suddenly of unknown, non-injury causewith same signs or symptoms and do NOT have any of the diseases or syndromes listed above.

3 or more deaths in same week in the same community or health

facility

Suspected Typhoid Fever STF

Any person with acute illness and fever of at least 38°C for 3 or more days with abdominal symptoms (diarrhea or constipation or abdominal tenderness progressing to prostration)and relative bradycardia.ORsymptomatic case contacted with confirmed case


Cutaneous Leishmaniasis Leish

Any person having skin lesions on the face, neck, arms, and legs (exposed body parts)which began as nodules and turned into skin ulcers, eventually healing but leaving a depressed scar.

≥ 50 of new cases in one area or health facility

Case Definitions:



APPENDIX 2 Sample Patient Register:

Patient Register

Facility Name:

Governorate / District :

Date Name Age Sex (M/F)Address or contact

informationFirst Visit for this

problem (Y/N)Signs and

SymptomsDiagnosis Treatment Physician



APPENDIX 3Monitoring Checklist:

Governorate/District Name:

GENERAL INFORMATION

I. Monitor /Supervisor name(s):

II. Date: - - 2016

III. Officer Name: _________________________ . Phone Number:

IV. Officer education: 1-Doctor 2-Nurse 3- Midwife 4- Other (specify)…………..…….

V. Number of sentinel sites : Implementer NGO:

1- STAFF No Yes Comment / Points

1.1 Is DLO/FLO present at work 0 1

1.2 Presence of job description 0 1

1.3 Is there any trained back up for FLO/DLO 0 1

1.4 Did FLO/DLO receive incentive/salary on time? 0 1

1.5 Training plan available for EWARN focal points? 0 1

1.6 Did FLO/DLO attend training in last six months? 0 1

2- OFFICE MANAGEMENT No Yes Comment / Points

2.1 Is the office well organized and clean? 0 1

2.3 Existence of Inventory sheet (match with equipment lists) 0 1

2.4 Are the Computer and printer in the office and active? (Check with inventory) 0 1

2.5 Are Chairs and table available? (Check with inventory) 0 1

2.6 Is there any cupboard for filing? (Check with inventory) 0 1

2.7 There is no need for structural and repair 0 1

2.8 Does any vehicle exist for EWARN, available and utilized? 0 1

2.9 Existence of Vehicle Log Book and filled out 0 1

3-LABORATORY MEDIA No Yes Comment / Points

3.1 Is there any active freezer (refrigerator) available? 0 1

3.2 Vaccine carrier with icepack (at least two) available? 0 1

3.3 Measles sampling kits 0 1

3.4 Swab 0 1

3.5 Cary Blair 0 1

3.6 VTM 0 1

4-EWARN BUFFER STOCK No Yes Comment / Points

4.1Is there adequate buffer stock of EWARN materials? (PPE kits, sampling kits, IEC materials…………)

0 1

4.2 Is the stock well organized? 0 1



APPENDIX 4 Contact List of Alert Notification team and outbreak Investigation Team:

Please complete the following table with the names and contact information of the EWARN surveillance staff, NGO Health Officer or health facility director, community and local health authorities, and others responsible for alert and outbreak activities take place at your facility. These individuals should be notified in case of an alert or potential outbreak. Please post this list for easy reference and update, as necessary.

Alert Notification Contact List:

Alert Notification Contact List

Title Name Mobile # Email

DLO –first contact

CLO-if not able to reach DLO

FLO in the health facility

NGO Health Officer

Local Health Authority

Other



The following list constitutes individuals or agencies that can support an investigation. Not every individual will be required during an investigation, but key persons should be identified immediately. This list must be updated regularly.

Outbreak Investigation Team Contact List

Alert Notification Contact List

Role/Responsibility Name Mobile # Email

Team lead/surveillance officer

Local authority/partner

Clinician

Sector specialist (WASH, vector)

Laboratory technician (or person capable of specimen collection)

NGO health officer

Logistician

Health educator

Security personnel



APPENDIX 5 Sample Alert Notification Form:

Alert Notification Form نموذج اإلبالغ عن إنذار

Reporting Unit Information معلومات الوحدة املبلغة

Reporting time وقت اإلبالغ : Reporting date تاريخ اإلبالغ :

Reporting person اسم املبّلغ : Reporting unit name الوحدة املبّلغة :

Contact number معلومات االتصال : Location املوقع :

Governorate املحافظة : District املنطقة :

Patient Information (In case of single case alert) معلومات املريض (يف الحالة املفردة)

Name االسم : Age العمر :

Gender الجنس : Name of head of household اسم رب األسرة :

Contact number رقم االتصال : Address العنوان :

Cluster Information (In case of group alert) معلومات العناقيد (يف حال اإلنذارات املجموعية)

Number of Cases عدد الحاالت : Number of Deaths عدد الوفيات:

Contact number رقم االتصال: Address العنوان :

Suspected Disease / Syndrome / Event Information معلومات املرض/املتالزمة/الحدث املشتبه

Acute Bloody Diarrhea إسهال دموي حاد : Acute Jaundice Syndrome متالزمة اليرقان الحاد :

Sus.Meningitis اشتباه التهاب السحايا : Sus.Typhoid Fever اشتباه حمى تيفية :

Acute Watery Diarrhea إسهال مائي حاد : Influenza like illness (ILI) املرض شبيه االنفلونزا :

Fever of Unknown Origin حمى مجهولة السبب : Leishmaniosis لشمانيا :

Acute Diarrhea إسهال حاد SARI املرض التنفسي الحاد الشديد

Unexplained Death/s وفاة غير مفسرة : Acute Flaccid Paralysis شلل رخو حاد :

Measles حصبة Unusual Cluster of Disease/events أحداث / أمراض عنقودية الشديد

Sign and Symptoms (Please tick all that applies) األعراض والعالمات )يرجى تحديد املتوافقة(

Watery or loose stool: إسهال مائي أو رخو

Acute weakness: ضعف عضلي حاد

Neck stiffness: صالبة عنق

Convulsions اختالجات :

Visible blood in stool دم : عياني يف البراز

Fever حمى : Jerking ارتعاش : Difficulty in suckling : ضعف رضاعة

Bleeding (nose/cough/vom-it/stool etc.) نزف )األنف، مع )السعال، مع اإلقياء، يف البراز

Cough سعال : Vomiting إقياء : Red eyesاحمرار يف : العينين

Acute paralysis شلل حاد Rash طفح : Severe dehydration : تجفاف حاد

Difficulty in suckling : ضعف رضاعة

Please specify below any other significant sign/s or symptom/s only

يرجى تحديد وجود أي أعراض أو عالمات مهمة أخرى



APPENDIX 6 Alert verification and investigation register :

EWARN Alret Verification and Investigations Log

YearEpi-

weekSus.

DiseaseAlert Type Governorate District

Loaca-tion

Health Facility

VerifiedVerification

StatusDate

Verified

Date Investi-

gated

<5 M

>5 M

<5 f >5 f

EWARN Alret Verification and Investigations Log

Actions Taken

Outcome #SamplesSample

Type#Positive

Causative Agent

Reported Cases

Reported Deaths

Inves-tigated

By

Alert Notifa-tion Date

Response Indicator

Alret Verification

Mean

Log data Status



APPENDIX 7Sample Outbreak Investigation Form and Line List:

Outbreak Investigation Form

Reporting Officer

District / Sub district

Date Alert Initially Reported

Governorate

Health Facility

Date Case Initially Identified

Brief Summary of Initial Report

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

SIGNS AND SYMPTOMS (S&S)

(CHECK ALL THAT APPLY)Number of

casesDisease / Syndrome Check if

observedS&S

CodeSigns and Symptoms (S&S)

Other Acute diarrhea (OAD)Acute watery diarrhea (AWD)Acute bloody diarrhea (ABD)Acute jaundice syndrome (AJS)Influenza Like Illness (ILI)Severe acute respiratory illness (SARI)Acute flaccid paralysis (AFP)Suspected measles (Mea)Suspected meningitis (Men)Unusual Cluster of event (specify)Unusual Cluster of death Suspected Typhoid Fever (STF)

Cutaneous Leishmaniasis (Leish)

Total Number of Cases

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Acute watery diarrheaBloody diarrheaFeverRashOther skin lesionCoughVomitingJaundiceNeck stiffnessConvulsions / SeizuresMuscle weaknessIncreased secretions/sweating /drooling

Altered level of consciousness

Other: Other:

Actions Taken:

Name and signature of Reporting Officer :



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

Governorate: _______________ District: _______________ Health facility: ____________

Governorate: .................................... Date: ……….…/……….…/……….…

Case No.

NameAge

(M/Y)0 SexSub

district

Com-mu-nity

Date of onset

(dd/mm/YY)

Date seen at

HF

Symp-toms

Lab spec-imen

taken¹

Treat-ment given

(Yes/No)

Out-come²(I, R, D,

X)

Date of Dis-

charge/ death

Contact with

case?³(Yes/No)

Line List

0M=months, Y=years

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

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

³ Known to have contact with a previously identified case (list case no. for which patient had contact, might be family member, friend, relative, school mate or co-worker, attended the same activity)



APPENDIX 8Steps to Conduct an Outbreak Investigation:

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

1. Prepare to investigate

a. Verify initial reports

b. Notify appropriate authorities (DLO, CLO, lab ,WASH , local council, NGO partners, Health Facility Directors)

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

d. Examine cases, interview contacts

e. Secure necessary supplies and arrange logistics

2. Verify the diagnosis and confirm outbreaka. Get laboratory confirmation; collect samples, perform rapid tests, as appropriate

3. Implement immediate control measures

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

more specific than the surveillance case definition.

5. Case identification

a. Conduct a systematic search based on case definition

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

c. Define the extent of an outbreak by counting the number of cases

6. Perform descriptive epidemiology

a. Person/place/time

b. Mapping

c. Epidemic curve

7. Develop hypotheses to explain exposure and disease

a. Design questionnaire

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

frequency from weekly to daily to monitor progress of ongoing outbreak.

9. Implement additional control measures and communicate public health messages

10. Refine hypotheses and perform epidemiological studies, as necessary

11. Communicate findings

a. Disseminate outbreak investigation report

b. Educate community

These steps may not necessarily happen in sequence; however, control measures should be implemented as soon as possible. In the initial stages, the cause of the outbreak may not be known, but general control measures should be instituted based on available data.



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

APPENDIX 9Checklist of Materials and Supplies :

Before embarking on an outbreak investigation, consider the disease or syndrome that you are going to investigate and determine whether any of the following items are needed.

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

Lead investigator Clinician (doctor, nurse, medical assistant, local or NGO partners) WASH or Environmental officer Data collectors / interviewers Logistics management (tracking supplies, setting up tents) Laboratory technician Vector control Health educator

2. What guidelines and references are needed?

Knowledge of local facilities and beds available Oral rehydration kits Vaccines Vaccine cards Vitamin A Zinc Antibiotics Disinfectant / bleach solution Water purification methods Field hospital tent

Treatment protocols Reporting protocols Hospital / health facility contact information

4. What logistics do I need to arrange?

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

5. What is needed for data collection?

Submission forms Specimen collection tubes, cups, and/or kits Cooler/Cold Pack Gloves Syringes/Needles Tourniquet Band-Aids Sharps Container Rubbing Alcohol Labels for specimens N-95 mask

Alert verification forms Case investigation forms Line list forms or paper for line lists Pens, pencils, folders, paperclips

Security Transportation Overnight stays / housing



APPENDIX 10Referral Laboratory and Diagnostic Testing:

The main responsibility of these laboratories is to establish early diagnosis of diseases with high mortality rates, and to provide high quality, accurate and timely laboratory-based information which can be used for public health decisions for effective control and prevention measures for priority diseases.

General guidelines for proper specimen collection:

The quality of laboratory test results depends on the proper collection and handling of the specimen. Correct patient preparation, specimen collection, packaging and transportation are essential factors in obtaining timely and valid test results

a. Collect specimen before administering antimicrobial agents when possible

b. Collect specimen with a little contamination from indigenous microbiota as possible to ensure that the sample will be representative of the infected site.

c. Utilize appropriate collection devices. Use sterile equipment and aseptic technique to collect specimens to prevent introduction of microorganisms during invasive procedures.

d. Clearly label the specimen container with the patient’s name and identification number or date of birth (DOB). Always includes date and time of collection and your initials.

e. Collect an adequate amount of specimen. Inadequate amounts of specimen may yield false-negative results.

g. Identify the specimen source and/or specific site correctly, so that proper culture media will be selected during processing in the laboratory.

The manual guidelines document for laboratory and standard operating procedures for sampling from Early Warning Alert and Response Network (EWARN) provides more detailed guidance, it is available at:

http://www.acu-sy.org/wp-content/uploads/2017/02/EWARNGuidelines_Laboratory_2016_AR.pdf



APPENDIX 11

Outbreak Response Plans for Priority Diseases/Conditions:

The goal of integrated disease surveillance and response is to use data for public health action. When an outbreak, acute public health event or condition is detected, an investigation should take place to determine the cause of the problem. The results of the investigation should guide the response.

1. Report the outbreak or event to the central level.

2. Alert nearby districts about the outbreak. If they are reporting a similar outbreak, coordinate response efforts with them.

3. Assign clear responsibilities to individuals or teams for specific response activities.

4. Provide orientation or training along with adequate supplies of relevant supplies for the district rapid response team and affected health facility staff.

5. Review existing resources as defined in the preparedness plan. Determine what addi-tional resources are required. For example, consider:

• Human resources that could be mobilized to manage the epidemic

• Funds to support response activities

• Emergency stocks or required drugs and other medical supplies

• Laboratory support for confirmation of pathogens/agents responsible for the epidemics/events.

6. Mobilize logistics support (travel of rapid response team, accommodation arrange-ment, communication, other essential equipment)

7. If supplies are not available locally:

• Contact the ministry of health or the local NGO to request alternate suppliers.

• Identify practical low-cost substitutes.

The following procedures should take place:

Convene the outbreak control team (OCT) to determine appropriate public health response :

Mobilize response teams for immediate action:

Rapid response teams should have already been identified during preparedness activities. Mobilize the teams and make sure that the membership of the team reflects the technical needs of the response.



Implement response activities and prevention measures :

• Strengthen case management and infection control measures

• Isolate cases where indicated (Pertussis, Measles)

• Educate the community and promote awareness about sources of contamination and ways to avoid infection.

• Ensure proper collection and handling of specimens

• Provide training for staff

• Enhance surveillance during the response

• Inform and educate the community

• Ensure appropriate and adequate logistics and supplies

• Ensure information sharing among stakeholders

• As appropriate:

- conduct a mass vaccination campaign

- Improve access to safe water and enhance hygiene practice.

- Ensure safe disposal of infectious waste, provide protective materials .

See Appendix 12.

Provide regular situation reports on the outbreak and eventson the outbreak and events :

Periodically, report on progress with the outbreak response. In the situation updates, provide information such as:

• Details on the response activities. Include dates, places, and individuals involved in each activity. Also include the “Epi” curve, spot map, table of person analyses, and the line list of cases

• Any changes that were made since the last report

• Recommended changes to improve epidemic response in the future such as a vaccination strategy to make the vaccination activity more effective or a transporting procedure for laboratory specimens to allow specimens to quickly reach the reference laboratory in good condition.

Document the response, including lessons learned and recommended improvements:

At the end of the response, the district health team should:

Collect all the documents including minutes of the meetings, activities, processes, epidemic reports, evaluation reports and other relevant documents.

This will become an essential source of data for evaluating the response.



If the alert threshold is exceeded, immediate action should be taken.In general, the steps in the management of a communicable disease outbreak (outlined below) should be followed.

• Routine surveillance

• Alert threshold exceeded, alert verified

• Activate outbreak control team (OCT)

Detection

• Notify required officials

• Complete Outbreak Investigation Form

Response

• Active case finding• Laboratory confirmation of cases and contacts• Epidemiologic investigation (descriptive data,

mode of transmission, risk factors, etc.)

Investigation and Confirmation

• Ensure case reporting• Follow lead of outbreak control team• Prevent exposure and infection

• Treat cases according to guidelines

Control

• Assess timeliness or detection and response• Provide recommendations to improve

performance in future outbreaks

Evaluation

Figure 4.1 : The steps in management of a communicable disease outbreak



Disease Type of PPE needed for contact with suspected cases

Cholera

Diarrhea with blood (Shigellosis)

Measles

ILI - SARI

Meningitis

Viral hemorrhagic fevers (e.g., Ebola, Lassa, Marburg and Yellow viruses)

Contact (gloves, gown,rubber boots)

Contact (gloves, gown)

Airborne (gloves, gown, surgical mask or N95 mask)

Droplet (gloves, gown, face shield or mask and goggles)

Droplet (inner/outer gloves, coveralls +/- hoods, reusable aprons, rubber boots, scrubs, face shield or mask and goggles)

APPENDIX 12Recommended list of personal protective equipment (PPE) by suspected priority disease:



• Standard case definition:

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

• Alert threshold :

≥ 5 cases in 1 location in 1 week.

• Surveillance goal:

- Detect and respond to dysentery outbreaks promptly.

- Determine antibiotic sensitivity pattern to guide

case management.

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

It is the most important cause of acute bloody diarrhea.

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

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

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

Basic Facts:

Shigella dysenteriae type 1:

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

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

• High risk patients include: children under 5 years and especially infants, children who are malnourished and those that have had measles within the last 6 weeks. Other high risk groups include older children and adults that are malnourished, patients that are severely dehydrated and adults over 50 years of age.

• Transmission is by fecal –oral route from person to person and through contaminated food and water. Transmission by flies has been implicated in some Shigella outbreaks.

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

• Treatment is with antimicrobials, which reduce severity and duration of illness. Monitoring of antimicrobial susceptibility is important as Sd1 is frequently resistant.

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

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

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

APPENDIX 13aAcute Bloody Diarrhea (Suspected Shigellosis):



- Causes bloody diarrhea often associated with fever, abdominal cramps and rectal pain.- Incubation period usually 1–3 days, but may be up to 1 week.- Complications include hemolytic uremic syndrome, seizures, sepsis, and rectal prolapse and toxic megacolon.- Diagnosis is by observing blood in a fresh stool specimen or asking the patient or mother of a child whether the stools are bloody.

Clinical Features:

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

Diagnosis:

1. Within 4 days of illness onset, collect a fresh stool sample including portions with blood and/or mucus from suspected cases. 2. Whole stool samples should be collected as soon as possible and before administration of antibiotics for eligible patients. If a stool specimen cannot be obtained, a rectal swab should be done.3. Fresh stool should reach the lab within 2 hours; if this is not possible, place samples in Cary-Blair transport media and refrigerate at 4 ⁰ C. Samples should be cultured within 48 hours of collection.

Collection and Transport of Specimens:

1. Immediately refer severe cases of bloody diarrhea or those with increased risk of death including children under 2 years, adults over 50 years, or individuals with malnutrition to the health facility.

2. Initiate active case finding through community leaders. Refer any case of bloody diarrhea found in the community to the health facility.

3. Establish a line list at facility and community level. Send weekly summaries of line lists by email to DLO, who will forward it to CLO

4. Obtain stool or rectal swab specimen for confirming the SD1 outbreak: Collect stool from 5-10 patients who have bloody diarrhea and Onset within last 4 days, and Before antibiotic treatment has started.

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

6. Use of anti-motility agents (e.g., loperamide) with dysentery patients is NOT recommended as this can prolong illness.

7. Immediately report any deaths associated with suspected shigellosis to the CLO.8. Communicate with Water, Sanitation, and Hygiene (WASH) sector in the Outbreak Control

Team to implement control measures.9. Complete Outbreak Investigation Form.

Outbreak Response:

- Inform community of outbreak through identified community leaders.- Conduct health education activities for community on signs and symptoms, what to do when sick, and how to avoid infection.- Train community leaders including religious leaders on simple signs and symptoms to assist in community surveillance and referral from the community level to the health facilities. - Hand-washing with soap is a key prevention measure. Ensure regular distributions of soap (250g/person/month; in addition to soap for laundry).- Provide the community with messages on the importance of hand washing with soap- Promote cooking food well, keeping it covered, eating it hot, and peeling fruits and vegetables.- Ensure the safe disposal of human waste by always using latrines. - Encourage continuation of breastfeeding of infants and young children- Ensure safe and clean drinking water is available- Implement fly control measures such as the covering of latrines, storage of food in covered containers- Implement disinfection of public or community latrines with chlorine solution (0.2%)

Public Health Awareness and Education:



Health Facility Interventions:

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

- Wash hands with soap before and after examining each patient

- Ensure that health workers who care for dysentery patients (or other diarrhea patients) do not prepare or serve food.

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

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

Funerals :

• Promptly and thoroughly disinfect a patient’s clothing, personal articles and immediate environment using chlorinated lime powder, 2% chlorine solution, and a 1-2% solution of phenol.

• Wash clothes thoroughly with soap and water and then boil or soak them in a disinfectant solution. Dry clothes in direct sunlight

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

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




Suspected case: Any person aged 5 years or more with severe dehydration OR death from acute watery diarrhea in the past 24 hours), with or without vomiting.

• Alert threshold : one case


Detect, confirm and respond promptly to confirmed cholera cases and outbreaks of watery diarrhoea. Immediate case-based reporting of cases and deaths when an outbreak is suspected.

Basic Facts:

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

- It is caused by a Gram-negative bacillus Vibrio cholera, which produces a powerful

enterotoxin that causes copious secretory diarrhea.

- Transmission is by the fecal–oral route. Infection results from ingestion of organisms

in contaminated water or food, or to a lesser extent from indirect person-to-person contamination (unwashed hands).

- Particularly vulnerable groups for cholera include individuals that are malnourished

and those living with HIV/AIDS.

- Acute carriers, including those with asymptomatic or mild disease, are important

in the maintenance and transmission of cholera. Patients discharged from a cholera treatment center can still transmit cholera.

- Cholera is asymptomatic in about 75% of infected cases, if symptomatic 90% is

moderate and 10% is severe form.

- Attack rates in displaced populations can be as high as 10–15%; in normal situations

it is estimated at 1–2%.

- Mass chemoprophylaxis and sanitary cordon are generally ineffective in controlling

an outbreak and are not recommended.

- Rehydration with appropriate fluids is chief in reducing mortality.

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

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

be reduced to 1% or less.

APPENDIX 13bAcute Watery Diarrhea (Suspected Cholera):



- Incubation period is less than 1 day (symptom onset within several hours) to 5 days.- Onset of symptoms is abrupt, with copious watery diarrhea, classic “rice-water” stool with or without vomiting.- Vomiting without associated nausea may develop, usually after the onset of diarrhea.- Fluid loss can lead to rapid and profound dehydration, low serum potassium and acidosis.- Severe dehydration leads to loss of skin turgor, malaise, tachypnea and hypotension.- Fever is unusual, except in children.- If no death, spontaneous recovery in 4 to 6 days

Clinical Features:

- Confirmed through isolation of Vibrio cholera from stool specimens or rectal swab- Rapid diagnostic tests (RDT) allow quick testing at the patient’s bedside, all positive RDTs should then be culture-confirmed.

Diagnosis:Figure 4.2: Signs of Severe Dehydration



• Whole stool samples should be collected as soon as possible and before administration of antibiotics for eligible patients. If a stool specimen cannot be obtained, a rectal swab should be done.

• Fresh stool collected at health facilities should reach the lab and be refrigerated within 2 hours; if this is not possible, place 2 stool swabs in Cary-Blair transport media and ensure they reach the lab as soon as possible.

o Stool swabs properly stored in Cary-Blair transport media can culture V. cholera up to 7 days after collection, but for outbreak detection purposes, identification should proceed quickly.

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

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

o Depending on availability, the hospitals may use rapid diagnostic tests for Vibrio cholera from the stool specimen of patients with AWD and severe dehydration before forwarding it for culture.

o The specimens should be packaged in accordance with the guidelines for the transport of dangerous biological goods (triple packaging using absorbent material).

o Specimens should be transported in a cold box at 40 C.

o Once an outbreak has been confirmed it is not necessary to collect specimens for all suspect cases. However, additional specimens should be tested over the course of the outbreak for antibiotic sensitivity testing.


• Establish treatment centre in locality where cases occur. Treat cases onsite rather than asking patients to go to standing treatment centres elsewhere.

• Treat with (ORS) immediately before administration of antibiotics• Obtain stool specimens at the first opportunity (before antibiotics are given)• Initiate active case finding through community leaders • Work with community leaders to limit the number of large gatherings for ceremonies or other

reasons and communicate messages about preventing cholera and other diarrheal illness, safe water treatment and storage, hygienic preparation of foods, hand washing, sanitation, and the importance of presentation to health facilities for care.

• Establish a line list of all cases at health facility and community level• Standard data collection system in all health facilities, analysis of incidence rate and case

fatality rate, by time and by place.• Provide relatives and/or caretakers of patients with ORS, soap, disinfectant (0.2% chlorine) and

hygiene education to allow them to protect themselves and relatives.• Communicate with Water, Sanitation, and Hygiene (WASH) sector in the Outbreak Control

Team to implement control measures. Information on locations of new cases should be promptly shared with the Outbreak Control Team.

• Survey the availability of clean drinking water. Investigate potential sources of contamination and transmission, including drinking water sources.

• Consider pre-emptive and reactive cholera vaccination campaigns as an additional control measure. Pre-emptive or reactive vaccination should cover as many people as possible who are eligible to receive the vaccine

Outbreak Response:

Prevention:

• Mainly based on basic sanitary and hygiene measures :ensure adequate disinfection of all drinking water supplies. Water providers should target a concentration of 1.0 mg/l of free residual chlorine at all tap stands during a cholera outbreak.• Newly developed oral vaccines are under consideration for their use in public health.

Figure 4.2: Signs of Severe Dehydration



• A multidisciplinary approach based on prevention, preparedness and response, along with an efficient surveillance system, is key for mitigating cholera outbreaks, controlling cholera in endemic areas and reducing deaths

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

• Key to reducing mortality from cholera is prompt rehydration. Suspect patients should seek care as soon as possible. If unable to reach a health facility, rehydration with ORS should be initiated at household level

• Health education activities for community members on topics including hand washing, sanitation, safe food preparation and storage, and hygiene

o 5 Basic Cholera Prevention Messages

• Drink and use safe water

• Wash your hands often with soap and safe water

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

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

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

• Special attention should be given to ensure proper hygiene and sanitation in markets, restaurants and other establishments that prepare food

• Encourage continuation of breastfeeding for infants and young children.


- Supplies and equipment• Establish a system to monitor use of buffer and emergency stocks and ensure their prompt

replacement.

• Determine emergency supply requirements and assign individuals to coordinate their procurement and distribution

o Supplies and equipment needed have been calculated on an attack rate of 0.2, that is 200 cases may be expected to occur in a population of 100,000.

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

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

- Infection risk reduction and isolation• Isolate patients being treated to limit the spread of infection.• If needed, establish a functioning Cholera Treatment Centre (CTC) to relieve pressure

on the hospitalo See WHO Communicable Disease Control in Emergencies. A Field Manual, Annex 7 page 236 for organization of an isolation center, essential rules in a CTC, and disinfectant preparation)o Apply standard precautions (hand-washing stations with chlorine solutions, safe disposal of contaminated articles) as well as enteric precautions. Adapt from the following website:http://www.washclustermali.org/sites/default/files/wash_in_cholera_treatment_centers_in_emergencies_tech_brief_who.pdfo Detailed outbreak guidance for Cholera are available from UNICEF and OXFAM in the references given below. A checklist for Cholera preparedness and response is available at:http://www.unicef.org/cholera/Cholera-Toolkit-2013.pdfhttp://www.unicef.org/cholera/Annexes/Supporting_Resources/Annex_6B/OXFAM_Cholera_guidelines.pdf

Health Facility Interventions:



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

• Those who prepare the body for burial must be meticulous about washing their hands with soap and clean water. Persons handling the body should not be involved in food handling for 24 hours and wash hands thoroughly with soap under running water or with 0.05% chlorine solution

• Bodies should be disinfected with a 2% chlorine solution and the orifices blocked with cotton wool soaked in 2% chlorine solution; they must then be buried in plastic sacks as soon as possible.

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

Funerals :

Figure 4.3: Cholera investigation form




Any person with acute diarrhea (three or more loose stools in the past 24 hours), not due to bloody diarrheal or suspected cholera.

• Alert threshold : Double the average of the last 3 weeks in a given location

• Surveillance goal:establish functional surveillance system for early detection of epidemics caused by diarrheal diseases.

- One of the most frequently common endemic diseases with epidemic potentials.

- Often cause explosive outbreaks

- Leading cause of morbidity and mortality in developing countries

- Similar mode of transmission – similar preventive measures

- Acute diarrhea is often the major cause of morbidity in acute phase of emergency. Without effective treatment, mortality can go substantially high.

- Important cause of morbidity in emergencies where initial mortality is low, and in post-emergency phase.

- Most acute diarrhea illness is NOT caused by cholera or dysentery

- Mode of transmission: • Unclean water• Contaminated food • Poor hygiene practice• Lack of latrines

An outbreak might be flared up very soon in case of unusual number of acute diarrhea cases in a week and the patients have the following points in common:

• they have similar clinical symptoms (watery or bloody diarrhea)

• they are living in the same area or location

• they have eaten the same food (at a burial ceremony for example)

• they are sharing the same water source

• there is an outbreak in the neighboring community

If you have some statistical information from previous years or weeks, verify if the actual increase of cases is unusual over the same period of time.

Basic facts:

APPENDIX 13cOther Acute Diarrhea (OAD):



o Implementation of standard case management in all health facilities.

o Improve access to standardized treatment (Establishment of ORT corners and units).

o Train health workers on the use of standardized treatment, prevent and control procedures.

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

Team to implement control measures and improve access to safe water and sanitation

(purify water at point of use).

o Use social mobilization program for behavior change of at risk communities and use

IEC materials for that.

o Strengthen laboratory surveillance and collect the proper samples.

o Improve environmental sanitation.

o Send health messages to the community in case of acute diarrhea :

o For detailed information about first steps for managing an outbreak of acute diarrhea , it is accessible at:

Outbreak response and health education:

- Start oral rehydration with ORS before going to the health center

- Go to the health center as soon as possible

• If ORS sachets are available: dilute one sachet in one liter of safe water

• Otherwise: Add to one liter of safe water: — Salt 1/2 small spoon (2.5 grams) — Sugar 6 small spoons (30 grams) And try to compensate for loss of potassium (for example, eat bananas or tomato juice)

http://whqlibdoc.who.int/hq/2010/WHO_CDS_CSR_NCS_2003.7_Rev.2_eng.pdf?ua=1




Acute onset of jaundice (yellowing of sclera of eyes or skin or dark urine),

AND Severe illness (Fatigue, nausea, vomiting and abdominal pain)

AND The absence of any known precipitating factors.

• Alert threshold :

≥ 5 cases in 1 location in 1 week.


- Detect and respond to Acute jaundice syndrome outbreaks promptly.

- Interrupt transmission and reduce the incidence and socioeconomic consequences of viral hepatitis.

- Acute jaundice syndrome can be caused by many different diseases including (yellow fever, leptospirosis, and acute hepatitis). Hepatitis A and E are more epidemic prone in acute emergencies and likely exist in Syria.- Outbreaks of hepatitis A and hepatitis E have been documented in refugee and internally displaced person camps.- Clusters of cases of acute jaundice should lead to epidemiological investigations to exclude transmissible diseases with important public health implications.- Both are spread by fecal-oral route from contaminated food and water.- Both can cause fulminant hepatitis, however this is rare for hepatitis A. - Hepatitis E can have a mortality of up to 20% in pregnancy.

- Can range from asymptomatic infection, acute uncomplicated jaundice and fulminant hepatitis- Signs and symptoms of viral hepatitis include jaundice with yellowing of eyes and dark-colored urine, loss of appetite, an enlarged tender liver, abdominal pain and tenderness, nausea and vomiting, moderate fever- Careful clinical examination should detect other causes of jaundice possibly requiring specific treatment (e.g. surgery and antimicrobial or anti-parasitic therapy for obstructive jaundice).

Clinical Features:

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

Basic facts:

Diagnosis:

APPENDIX 13dAcute Jaundice Syndrome (Hepatitis A , E):



- Collect 5 ml blood by venipuncture in a sterile tube labeled with patient identification and collection date.- Whole blood should be centrifuged or kept in a refrigerator until there is complete retraction of the clot from the serum.- Store the serum at 4-8°C until shipment takes place.

Collection and Transport of Specimens

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

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

3. Establish a line listing at the facility.

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

5. Communicate with Water, Sanitation, and Hygiene (WASH) sector in the Outbreak Control Team to implement control measures.

6. Complete Outbreak Investigation form.

7. Risk factors for infection All confirmed cases of acute Hepatitis A should be interviewed to identify a potential source or risk factor for infection during the 2-6 weeks prior to illness onset.

8. Identification of contacts requiring post exposure prophylaxis in Hepatitis A : immuno-prophylaxis with immune globulin (IG) should be provided to persons recently exposed to a person with acute Hepatitis A including close personal contacts. IG should be given as soon as possible but not >2 weeks after the last exposure.

There is no available immunoglobulin (IG) prophylaxis at present for Hepatitis E.

- Inform community of outbreak through identified community leaders.- Conduct health education activities for community on signs and symptoms, what to do

when sick, and how to avoid infection.- Train community leaders (local council) on simple signs and symptoms to assist in

community surveillance and referral from the community to the health facilities. - Hand-washing with soap is a key prevention measure. Ensure regular distributions of

soap (250g/person/month; in addition to soap for laundry).- Provide the community with messages on the importance of hand washing with soap- Promote cooking food well, keeping it covered, eating it hot, and peeling fruits and

vegetables.- Ensure the safe disposal of human waste by always using latrines. - Encourage continuation of breastfeeding of infants and young children.- Ensure safe and clean drinking water is available.- For travelers to high endemic areas, the usual elementary food hygiene precautions are

recommended.

Public Health Awareness and Health Education

Outbreak response:



A. Influenza Like Illness :

- measured fever (≥ 38°C)

- Cough

- Onset within the last 7 days

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

- Cough

- Onset within the last 7 days

- Requires hospitalization (whether possible or not)

B. Sever Acute respiratory illness:

• Standards case definition:

• Alert threshold:

Double the average of the last 3 weeks in health facility.



: ≥ 5 cases in 1 health facility or hospital in 1 week OR 1 death due to influenza like illness.

C. Suspected case of Influenza A (H1N1)

- Close contact with a person who is probable or confirmed case of Influenza A (H1N1) pdm09 virus infection

- Travel to a country/community where there has been one or more confirmed cases of Influenza A (H1N1) pdm09 virus infection

- Resides in a community where there is one or more confirmed cases of Influenza A (H1N1) pdm09 virus infection

An individual with acute respiratory illness with fever (≥38 ºC; reported or documented fever) and one of the following symptoms; cough, shortness of breath, difficulty in breathing or chest pains ANDOne or more of the following exposures within the 7 days prior to symptom onset:

• Surveillance goal

Continuous monitoring of the epidemiological, virological and clinical picture of the pandemic and its impact on the health ⁰care infrastructure.

Acute respiratory illness with:

Acute respiratory illness with:

APPENDIX 13eInfluenza Like Illness and Severe Acute Respiratory Illness



D. Basic facts:

- The initial event in influenza is infection of the respiratory epithelium with influenza virus acquired from respiratory Secretions of acutely infected individuals. In all likelihood, transmission occurs via aerosols generated by coughs and sneezes, although hand-to-hand contact, other personal contact, and even fomite transmission may take place.

- The incubation period of illness has ranged from 18 to 72 hours despite the frequent development of systemic signs and symptoms such as fever, headache, and myalgia, influenza virus has only rarely been detected in extra pulmonary sites (including the bloodstream).

- Signs and symptoms: headache, fatigue, diarrhea and vomiting, feverishness, chills, myalgia, malaise, cough, sore throat. Temperatures of 38 to 41, Fever may last for as long as a week. Arthralgia. Pain on motion of the eyes, photophobia, and burning of the eyes. The patient appears flushed and the skin is hot and dry, mild cervical lymphadenopathy may be noted, especially in younger individuals. Wheezes and scattered rales. Frank dyspnea, hyperpnoea, and cyanosis, diffuse rales, mild ventilatory defects and increased alveolar-capillary diffusion gradients.

E. Response to a suspected case of human influenza or to an usual event of severe acute respiratory infection:

• Implement acute respiratory disease infection control precautions immediately and enhance Standard Precautions throughout the health care setting.

• Treat and manage the patient according to national guidelines.

• Collect laboratory specimens (Nasal viral Swabs) from case-patient and from symptomatic contacts and arrange for laboratory testing.

• Review clinical and exposure history during 7 days before disease onset.

• Identify and follow-up close contacts of case-patient.

• Search for additional cases.

• Conduct epidemiological investigation to identify risk factors for infection and populations at risk for severe disease.

• Plan and implement prevention and control measures.

Triggers/signals for the investigation of suspected cases or clusters of pandemic (H1N1) virus infection include:

• cluster(s) of cases of unexplained ILI or acute lower respiratory tract infection

• severe, unexplained respiratory illness

• changes in the epidemiology of mortality associated with the occurrence of ILI or lower respiratory tract illness, an increase in the number of deaths observed from respiratory illness or an increase in the occurrence of severe respiratory disease in previously healthy adults or adolescents and/or among pregnant women

• abnormally high levels of absenteeism in a school or workplace setting.



F. Laboratory confirmation

1. Detection of influenza-specific RNA by reverse transcriptase-polymerase chain reaction

2. Isolation in cell culture (BSL3 lab required for suspected new subtype)

3. Direct antigen detection (low sensitivity)

Highest priority:o Pregnant women

Priority (in no particular order):o Children aged 6-59 monthso Elderlyo Individuals with specific chronic medical conditions.o Health-care workers

G. Vaccination

Diagnostic tests:

• WHO recommends seasonal influenza vaccination for:

• Health-care workers are an important priority group for influenza vaccination, not only to protect the individual and maintain health-care services during influenza epidemics, but also to reduce spread of influenza to vulnerable patient groups.

• It is especially important to vaccinate pregnant women because of their increased risk for influenza-related complications.

Vaccination can occur in any trimester, including the first. Only inactivated vaccine should be given to pregnant women.

• Protective immunity doesn’t develop until 1-2 weeks after vaccination.

Some people who get vaccinated later in the season may get influenza shortly afterward.



Figure 4.4: SARI cases Line List



Evaluate and treat as appropriate:

Home care and isolation

Symptomatic treatment

Heath education

Mild disease + High Risk population

SARI Severe Acute Respiratory Illness

Risk Factors :

*Pregnant women

*children younger than 5 years

* Adults 65 years of age or older

*Persons with the following conditions :

# Chronic broncho-pulmonary diseases

# Chronic cardiovascular diseases (except hypertension).

# Chronic neurological diseases

# Immunosuppresion including caused by medication.

# Chronic liver or Renal failure , hematological disorders

# Metabolic diseases like Diabetes Mellitus

# Obesity BMI > 30

# Tumors and malignancies

One of the following signs :

* Respiratory distress

*Tachypnea

* Severe dehydration signs

* Shock signs

* Clouding consciousness

* Rapid progressive or long term disease with or without risk factors

Referred to health center in case of one signs from the following :

- Tachypnea or Dyspnea

- Cyanosis

- Dizziness or Clouding consciousness

- Fever lasted more than 2 days

- Persistent vomiting with or without diarrhea

- Dehydration.

- decreased urine output

- Irritation or no response in children

antiviral medication

home isolation

Immediate review to the hospital if turned into a severe illness (SARI )

Admit the patient to hospital

Start antiviral medication

ICU doctors decision to transfer the patient to the ICU or his need to

ventilation according to the clinical status

PCR test

Mild disease ( No Risk factors - No severe signs or symptoms)

Suspected Case of H1N1 influenza

Figure 4.5: Algorithm of Suspected Case of H1N1 influenza approaches



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

Any paralytic illness in a person of any age if poliomyelitis is suspected.



1 case

The manual guidelines and standard operating procedures document for AFP surveillance from Early Warning Alert and Response Network (EWARN) provides more detailed guidance, it is available at:

APPENDIX 13fAcute Flaccid Paralysis (Suspected Poliomyelitis):

http://www.acu-sy.org/wp-content/uploads/2017/02/EWARNGuidelines_AFPSurveillance_2016_AR.pdf



Any person with fever ≥ 38°C, AND; maculopapular (non vesicular) generalized rash,

AND ONE of the following:

-Cough - Runny nose (coryza) - Red eyes (conjunctivitis),

OR;

Any person in whom a clinician suspects measles



1 case

- The manual guidelines and standard operating procedures document for measles surveillance from Early Warning Alert and Response Network (EWARN) provides more detailed guidance, it is available at:

APPENDIX 13gSuspected Measles

http://www.acu-sy.org/wp-content/uploads/2017/02/EWARNGuidelines_MeaslesSurveillance_2016_AR.pdf



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

- Neck stiffness.

- Bulging fontanel (in a child < 1 year).

- Altered consciousness.

- Petechial or purpuric rash OR other meningeal sign



1 case in a crowded camp setting OR

Population ≤ 30.000 : 2 cases per week in the same community OR

Population ≥30,000: 5 cases per week in the same community.


- To promptly detect and confirm aetiology of meningitis outbreaks.

- To use data to plan for treatment, vaccination campaigns and other control measures.

- To assess and monitor the progress of the epidemic and effectiveness of control measures.

- Meningococcal meningitis is a bacterial form of meningitis, a serious infection of the meninges (thin lining that surrounds the brain and spinal cord).

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

- Close and prolonged contact –such as kissing, sneezing, or coughing on someone, or living in close quarters, sharing eating or drinking utensils with an infected person facilitates the spread of the disease.

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

- 80% of cases of meningococcal meningitis occur in those under 30 years of age (in epidemics those most at risk are six months to 30 years).

- Without appropriate treatment, the case-fatality rate in meningococcal meningitis can be as high as 50%; with appropriate treatment this can be reduced to 5–15%.

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

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

- Examine for common signs including: meningeal rigidity, i.e. neck stiffness, lethargy, delirium, coma, purpura (characteristic sign of meningococcal septicemia) or symptoms of shock (low blood pressure).

- In children aged <1 year, classic signs are rare; look for fever, diarrhea, vomiting, drowsiness, convulsions, or bulging fontanels.

APPENDIX 13hSuspected Meningitis

Clinical Features:

Basic facts:



- Complete lumbar puncture for the first 25 cases during an epidemic to confirm diagnosis and sero-group

o Once sero-group identified and confirmed, no need to do lumbar puncture on every case

- Collect 1 to 2 ml of CSF aseptically in 2 tubes (each tube containing at least 20 drops of CSF, depending on the tests to be requested (gram stain, cell count, latex agglutination and culture)

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

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

- CSF should be sent for culture to pre-identified laboratory as soon as possible

- Refer all patients to hospital

- Investigate and laboratory confirm the cases.

- Ensure prompt and appropriate case management with the aappropriate antibiotics

as recommended by protocol. Chemoprophylaxis of contacts is not recommended in emergency situations.

- Initiate active case finding and update outbreak line list with identified suspected cases

- Decide whether a vaccine campaign is indicated, determine vaccine availability, and

reactivate campaigns as necessary

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

- Complete Outbreak Investigation Form

- Prepare to conduct a mass vaccination campaign.

- Distribute medical supplies to health center.

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

- Train community leaders including religious leaders on simple signs and symptoms to assist in community surveillance and referral from the community to the health facilities.

- Reinforce sensitization to the community leaders to advise new arrivals to report to health facilities so that immunization status can be ascertained.

- Disseminate public health education messages to the community to inform them of ways to avoid infection. Messages to include are:

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

o Information about what to do when sick (seek medical care immediately; take appropriate treatment)

o Proper and thorough hand washing with soap and water

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

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

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

Collection and Transport of Specimens

Public Health Awareness and Education

Outbreak response:

Diagnosis:



Any person with acute illness and fever of at least 38° C for 3 or more days with

abdominal symptoms; diarrhea or constipation or abdominal tenderness progressing to prostration and relative bradycardia.

OR

symptomatic case contacted with confirmed case



≥ 5 cases in 1 location in 1 week

- Typhoid fever is a global health problem. Its real impact is difficult to estimate because the clinical picture is confused with those of many other febrile infections

- Transmitted by food and water contaminated by feces and urine of patients or carriers

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

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

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

- Period of communicability first week of illness until convalescence

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

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

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

- Less commonly, there may be rose spots on the trunk (30 % of Caucasians), abdominal

pain (20–40 %), constipation (38 %), diarrhea (10 %) and cerebral dysfunction.

- Treat typhoid fever cases with antibiotics. More than 90 % of patients can be managed at home with oral antibiotics, reliable care and close follow up for complications or failure to respond to therapy.

- Untreated may last for 3-4 weeks and complications include intestinal perforation (3-10 %) or hemorrhage, death (12-30 %) or relapse (up to 20 %).

Clinical Features:

Basic facts:

APPENDIX 13iSuspected Typhoid Fever



- Culture: The definitive diagnosis of typhoid fever depends on the isolation of S. typhi from blood culture or bone marrow culture. Stools can be collected from acute patients and they are especially useful for the diagnosis of typhoid carriers.

- Serological procedures:

Felix-Widal test:

This test measures agglutinating antibody levels against O and H antigens. This test has moderate sensitivity and specificity. It can be negative in up to 30% of culture-proven cases of typhoid fever.

Tubex® test :

simple and rapid . In a preliminary study involving stored sera the test performed better than the Widal test in both sensitivity and specificity.

IgM dipstick test :

sero- diagnosis of typhoid fever through the detection of S. typhi-specific IgM antibodies.

Collection and Transport of Specimens- Collect blood culture specimens and properly label with name, date of birth, health facility name and date of collection.

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

- Whole stool samples should be collected for stool culture before administration of antibiotics for eligible patients. If a stool specimen cannot be obtained, a rectal swab should be done.

- Fresh stool should reach the lab as soon as possible; if this is not possible, place samples in Cary-Blair transport media and refrigerate at 4 ⁰ C.

Outbreak Response

- Refer severe cases with persistent vomiting, severe diarrhea and abdominal distention to the health facility.

- More than 90% of patients can be managed at home with oral antibiotics.

- Initiate active case finding through community health workers, hygiene promoters, and community leaders.

- Establish a line list at facility and community level.

- Search for case/carrier that is the source of the outbreak and for the vehicle (water or food) through which infection is transmitted.

- Identify areas/populations at high risk to identify source(s) and mode(s) of transmission in order to prevent and control the disease.

- Communicate with Water, Sanitation, and Hygiene (WASH) sector in the Outbreak Control Team to implement control measures.

Support provision of clean water and proper sanitation to affected populations. Chlorinate suspected water supplies. All drinking water should be chlorinated or boiled before use.

- Communicate with the Outbreak Control Team to implement control measures. Information on locations of new cases should be promptly shared with the Outbreak Control Team.

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

- Immediately report any deaths to Central Level Surveillance Officer.

- Complete Outbreak Investigation Form.

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

Diagnosis:



Public Health Awareness and Education

- Inform community of outbreak through identified community leaders

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

appropriate communication strategies and engage the community

- Conduct health education activities for community on signs and symptoms, what to do

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

- Conduct health education programs on hygiene with simple messages on safe water,

safe food handling practices, hygiene and handwashing

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

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

- Promote cooking food well, keeping it covered, eating it hot, and peeling fruits and

vegetables.

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

- Encourage continuation of breastfeeding of infants and young children

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

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

restaurants and other establishments that prepare food



Figure 4.6: STF investigation form



Any person having skin lesions on the face, neck, arms, and legs (exposed body parts), which began as nodules and turned into skin ulcers, eventually healing but leaving a depressed scar.



≥ 50 of new case in one area or health facility.

APPENDIX 13jCutaneous Leishmaniasis

Figure 4.7: Status of endemicity of Cutaneous Leishmaniasis , World Wide 2012.



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

• Leishmania parasites are transmitted from animal to animal, from human being to human being or from animal to human being by a tiny 2–3 mm-long insect vector, the phlebotomine sandfly. Only the female sandfly bites vertebrates and can therefore transmit the parasite.

• Epidemics of cutaneous leishmaniasis are often associated with migration and the introduction of non-immune people into areas with existing transmission.

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

• The procedure used to find parasites in lesions is important in order to reduce discomfort and enhance the probability of confirming the diagnosis.

• Many different therapeutic interventions, including local, systemic and physical treatments have been used and tested in cutaneous leishmaniasis.

• A clinical history suggestive of cutaneous leishmaniasis is characterized by the appearance of one or more lesions, typically on uncovered parts of the body. The face, neck, arms and legs are the commonest sites.

• In localized cutaneous leishmaniasis, a typical lesion starts as a raised papule at the site of inoculation. It grows over several weeks to reach a final size of a nodule or a plaque.

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

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

Skin sampling is taken as following:

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

• Inject 0.1–0.5 ml of lidocaine with adrenaline, using a short 23-gauge needle thereby creating a blanching area. It is not necessary to anaesthetize the whole lesion. For lesions on fingers or toes use lidocaine without adrenaline (necrosis risk).

• Pinch strongly the lesion to further prevent bleeding.

• Remove the crust, remove blood with a gauze, scratch firmly (using a sterile scalpel with a short angle curved blade) the border and the centre of the lesion until tissue material is visible on the blade .

• Gently move the blade on the surface of a slide to deposit a thin layer of the scraped material. Repeat the procedure on different parts of the anaesthetized zone until at least half of the surface of each of three slides is covered with material.

• Dry the three slides at room temperature.

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

Clinical Features:


Basic facts:

Diagnosis:

• If left without therapy, lesions usually heal gradually over months or years, usually leaving a depressed scar.



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

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

• In severe situations such as epidemics and highly endemic areas vector control is also used. It consists of house spraying or the use of insecticide-impregnated bed nets.

• No vaccines or drugs to prevent infection are available.

Procedure of Giemsa staining:

- Fix air-dried slides in methanol .

- let slides to dry in air.

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

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

- Let air dry.

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

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

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

Materials:

-Reagents: Giemsa stain and Giemsa buffer.

-Supplies: glass slides, alcohol washed, glass marker

-Equipment: microscope, binocular with mechanical

stage; low (10×), high dry (40×) and

oil immersion (100×) lens.

• Social mobilization and strengthening partnerships: mobilization and education of the community with effective behavioral change interventions with locally tailored communication strategies. Partnership and collaboration with various stakeholders and other vector-borne disease control programs is critical at levels.


Outbreak response:



Due to the crisis in Syria since 2011, water supplies, water quality monitoring systems, solid waste collection and sanitation systems from residential areas have been affected by the lack of services and the collapse of some systems, which resulted in the increase of WBD and environmental sanitation.

This requires a new system able to work within emergency conditions, and do the works that was done by the services institutions (Water and Sanitation Association - Municipal Councils).The System of monitoring and controlling water quality:

Water Quality :

The quality of water is the physical, chemical and biological properties of water.

The quality of water testing indicates the criteria of the validity of Water for human use and healthy environmental systems.

Water is considered as a vital and necessary material, but in case of damaging its quality it becomes so dangerous and unsafe. Therefore, monitoring and protecting water is absolutely a necessary matter.

In this context, EWARN program provide the portable devices of laboratory for chemical, biological and physical analysis.

WASH Officer Responsibilities:

A specialized person for controlling water quality and implement the environmental sanitation procedures, he got the needed training to perform his work according to international approved methodology, he is responsible for the following activities:

• Monitoring the water quality at the level of public distribution system: water resources location, reservoirs and network, also it is done by taking samples of water in the total distribution system for analysis. Population is considered while taking water samples per month.

• Monitoring the processes of cleaning and cleansing for the new networks.

• Implementing the investigation and following-up in case of community complain about water quality source.

• Implementing the investigation and following-up about the water quality when a high number of WBD cases are reported.

• Providing advices and suggestions for the issues related to water sector and environmental sanitation.

• Participation in WBD response missions, such as health education campaigns, distributing chlorine pills and clean-up campaigns.

APPENDIX 14Water Quality guidelines



In cases of emergency and war situations, portable laboratories are considered to be more appropriate to perform the water quality testing due to the possibility of conduct field analysis, easy to be transported, in addition to its compatibility with the lack of electric power.

These laboratories include the following devices:

1. Incubator with filtration set and dishes for biological tests

2. Conductivity measurement device

3. PH measurement device

4. Turbidity measurement device

5. Spectrophotometer device

Sampling System:

The goals of sampling and analyzing are:

1. Follow up the quality of produced and distributed water and its conformity with

the standards of water quality.

2. Monitoring of water sterilization and ensuring its effectiveness

3. Secured preventive monitoring for water distribution networks

4. Making quick decision in case of abnormal findings.

The monitoring of drinking water quality is constantly measured by many microbiological and chemical indicators, also it’s identified in the health quality of drinking water systems which are periodically updated.

When testing the water quality, the results usually indicate to the tested samples only, so the samples must reflect the water that were taken from in best way. Sampling process is the first and essential stage of water testing procedure, so correct sampling is important to obtain correct results.

Sampling of drinking water program is determined by the water quality employee and with the invested group of water project coordination.

The frequency of analysis are undergo to global regulations, and related to the type of the water , water source and the number of beneficiaries.

The Laboratories are used to monitoring water quality:



As a part of health sector collapse during the Syrian crises, the decline in vaccination coverage resulted in the re-emergence for VPDs as multiple outbreaks in different areas. Measles outbreaks appeared at start of 2013 and polio reemerge in the end of 2013 , as well as for other VPDs such as pertussis, mumps, T.B and hepatitis B. All those diseases were rare before National Immunization Program was interruption in many areas.The Early warning alert and response Network (EWARN) played a major role in the investigation and sampling process, thus confirming them.Therefore, the cross borders vaccination activities became a necessity in northern of Syria, later on the Syrian Immunization Group (SIG) was formed by the involvement of the humanitarian organizations and the supervision of WHO and UNICEF. The EWARN participated and joined the group as a member.In addition to that, EWARN collaborate with SIG in all vaccination campaigns by tracking adverse events following immunization (AEFI) on a daily basis. Recently, playing a key role in planning and developing the sustainability of immunization status for the children of Syria when SIG launched the Expanded Program on Immunization in northern Syria.

Roles and Responsibilities:

- On-going training for the teams in Syria on vaccination activities.

- Planning for campaigns (macro and micro plans).

- Developing and providing the needed guidelines , protocols , SOPs and forms

- Delivery the vaccines to the besieged and hard to reach areas.

- Supervising the all stager of vaccine management.

- Coordinating the implementation of campaigns.

- Social mobilization and community awareness activities.

- Rapid response to outbreaks in camps or areas with critical circumstances.

- Supervision of the EPI implementation in pre-selected centers to compensate the

shortage.

- AEFI surveillance (adverse event following immunization) during the campaigns and routine immunization.

APPENDIX 15Vaccination Response



Assistance Coordination Unit, Early Warning Alert and Response Network Guidelines, a field Manual First edition 2014 :http://www.acu-sy.org/en/wp-content/uploads/2017/04/EWARNGuidelines_EpiSurveillance_2014_EN.pdfOutbreak surveillance and response in humanitarian emergencies, WHO guidelines for EWARN implementation 2012http://whqlibdoc.who.int/hq/2012/WHO_HSE_GAR_DCE_2012_1_eng.pdfCommunicable disease control in emergencies – a field manual. WHO, 2005 :http://www.who.int/diseasecontrol_emergencies/publications/9241546166/en/ Communicable disease risk assessment: Protocol for humanitarian emergencies, World Health Organization 2007: http://www.ifrc.org/docs/idrl/I1036EN.pdfMINISTRY OF HEALTH LIBERIA NATIONAL TECHNICAL GUIDELINES FOR Integrated Disease Surveillance & Response 2016 : h t t p : // w w w. a f r o .w h o . i n t / i n d ex . p h p ? o p t i o n = c o m _ d o c m a n & t a s k = d o c _download&gid=10631&Itemid=2593Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance:http://www.who.int/csr/disease/swineflu/WHO_case_definition_swine_flu_2009_04_29.pdfFirst steps for managing an outbreak of acute diarrhea ,WHO GLOBAL TASK FORCE ON CHOLERA CONTROL 2010:h t t p : //a p p s .w h o . i n t / i r i s / b i t s t r e a m / 1 0 6 6 5 / 7 0 5 3 8 / 1 / W H O _ C D S _ C S R _NCS_2003.7_Rev.2_eng.pdfCHOLERA OUTBREAK GUIDELINES , PREPAREDNESS, PREVENTION AND CONTROL, OXFAM June 2012:http://www.unicef.org/cholera/Annexes/Supporting_Resources/Annex_6B/OXFAM_Cholera_guidelines.pdfUNICEF Cholera Toolkit 2013 : https://www.unicef.org/cholera/Cholera-Toolkit-2013.pdfWater, sanitation and hygiene (WASH) in cholera treatment centers in emergencies , WHO 2012:http://www.washclustermali.org/sites/default/files/wash_in_cholera_treatment_centers_in_emergencies_tech_brief_who.pdfHepatitis A , factsheets WHO 2016 :http://www.who.int/mediacentre/factsheets/fs328/en/Hepatitis E , factsheets WHO 2016 :http://www.who.int/mediacentre/factsheets/fs280/en/Surveillance Tools for Meningitis Sentinel Hospital Surveillance, WHO 2015 :http://apps.who.int/iris/bitstream/10665/173697/1/WHO_IVB_15.02_eng.pdf?ua=1

APPENDIX 16References

1-

2-

3-

4-

5-

6-

7-

8-

9-

10-

11-

12-

13-



For more information contact Us:

e w a r n @ a c u - s y . o r gwww.acu-sy.org/ewarn

Documents

A Field Manual Second Edition EWARN Guidelines · Field Manual Second Edition 3 Foreword The guidelines serve as a general reference for surveillance activities across all levels,