Operational guideline for ARI, ILI & SARI surveillance · ARI/ILI/SARI Surveillance Guideline 1...

Operational guideline for

ARI, ILI & SARI surveillance

First Edition 2012

Public Health LaboratoryDepartment of Public Health

Ministry of HealthThimphu: Bhutan

ARI/ILI/SARI Surveillance Guideline

iii Pages

Table of Contents

Acronyms..............................................................................................................iv

1. Background................................................................................................1

2. Objectives...................................................................................................2

3. OperationalaspectsofARI/ILI/SARIsurveillance.....................................2

4. Figure1:ARISurveillanceOverview.........................................................4

5. Figure2:ILI/SARISurveillanceoverview.................................................5

6. RolesandResponsibilitiesofHealthcenters............................................6

7. CaseDefinitions........................................................................................8

8. Reportingsystem......................................................................................9

9. DataCollectionTool...................................................................................10

10. DataAnalysisandFeedback.....................................................................11

11. Samplecollection,storageandtransportation..........................................11

12. ARI/ILIoutbreakandrapidresponse.......................................................12

13. ARI/ILI/SARIMonitoring&Evaluation.......................................................14

14. References.................................................................................................16

15. Annexure1:FormA:ARIreportingformfromBHUs/Hospitals

toDistrictHealthAuthority.........................................................................17

16. Annexure2:FormB:ARIreportingformfromDistricttoARI

Program......................................................................................................18

17. Annexure3:FormC:WeeklyILIandSARIreportingform......................19

18. Annexure4:FormD:ILIcaseInvestigationandSample

collectionform............................................................................................20

19. Annexure5:FormE:SARIcaseinvestigationandsample

collectionform...........................................................................................21

20. Annexure6:Proceduresforsamplecollection.........................................22

21. Annexure7:Samplestorage....................................................................24

22. Annexure8:SpecimenTransportationProcedures.................................25

23. Annexure9:ColdChainMaintenanceTable............................................28

iv Pages

Acronyms

AHB AnnualHealthBulletinARI AcuteRespiratoryIllnessBHU BasicHealthUnitCDD ControlofDiarrheaDiseasesCMO ChiefMedicalOfficerDHO DistrictHealthOfficerDMO DistrictMedicalOfficerH1N1 Hemeagglutinin1Neuraminidase1H5N1 Hemeagglutinin5Neuraminidase1HIMS HealthInformationandManagementIEC InformationEducationandCommunicationILI InfluenzaLikeIllnessIMCI IntegratedManagementofChildhoodIllnessMS MedicalSuperintendentMT MedicalTechnician/TechnologistNRRT NationalRapidResponseTeamOPD OutPatientDepartmentPCR PolymeraseChainReactionPHL PublicHealthLaboratoryRRT RapidResponseTeamRSV RespiratorySyncytialVirusSARI SevereAcuteRespiratoryIllnessVTM ViralTransportMediaWHO WorldHealthOrganization

Public Health Laboratory


v Pages

Acronyms

AHB AnnualHealthBulletinARI AcuteRespiratoryIllnessBHU BasicHealthUnitCDD ControlofDiarrheaDiseasesCMO ChiefMedicalOfficerDHO DistrictHealthOfficerDMO DistrictMedicalOfficerH1N1 Hemeagglutinin1Neuraminidase1H5N1 Hemeagglutinin5Neuraminidase1HIMS HealthInformationandManagementIEC InformationEducationandCommunicationILI InfluenzaLikeIllnessIMCI IntegratedManagementofChildhoodIllnessMS MedicalSuperintendentMT MedicalTechnician/TechnologistNRRT NationalRapidResponseTeamOPD OutPatientDepartmentPCR PolymeraseChainReactionPHL PublicHealthLaboratoryRRT RapidResponseTeamRSV RespiratorySyncytialVirusSARI SevereAcuteRespiratoryIllnessVTM ViralTransportMediaWHO WorldHealthOrganization

Developed by:SonamWangchuk,M.Sc.Microbiology. Head&Microbiologist PublicHealthLaboratory

Contributors:BinayThapa,M.Sc.Med.Microbiology. MicrobiologistPublicHealthLaboratory

SangayZangmo,B.Sc.AlliedHealthSciences.MedicalTechnologist

PublicHealthLaboratory

TsheringDorji,B.Sc.Medical(Laboratory)Technology.MedicalTechnologist

PublicHealthLaboratory


1 Pages

1. Background

Respiratoryillnessduetoinfluenzavirusinfectionandotherrespiratorypathogensisamajorcauseofmorbidityandmortalityworldwide.Annualinfluenzaepidemicsareestimatedtoresultinbetween3-5millioncasesofsevereillnessandbetween250,000and500,000deathseveryyeararound the world. Additionally, lower respiratory infections are theleadingcauseofdeath in low incomecountriesandthethird leadingcauseofdeathworldwide.

In Bhutan,AcuteRespiratory Infection Illness(ARI) is amajor publichealthconcernandaffectsmajorityof thepopulation inBhutan.(ARIrankednumberonepublichealthdisease in thecountry for thepastfive years and it has dominated the morbidity among public healthdiseases (Annual Health Bulletin-2010). The rate of pneumonia isveryhighamongchildrenlessthan5yearsbutthecommoncausativeagentcausingthepneumoniaisunknown.Moreover,thecountryhasnowbecomeendemictoavianinfluenza,therebyposingasignificantthreat to thepeopleof thecountry.So far, thespreadofH5N1virusfromperson-to-personhasbeenvery rare, limitedandun-sustained.However,thisepizooticdiseasecontinuestoposeanimportantpublichealth risk because of its severity with high mortality. Influenza (A/H1N1)2009pandemichastakeneverycountrybysurpriseandmostdevelopingcountrieswereneverpreparedtosuchscaleofpandemic.However,itisfortunatethatthe2009pandemichasbeenrelativelymildbutthenextpandemicmighttakeadifferentcourseintermsofseverity.

As of now the country does not have systematicARI/Influenza LikeIllness/Severe Acute Respiratory Infection(ILI/SARI) surveillancetomonitor the trend of respiratory illnesses and also to find out thecausativeagentsof respiratory infection.Therefore,Bhutanneeds toestablishanefficientARI/ILI/SARIsurveillancesystem formonitoringinfluenza illness to understand the true burden, epidemiology ofinfluenza and other respiratory pathogens, the social and climaticfactors that influence community transmission to help in planning ofinterventionandpreventivemeasures.


2 Pages

2. Objectives

1. Todeterminetheburdenofrespiratorydiseasesinthecountry;

2. Monitorepidemiologyandseverityofinfluenzaandotherrespiratorypathogens(e.g.Respiratorysyncytialvirus(RSV),adenovirus,para-influenzavirus,andrhinovirus);

3. Provideinformationongroupsathighriskforsevereoutcomes,includinghospitalizationanddeathtoinstitutepreventionandcontrolmeasures.

3. Operational aspects of ARI/ILI/SARI surveillance

3.1 ARI surveillance

ARIwillbeexclusivelyaclinicalbasedsurveillanceandwillbecarriedoutinallhealthcenters.Itwillbeoperationalizedatthreelevels(BHU’s,district/referralhospitalandnationallevel)withtheDistrictHealthOfficerasthenodalofficerinthedistricthospitalsandMedicalSuperintendentin referral hospitals.ARI cases fromhealth facilitieswill be reportedto district health authority and then to nationalARI/CDDprogrammeincluding referral hospitals. The district health officers/medicalsuperintendents will coordinate the overall ARI surveillance in thedistrictandreferralhospitals.Thekeypersoncoordinatingsurveillanceat BHU and hospitalswill be a nodal officer identified by respectiveBHUor hospitalmanagement forARI surveillance in health centers.The national programofficer ofARI/CDDprogrammewill coordinatetheactivityatnationallevel.DatacollectedonARIsurveillancewillbecollatedandanalyzedbyARI/CDDprogrammeandfeedbackprovidedtodistricthealthauthorityforfurtherdisseminationtothehealthcenters(Figure 1).

3.2 ILI/ SARI surveillance

ILIandSARIwillbebothclinicalaswellaslaboratorybasedsurveillanceandthesesurveillanceswillbecarriedoutexclusivelyintheidentifiedsentinel sites (TableNo.1) selected based on geographical location,climaticcondition,populationandpatientreferral.TheCMOorMSwillcoordinate the overall surveillance activities in their respective site.ThereportsfromthesentinelsiteswillbecommunicatedtoPHLbyanidentifiedfocalpersoninsentinelsitesbyhospitalmanagement.


3 Pages

Table No. 1: Sentinel sites for ILI/SARI surveillanceSelected sentinel sites

Western region Code C e n t r a l

region Code Eastern region Code

Parohospital PAR Trongsa

hospital TON Trashiganghospital TGA

Punakhahospital PUN Damphu

hospital DAM MongarRRhospital MON

P/linghospital PHU

G e l e p h uRRhospital

GAY SamdrupJongkharhospital SZK

Samtsehospital SAM

PHLwillcoordinatetheactivityatnationallevel.DatacollectedforILI/SARIsurveillancewillbecollatedandanalyzedbyPHLandfeedbackprovidedtoCMOofrespectivesentinelsites(Figure 2).PHLwillsendsamplestoreference lab ifdeemednecessaryfor further testingandstudy.

Eachidentifiedsentinelsites(hospitals)forILI will register 3-5 ILI cases randomly for sample collection every week (15-20 per month).Criteria for those ILI cases registered for sample collection should have fever or history of onset of fever within the last 72 hours.A patientmeeting the criteria for sample collection fromOPD/Ward/EmergencyshouldbereferredorreportedtoLaboratorybyconcernedclinicians/nursesforILIcaseregistrationandsamplecollection.Similarlyeach identifiedsite forSARIwill registerallSARIcasesandcollect samples from every SARI case.AllILI/SARIsentinelsiteswillcollectonenasalandonethroatswabsamplesfromILIselectedcasesandallSARIfortestingbyrapidtestkitandreferraltoPHLforPCR/RealTimePCRtesting. Throatswabcollected forPCR/RealTimePCRshouldbeshippedtoPHLonaweeklybasis.Allsentinelsiteswilltestnasalsamples for influenzavirusand inaddition, the sentinel siteshavingbacteriology culture facilities will collect sputum sample/appropriaterespiratory specimen from all SARI cases to carry out culture andidentificationofbacterialrespiratorypathogens(namely Haemophilus influenza B and streptococcus pneumoniae).ThebacteriologyreportsshouldbesharedtoPHLeverymonth.


4 Pages

1. Figure 1: ARI Surveillance Overview

2. Figure 2: ILI/ SARI Surveillance overview

ARI/ILI/SARI surveillance guideline 15 | P a g e


ARI case detection and reporting

Health centers (BHUs/BHU-1s/hospitals/referral hospitals

Weekly reporting

Data collation, analysis and monthly reporting

District Health Authority

National ARI Programme

Monthly feedback

Monthly feedback

HIMS

Monthly reporting


5 Pages

Mon

thly

rep

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Figure 2: ILI/ SARI Surveillance Overview

ILI/SARI case detection and reporting

ILI/SARI case selection for samples collection

One nasal swab for rapid test

Two throat swabs sample in VTM

ILI/SARI case registration and samples collection


Sentinel sites (hospitals/referral hospitals)

Testing by real time PCR

Data analysis

WHO HIMS Sputum/appr. samples culture for SARI where facilities are available

Wee

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rep

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Weekly shipment


6 Pages

4. Roles and Responsibilities of Health centers

4.1. Roles of BHUs/hospitals including referral hospitals on ARI surveillance

Eachhealthfacilityshouldhavea focal point responsiblefortheroutinesurveillanceoperations.Thehealthfacilityfocalpoint(s)/managementshouldensurethat:

• Casedefinitionsareknownandadheredto;• Alldatacollectionformsarefilledoutcompletelyandaccurately;• Epidemiologicdataareappropriatelymanagedandtransmitted

fromallheathcenterstoARI/CDDprogramme;• Datareportingareoccurringinatimelywayandaccordingto

theindicatorsoutlinedinthesystemmonitoringsection.

4.2. Roles of ILI/SARI surveillance sentinel sites (hospitals including referral)

Eachsentinelsiteshouldhavea focal point responsiblefortheroutinesurveillanceoperations.Thehealthfacilityfocalpoint(s)/managementshouldensurethat:

• Casedefinitionsareknownandadheredto;• AlldatacollectionformsincludingILI/SARIcaseinvestigation

and samples collection forms are filled out completely andaccurately;

• EpidemiologicdataareappropriatelymanagedandtransmittedtoPHL;

• Respiratoryspecimensarecollectedfromappropriatepatientsmeetingthecasedefinitionsandareproperlylabeled,packaged,stored,andtransportedtoPHLaccordingtotheguidelines;

• Datareporting,specimencollection,andspecimentransportatthesentinelsitesareoccurringinatimelywayandaccordingtotheindicatorsoutlinedinthesystemmonitoringsection.

4.3. Roles of ILI and SARI sentinel sites laboratories• Ensureallrespiratoryspecimensandcorrespondingformsare

assignedauniqueIDnumber• Ensurerespiratoryspecimensarecollectedfromappropriate

patientsmeetingthecasedefinitionsandareproperlylabeled,packed, stored, and transported to the PHL according toguidelines

• Performrapidflutest(Rapid flu test kit has limitation in terms


7 Pages

of sensitivity and identifying influenza subtype).• Ensurerapidflutestresultsarereportedtothetreatingclinician

assoonastestiscompletedandsimultaneouslyrecordedintherelevantform(ILI/SARI).

• Ensure there is adequate stock of test kits, VTM, barcodesandrelevantformsinthelaboratory.

• Referralhospital laboratorieswill, inaddition,collectsputumsamples from same patients enrolled for SARI surveillanceandperformbacteriological tests.ReportsshouldbesharedtoPHLeverymonth.

4.4. Roles of Public Health Laboratory• PHLwill serveas the technical and scientific focal point for

activitiespertainingtoILIandSARIsurveillance• Providetrainingonpropercaseselection,specimencollection,

storageandtransport• Receiving,archivingandstoringoriginalclinicalspecimensat

-70°CforILI/SARIforatleastoneyear.• TestingsamplesusingrealtimePCR/conventionalPCR• Managingcomputerdatabaseanddisseminatingthemonthly

andannualinfluenzasurveillancereports• ReportingtoIHRanycasesofinfluenzanovelstrainsasper

theIHRrequirements• Sharing with WHO collaborating centres a representative

clinicalsampleofseasonalandpandemicinfluenza,• Sharing of samples that react poorly with the WHO CDC

reagentskit,andallnovelvirusesdetected.• Communicating theresultsofall individualconfirmatory tests

forILI/SARIcasesbacktothesentinelsitefocalpointsassoonastheyareknown

• Reportingweeklynationalsurveillancedata intoregionalandglobalinfluenzasurveillanceplatforms

• ParticipatingintheWHOGlobalExternalQualityAssessmentProjectforthemoleculardetectionofinfluenzavirusesaswellasinregionalprogrammes


8 Pages

5. Case Definitions Therearethreecasedefinitionsinthisguideline;ARI(outpatient),ILI(outpatient)andSARI(Inpatient).TheSARIcasedefinitionisfurtherbrokendown intocasedefinitionsusedforperson≥5yearsoldandchildren<5yearsold.ThecombinationofILIsurveillancewithSARIsurveillancewill provide a description of a broad range ofmedicallyattendedinfluenza.

5.1 Case definition for ARIAnypersonwithsuddenonsetofat leastoneof the four respiratorysymptoms;

• cough,• sorethroat,• coryza,• shortnessofbreath OR• clinician’sjudgmentthattheillnessisduetoaninfection

(Note:ARI may present with or without fever)

5.2 Case definition of ILIAnypersonwithsuddenonsetoffever>38°Candcoughorsorethroatintheabsenceofotherdiagnosis

(Note:Consider sample collection from ILI patients only if onset of fever is within the past 72 hours/3 days)

5.3Case definition for SARI in persons ≥ 5 years oldOnsetofthefollowingsignsandsymptomsduringtheprevious7daysthatresultinhospitalization

• Fever>38ºC;AND• coughorsorethroat;AND• Shortnessofbreathordifficultyinbreathing

(Note:In adult, SARI is not equivalent to classic pneumonia and would not always present as pneumonia).

5.4 Case definition for SARI in children < 5 years oldFor children < 5 years old, theWHO case definition for pneumoniaandseverepneumoniafromtheIntegratedManagementofChildhood


9 Pages

Illness(IMCI)programmeshouldbeused.TheIMCIcasedefinitionforpneumoniaisanychildaged2monthsto5yearswithcoughordifficultybreathingand:

• breathingfasterthan40breaths/minute(ages1–5years);• breathingfasterthan50breaths/minute(ages2–12months)

(Note:Infants less than 2 months of age with fast breathing of 60 breaths or more per minute should be referred for serious bacterial infection).

The IMCI case definition for severe pneumonia is any child aged2months to5 yearswith coughordifficult breathingandanyof thefollowinggeneraldangersigns:

• unabletodrinkorbreastfeed,or• vomitseverything,or• convulsions,or• lethargicorunconscious,orchestindrawingorstridorinacalm

child

6. Reporting system

ARIsurveillancewillbereportedatthreelevels(BHU’s,district,regional/nationalreferralhospitals)whileILI/SARIsurveillancewillbereportedfromselectedsentinelsites.

6.1. ARI reporting from BHU levelBHUwillreportnumberofARIcasestoDistrictHealthOffice(DHO)weeklyinARIreportingFormA(Annexure 1)byfaxorphone/mobile(with availability of mobile network across the country, reporting by mobile can also be considered as formal reporting from any BHU’s to respective District Health Office and accordingly documenting the data in appropriate form/format).TheDHOofficewillcompiledatafromallBHUsindistrictARIreportingForm B (Annexure 2) and submit to ARI/CDD programme everymonth.CopyofthereportmustberetainedbyDHOoffice.

6.2 ARI reporting from District Hospitals/BHU-I levelRegionalreferral/Districthospital/BHU-1willreportARIcasestoDHOOfficeweeklyinARIreportingFormA(Annexure 1)byfax/post/e-mail/webbased.TheDHOofficewillcompilereportsinARIreportingForm


10 Pages

B(Annexure 2)fromallhospitalsandsubmittoARI/CDDprogrammeeverymonth.CopyofreportmustberetainedinDHOoffice.

6.3 ARI reporting from Regional/National Referral hospitalsReferralhospitalwillsubmitARIreporttoARI/CDDprogrammeeveryweekinweeklyARIreportingFormA(Annexure 1)byfax/email.Copyofreportmustberetainedbythehospital.

6.4 ILI/SARI reporting from sentinel sitesSentinel sites identified for ILI/SARI surveillancewill collect ILI/SARIdata inFormC (Annexure 3) andsend toPublicHealthLaboratoryweeklyfax/email/webbased.

7. Data Collection Tool

TherearetworeportingformsforARIsurveillanceandonereportingform for ILI/SARI surveillancewith an additional of two case-baseddatacollectionformsforILI/SARIsurveillance.

7.1 Weekly ARI reporting form from health centers (Form A):All focal persons in BHU’s and hospitals BHU’s including referralhospitalsshouldprovideweeklyARIdataintheformA.

7.2 Monthly ARI reporting form from district health office (Form B):DHOofficeshouldcompileandprovidemonthlyARIdatainformB.

7.3 Weekly ILI/SARI reporting form from sentinel sites (Form C):AllILI/SARIsentinelsitesshouldprovideILI/SARIdatainformC.

7.4 ILI sample registration/investigation and sample collection (Form D): All ILI/SARIsentinelsitesshouldprovide information fromILIpatientsselectedforthroat/nasalswabsamplecollectioninformD(Annexure 4).TheformDshouldbefilledoutbylaboratorystaffinthefollowingorder;(seeBox-1)

• assignuniqueILIidentificationnumberintheforms• filluptherelevantinformationasrequiredbytheform• assignthesameuniqueILIidentificationnumbertothesample• shippedsampletoPHLonaweeklybasis


11 Pages

Acopyoftheformshouldremainatthesentinelsite.

7.5 SARI sample registration/investigation and collection (Form E): AllILI/SARIsentinelsitesshouldprovideinformationofSARIpatientsandcollect throat/nasalswabsample for laboratory testing in formE(Annexure 5). The formEshouldbefilledoutbyclinicians/nursesand sent/reported to the laboratory for sample collection. LaboratorywillassignuniqueSARIidentificationnumberintheforms(seeBox-1),sameuniqueSARI identification number to the sample and shippedsampletoPHLonaweeklybasis.Acopyoftheformshouldremainatthesentinelsite.

Box-1: Assigning Identification Unique number

8. Data Analysis and Feedback DatacollectedfromdistrictswillbemaintainedandanalyzedmonthlyinMicrosoft spread sheet.Monthly feedbackwill be brief descriptive(time,placeandperson)analysisfollowedbycomprehensiveannually.ARI/CDDprogrammewill sharemonthly feedback todistrictsonARIandPHLonILI/SARI(FluView)whichwillbeavailableinPHLwebsite.

9. Sample collection, Storage and TransportationSpecimens for the direct detection of viral antigens or nucleic acidsshould be taken no later than seven days after the onset of clinicalsymptoms, and preferably within three days. Specimens should

The first three alphabets specify the sentinel site. Thesentinel site code is followed by a two digit number thatindicatestheyearofsymptomonset/samplecollection.Thelast digits are the case number.The case number shouldbeginatthenumber1atthestartofeachinfluenzaseasonateachsentinelsite.(Sentinel Site) (Year) (Case Number) An Example: MON/11 /0001 means the sentinel site isMonggar, year of collection is 2011 from the first caseassignedonILIinvestigationform.SameappliestoSARI.


12 Pages

preferablybetakenbeforecommencementofanti-viralchemotherapy.ProcedureforcollectionofspecimensisprovidedinAnnexure 6.

Typesofspecimentocollect:• nasalswab(forrapidinfluenzatesting)• throatswab(forPCR)• nasopharyngealswab(forPCR/culture)• sputum(bacterialisolation)

Allsamplesshouldbeaccompaniedbytherelevantsurveillanceformsdulyfilledbytheconcernedhealthworker.AnythroatswabcollectedinVTMshouldbe immediatelystoredgiven inAnnexure 7 and latertransportedtoPHLasgiveninAnnexure 8.

10. ARI/ILI Outbreak and Rapid Response

10.1. ARI/ILI OutbreakARI/ILIoutbreakisdefinedasan‘abnormalincrease’ofcasescomparedwithnormalcasesor trend inagivenperiod.An ‘abnormal increase’shouldbedefinedasanincreaseaboveandbeyondthenormalrangeofseasonalvariationofreportedcaseswhichcanonlybedeterminedifprevalenceisknown.However,abnormalincreasewilldifferfromplacetoplaceanddistrict todistrict.Toconfirmanoutbreak,at least5-10samples fromARI/ILIcasesshould tobecollectedandconfirmedbyPHL.Theoutbreakshouldbeinvestigatedatthelocallevelbyadistrictrapidresponse team. The Rapid Response Team from national level willonlycometositeifdistrictcannotconductoutbreakinvestigationoranoutbreakhasmajorprogrammatic implications.ThecompositionandresponsibilitiesoftheRRTareasfollows:

10.2. National Rapid Response Team (NRRT)• Epidemiologist• Microbiologist• Pediatrician/Physician


13 Pages

10.3. Responsibilities of NRRT at national level• Provide technical expertise for any outbreak and provide all

technicalassistancetotheRRTatdistrictlevel.• Visit outbreak sites to investigate outbreak at the request of

districtRRT.• Provide all logistic support including drugs, PPE and other

necessarysupplies• Recommend appropriate interventions to be undertaken

by DoPH/ MoH based on findings and/ or outbreak reportssubmittedbydistrictRRTtopreventfutureoutbreaks.

10.4. Rapid response team (RRT) at district level• DistrictMedicalOfficer(DMO)/ChiefMedicalOfficer(CMO)• DistrictHealthOfficer(DHO)• MedicalTechnologist/Technician(MT)

10.5. Responsibilities of RRT in district • In ARI/ILI outbreak, the RRT team from district should

immediatelyvisittheaffectedsite.• Ascertain cases based on clinical case definition and send

appropriatesamplesfrom5–10casestothePHLforlaboratoryconfirmation.

• InformtheNationalRRTforanyassistanceifrequired.• Informthelocalauthorityaboutthesituationandpossiblerisks.• Ensure logistics support including drugs, PPE and other

necessarysupplies• Immediately implement interventionmeasures to contain the

outbreak.

10.6. Rapid Response to ARI/ILI outbreakOnceanoutbreakisbelievedtohaveoccurred,theRRTindistrictshouldimmediatelyconductarapid investigationand implementappropriateinterventionmeasures. A national Rapid Response Teammay visitthesitetoconductoutbreakinvestigationifdistrictlackscapacityandrequest national RRT to intervene.A detailed outbreak investigationwill be conducted to establish outbreak epidemiology, etiology, andrecommendbothshortand long term interventions to respond to theoutbreakandpreventfutureoutbreaks.Anoutbreakresponseshouldincludethefollowingsteps/actions:


14 Pages

Investigationstoconfirmtheoutbreak• Establishthatthe‘suspectcases’fitthecasedefinitionofARI/

ILI byobtaining information regarding signandsymptomsofdisease, onset of illness, placeof residence, etc.The casesmustbelinelisted.

• Conduct a rapid search for additional cases that may haveoccurredinthelocalitybutnotreportedtothehealthfacilities.

• Deaths, if any, should be determined that have not beenreportedorforwhichnocausehasbeenknown.

Information,EducationandCommunication• IECcampaignshouldbeplannedonceoutbreakisconfirmed

and launched forgeneralpublic toensureARI/ILI casesaretakentothenearesthealthfacilityforcheckupandsupportivecare.

• IECmustprovidetheinformationtothecommunityregardingthediseaseanditspossiblethreats.

• IECshouldbecommunicatedthoughlocalmediaifavailabletilloutbreakiscontained.

11. ARI/ILI/SARI Monitoring & Evaluation

Theoverallusefulnessofasentinelsurveillancesystemwilldependonwhetheritcontributestothepreventionandcontrolofadversehealthevents. A surveillance system should undergo regular monitoringto routinely assesswhether it is functioning efficiently and providingquality data. Additionally, routine assessment will indicate areas inwhich personnelmay need technical or logistical support and/or re-training.Indicatorstoassesssurveillancesystemaredescribedbelow:

Table No. 2. Indicators for Monitoring and Evaluation

Indicators Frequency of monitoring

Source of information

Timelinessofreporting Weekly Routinedata

Completenessofdatacollected Weekly Routinedata

Numberofsamplescollected Weekly Routinedata

NumberofARI/ILIoutbreaksdetected Quarterly Routinedata


15 Pages

11.1. Timeliness of reporting Timelinessreferstothespeedbetweenstepsinasurveillancesystem.Data must be timely, if it is to be useful to clinicians, public healthauthorities,andthecommunity.Indicatorsoftimelinessinclude:

Expected dates of data reporting from sentinel site to PHL ascomparedtoactualdatesofreporting;

TimeelapsedfromspecimencollectionatsitetoarrivalatPHLfortesting;

Time elapsed from receipt of specimens at PHL to processing,testingandgeneratingresults;

Timeelapsedfromreceiptoflaboratoryresultsforindividualcasesbythesentinelsitefocalpointtonotificationofthepatient’sdoctor;

11.2. Completeness of data collected Completenessreferstothedatacollectedwithcompleteinformationandcanbemeasuredbyassessingthefollowing:

Percentageofformsreceivedfromeachsitewithcompletedata;Percentageofformsthatarereceivedascomparedtothe

expectedforms;

11.3. Number of samples collected Number of samples collected in each site can be used to monitorsurveillanceandcanbeassessedby:

ComparingnumberofILI/SARIsamplescollectedascomparedtothatofrequirednumberofsamples.

11.4. Number of ARI/ILI outbreaks detected

Thesurveillancecanbemonitoredbyassessingtheoutbreaksthatweredetected.Theindicatorsusedcan:Numberofoutbreaksreportedascomparedtothatoftheprevious

year;Numberofoutbreaksinvestigatedandconfirmedbylaboratory;Numberofoutbreaksthathavebeenintervenedandcontrolled.


16 Pages

12. References

1. WHO regional office for Europe Guidance for Influenza

SurveillanceinHumans.

2. AnnualHealthBulletin,2010,MinistryofHealth,Bhutan

3. OperationalManualforNationalNotifiableDiseaseSurveillance,

PublicHealthLaboratory,Bhutan

4. Protocolfortheevaluationofthequalityofclinicaldatawithin

theEuropeanInfluenzaSurveillanceScheme.www.euroflu.org

[email protected]

5. CoreTermsofReferenceforWHOCollaboratingCentres for

ReferenceandResearchonInfluenza

http://www.who.int/csr/disease/influenza/whocccoretor2006.pdf

6. IndicatorsofInfluenzaActivity.www.ecdc.europa.eu


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14. Figure 2: ILI/ SARI Surveillance overview

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18 Pages

15. Annexure 1: Form A:ARIreportingformfromBHUs/HospitalstoDistrictHealthAuthority

16. Annexure 2: Form B:ARIreportingformfromDistricttoARIProgram

16. Annexure 2: Form B: ARI reporting form from District to ARI Program

WEEKLY ARI & PNEUMONIA SURVEILLANCE REPORTING FORM (From District to ARI program)

Reporting Center Name Month Year

From………./……/…….…

To…………/……….../………

Type of cases

Age group

0-11 Mths 1-4 years 5-14 years 15-29 years 30-64 years 65+ years

Male Female Male Female Male Female Male Female Male Female Male Female

Week: ² 1. No. of ARI cases 2. No of Pneumonia cases

3. Death due to ARDS/ Pneumonia

4. Total OPD cases

Week: ²

1. No. of ARI cases 2. No of Pneumonia cases


4. Total OPD cases

Week: 3



4. Total OPD cases

Week: 4



4. Total OPD cases Reported By: Signature: Mobile No.: Date:


19 Pages

17. Annexure 3: FormC:WeeklyILIandSARIreportingform

ARI/ILI/SARI surveillance guideline 19 | P a g e

17. Annexure 3: FormC:WeeklyILIandSARIreportingform

WEEKLY ILI & SARI SURVEILLANCE REPORTING FORM

SENTINEL ILI & SARI SURVEILLANCE AGGREGRATE DATA

WEEK _____________ From: …../……./…… To …../……/…..… Year………

Site Name:

Aggregate cases

Age group (Years)

0-1 2-4 5-14 15-29 30-64

65+

Number of ILI cases during the week

Number of SARI cases during the week

Number of deaths due to SARI/Pneumonia during the week*

Total OPD cases ** during the week

*Death cases details:

Name Age/ Sex Sample collected for testing (Influenza/ other viral agents)? (Yes/ No)

**The OPD cases includes patients seen with and without ILI in the OPDs (total OPD registration)

Reported By: Signature:

Mobile No.: Date:


20 Pages

18. Annexure 4: Form D:ILIcaseInvestigationandSamplecollectionform

20 | P a g e PUBLIC HEALTH LABORATORY


Influenza –Like Illness Case investigation/sample collection form Patient ID number * Site: Month/Year Sample #

Name of Patient:

Age: Sex:

Date of onset of illness:

Sign and Symptoms: Fever ≥0C: Cough: Sore throat:

Others:

Travel history prior illness: □No □Yes, travel to ___________duration____________(weeks/month)

Direct exposure to animal: □No □Yes, poultry □ Yes, swine □Yes other (specify)_________

Date of specimen collection:

Specimen type Throat swab: Nasal swab: Others:

Laboratory use only

Rapid Test Result

Influenza A: Influenza B: Influenza A+B: Negative:

Analyzed by: Date:

* Patient ID number example: if the sample is the first specimen collected in January 2012 from a patient in Mongar, the patient ID number would be: MON/Jan/12 /0001.

ID#:

/Sex: Occupation:

20 | P a g e PUBLIC HEALTH LABORATORY


Influenza –Like Illness Case investigation/sample collection form Patient ID number * Site: Month/Year Sample #

Name of Patient:

Age: Sex:

Date of onset of illness:

Sign and Symptoms: Fever ≥0C: Cough: Sore throat:

Others:

Travel history prior illness: □No □Yes, travel to ___________duration____________(weeks/month)

Direct exposure to animal: □No □Yes, poultry □ Yes, swine □Yes other (specify)_________


Specimen type Throat swab: Nasal swab: Others:

Laboratory use only

Rapid Test Result


Analyzed by: Date:

* Patient ID number example: if the sample is the first specimen collected in January 2012 from a patient in Mongar, the patient ID number would be: MON/Jan/12 /0001.


21 Pages

19. Annexure 5: Form E: SARI case investigation and samplecollectionform

ARI/ILI/SARI surveillance guideline 21 | P a g e 19. Annexure 5: Form E: SARIcaseinvestigationandsamplecollectionform

SARI CASE INVESTIGATION AND SAMPLE COLELCTION FORM(Send one copy of this form to PHL along with the sample. The original form should be kept at the

surveillance site)SAMPLE COLLECTION INFORMATION

Health Centre:

Date of onset of symptoms


Specimen ID:

PATIENT IDENTIFICATION Patient name: Age/Sex: Occupation:

Address:

Date of reporting to the health worker/Health facility:

CLINCIAL INFORMATION SARI Case Criteria Fever measured >38 degrees? � Yes � No �Unknown Cough? � Yes � No � Unknown Sore throat? �Yes � No � Unknown Shortness of breath or difficulty breathing? �Yes �No � Unknown Requiring hospitalization? � Yes � No � Unknown Clinical Signs of Pneumonia: � Yes � No � Unknown Others (specify):________________________________________________________________________ Pre-Existing Medical Conditions � Heart Disease � Asthma � Chronic Lung Disease � Liver Disease � Pregnant � Diabetes � Neuromuscular Dysfunction � Immune compromised � Others (specify) ________________________ � Unknown Antiviral and Vaccine Exposure to influenza virus drugs during last 14 days: : � None � Yes � Unknown If Yes, Name of antiviral: ___________________________ Vaccination for influenza: � Yes � No � Unknown EPIDEMIOLOGY INFORMATION Travel History: History of Travel within the last 7 days: Area and Location: ___________ Exposure History Direct exposure to animals: � No � Poultry Yes, � Swine Yes, � Other(specify)__________________________

Reporting Physician/Clinician: Telephone/Mobile No: Signature:

Rapid Test Result (For Laboratory Purpose only)


Analyzed by: Date:


22 Pages

20.

20.1. Throat swab: • LabelVTMtubewithLabIDnumber.• Askpatient (adults) to sit comfortably

on chair or lay down the patient(infants/young children) in a supineposition on bed with extendedpositioningofthepatient’sarmsabovethehead(Figure1&2)(Note:throatswab from infants/young childrenshouldbecollectedbyPediatricianoronlytrainedpersonnelonly).

• Holdthetongueoutofthewaywithatonguedepressor(Fig3).

• Use a sweeping motion to swab theposteriorpharyngealwalland tonsilarpillars.Havethesubjectsay“aahh”toelevatetheuvula.Avoidswabbingthesoftpalateanddonottouchthetonguewiththeswabtip(Figure4).(Note.Thisprocedurecaninducethegagreflex).

• OpenandputtheswabintoVTM.• Immediately close the VTM tube

and store in 2-4°C till the sample isprocessed or transported to PHL/referencelab.

FIGURE 1

FIGURE 2

FIGURE 3

Annexure 6: Procedures for sample collection

FIGURE 4


23 Pages

20.2. Nasopharyngeal swab: • LabelVTMtubewithLabIDnumber,• Askpatient(adults)tositcomfortablyon

chair• Holdpatient’sheadslightlybackbyleft

hand.• Insert a flexible,fine-shafted polyester

swab into the nostril and back to thenasopharynx(Fig5and6).Theswabisinsertedfollowingthebaseofthenostriltowards the auditory pit till resistanceismet. (Need to insert at least 5–6 cmin adults to ensure that it reaches theposterior pharynx). (DO NOT use rigid shafted swabs for this sampling method).

• Leavetheswabinplaceforafewsecondsandwithdrawslowlywitharotatingmotion

• OpenandputtheswabintoVTM• A second swab should be used for the

othernostrilandput intoasecondtube.This can serve as the second samplefromthepatient.

• Immediately close the VTM tube andstorein2-4°CtillthesampleisprocessedortransportedtoPHL.

20.3. Nasal swab: • Askpatienttositcomfortablyonchair• Holdpatient’sheadslightlybackbyleft

hand• Use the same type of rigid swab as for

samplingfromthethroat.• Advance theswab tippast thevestibule

FIGURE 5

FIGURE 6

FIGURE 7


24 Pages

(anterior nares) to thenasalmucosa (approximately 2–3 cmfromthenostrilsinadults)

• Store in 2-4°C till the sample is processedor transported toPHL/reference lab. Gently rotate to collect nasal secretionsfromtheanteriorportionsoftheturbinateandseptalmucosa(Fig7).

• OpenandputtheswabintoVTM• Asecondswabshouldbeusedfortheothernostrilandputinto

asametube.ImmediatelyclosetheVTMtubeand

21. Annexure 7: Sample storage

21.1. Sample Storage Procedure (for sentinel sites)

• Wearanapron,glovesandotherprotectivebarriers.• SealallVTMtubescontainingspecimenswithparafilmairtight.• ArrangespecimensinserialorderbasedonsampleIDnumber

instoragerack.• Labelstoragerackswithdetailed informationofspecimens it

contain.• Placethespecimenracksinarefrigeratorat2-8°Cuntilready

totransporttoPHL.

21.2. Sample Storage Procedure (for PHL)

• Wearanapron,glovesandotherprotectivebarriers.• CheckwhetherallVTMtubescontainingspecimensaresealed

withparafilmairtight.• ArrangespecimensinserialorderbasedonsampleIDnumber

instoragerack.• Arrange surveillance specimen from sentinel sites serially in

differentstorageracks.• Label storage rack with detailed information of specimens it

contain• Store the specimens in -70°C until ready to be shipped to

referencelass.


25 Pages

22. Annexure 8: Specimen Transportation Procedures

22.1. Domestic transport (district labs to Referral labs/PHL)• Placethespecimeninaprimarycontainer(polysterelynescrew

cappedvials)containingVTM.Theprimarycontainermustbeleak-proofunbreakableandairtight.

• Aftertighteningthecap,applysealingtape(para-film)overthecapand topof thecontainerandwrap inabsorbentmaterial(e.g.absorbentcottonortissuepaper)toabsorbtheaccidentalleakage.

• The sealed specimen container with a small amount ofabsorbent material must be placed in a suitably sized selfsealingplasticbag.

• Sealthebag.Twoormoresealedspecimensfromthesamesourcemaybeplaced ina largerplasticbag inbatchesandsealed.Specimenfromadifferentsourcemustnotbeplacedinthesamebag.

• Place the sealed bags containing the specimens inside asecondaryselfsealingplasticcontainerandsealit.Specimensfromseveralsourcesmaybepackedinsidethesamesecondaryplasticcontainer.

• Place additional absorbent material inside the secondarycontainer to cushion and to absorb any leakage that mayoccur.

• Tapethelaboratoryrequestformsealedinaplasticbagtotheoutsideofthissecondarycontainer.

• Place thesecondarybagcontaining thespecimen inwizard/coolboxcontainingice/icepacks.

• Sealthecoolboxproperlywiththehelpofbrowntaperunningaroundfulllengthandbreadthoftheboxsothataplusorcrosssignismade.


26 Pages

• Label the box with appropriate addresses and a biohazardsymbol.

22.2. Transportation from PHL to Reference lab

• Aftercollectingthesampleinsamplevialsprovided,makesurethatthevialiscappedverytightlyandsealedwithparafilm.

• Wrap the sample vial(s) in absorbent (tissue paper can beused)usingrubberband.

• Placethesampleinprimaryreceptacle(sealedplasticbag).• Batch the sample according to the size of the secondary

receptacleandplaceinit.Useadditionalabsorbentandsealthesecondaryreceptacle.Fore.g.fiveprimaryreceptaclescanbebatchedtogetherandplacedinsidethesecondaryreceptacle.

• Put the secondary receptacle in transport container/shippingcontainerfortransportingtoadesignatedlaboratory.

• Place specimen data forms, letters and other relevantdocuments in a water proof bag (preferably sealed plasticbag) carefully tapped either to the outside of the secondaryreceptacleorinsideofthetransportationcontainer.

• Placedryicebetweenthesecondaryandtransportcontainerto keep the sample at the required temperature duringtransportation.

• The outer shipping or transportation container should belabelled with the name of the receiver, indication of storageconditions requiredduring transport,andbearanyadditionallabels or stickers (biohazard sign) as per the national/internationalregulations.


27 Pages

Figure 8: Triple packaging system


28 Pages

FIGURE 4

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Operational guideline for ARI, ILI & SARI surveillance · ARI/ILI/SARI Surveillance Guideline 1...

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Transcript of Operational guideline for ARI, ILI & SARI surveillance · ARI/ILI/SARI Surveillance Guideline 1...