first quarter 2015 · giardia lamblia 4 0 entamoeba histolytica 1 0 shigella flexneri 3 01 shigella...

DISEASE SURVEILLANCE BULLETIN

Volume 1 1 1st Quarter (January – March) 2015

Contents Page No

Surveillance of Diarrhea Etiologic Agents among children under 5 years

1 - 2

Surveillance of Multi Drug Resistance Tuberculosis

2 – 3

Influenza Surveillance 3 - 8

Measles and Rubella Surveillance 8

Acute Encephalitis Syndrome Surveillance 8 - 9

Dengue Surveillance 9

Surveillance on Urban Drinking Water quality Monitoring

9 - 12

External Quality Assessment Programme 12 - 14

Summary of Disease Outbreaks Report 15

Summary of National Notifiable Diseases Surveillance

16

Volume 1

January

- Marc

h

2015

First Quarter 2015

Department of Public Health Ministry of Health www.phls.gov.bt

PUBLIC HEALTH LABORATORY

From Editor: Public Health Laboratory (PHL) is pleased to launch its first Quarterly Disease Surveillance Bulletin for 2015 and henceforth the bulletin will be produced regularly at the end of every quarter. The aim of the bulletin is to provide insight and regular update on various disease surveillance conducted by Public Health Laboratory to policy makers in the Ministry of Health, health professionals and relevant stakeholders. The current bulletin covers disease surveillance data from January to March, 2015, and it is uploaded in PHL website (www.phls.gov.bt) for ready access.

Edited By:

Mr. Sonam Wangchuk, Chief Laboratory Officer. Head, PHL

Mr. Binay Thapa, Dy.Chief Laboratory Officer, Influenza/Molecular Laboratory.

Mrs. Sonam Peldon, Sr.Laboratory Officer, Infectious Disease Serology Laboratory

Layout and Design By:

Mr. Thinley Jamtsho, Sr. ICT Officer, ICT Unit

Mr. Govinda Ghimeray, ICT Technical Associate II, ICT Unit

http://www.phls.gov.bt/



1. Surveillance of Diarrhea Etiologic

Agents among children under 5

years

Surveillance of diarrhea etiological agents is sentinel

surveillance. A total of 343 samples were collected,

of which, 53% (181) and 47% (162) were cases and

controls respectively (Table 1). The most common

enteric bacterial pathogens other than Escherichia

coli (E.coli) isolated among case were

Camphylobacter, Shigella and Giardia. Among

controls, Aeromonas species and Yersinia species

(Figure 1). Bacterial isolates from sites are given in

(Table 2). However, test result for enteric viruses

(rotavirus, norovirus and adenovirus) are pending

due to shortage of test kits.

From 343 samples, 295 isolates from the culture was

E.coli and all isolates from both cases and controls

were subjected to Multiplex PCR to identify and

confirm diarrheagenic E.coli (Figure 2). As per the

finding enteropathogenic E.coli (EPEC) and

enterotoxigenic E.coli (ETEC) were found to be

pathogens in the children.

Table 1: Number of samples collected for the first quarter,

2015 by each sentinel sites.

Study Sites Target Sample No. of samples collected

Case Control Case Control

Gelephu RRH 30 30 37 34

JDWNRH 75 75 106 105

Mongar RRH 30 30 9 7

P/ling Hospital 30 30 29 16

Total 343

Giardia lamblia

15%

Entamoeba histolytica

4%

Shigella spp18%

Aeromonas spp.30%

Campylobacter spp.

26%

Salmonella spp.7%

Fig 1: Common enteric etiologic agents isolated (other than

Escherichia coli)

Table 2: Site-wise distribution of commonly isolated enteric

bacterial pathogens

0

5

10

15

20

Cas

e

Con

tro

l

Cas

e

Con

tro

l

Cas

e

Con

tro

l

Cas

e

Con

tro

l

Cas

e

Con

tro

l

EAEC EPEC ETEC STEC EIEC

Nu

mb

er

of

Ca

ses/

Co

ntr

ols

Type of E. coli Strain

Fig 2: Multiplex PCR showing different diarrheagenic E.coli

Organism

isolated from

case and control

Study Sites

JDWNRH GRRH P/ling

Hospital MRRH

Giardia lamblia 4 0 0 0

Entamoeba

histolytica 1 0 0 0

Shigella flexneri 3 0 1 0

Shigella sonnei 1 0 0 0

Aeromonas spp. 4 1 3 0

Campylobacter

spp. 2 1 4 0

Salmonella spp. 1 1 0 0

LF E. coli 136 44 22 7

NLF E. coli 58 16 8 4

Total 210 63 38 11



Antimicrobial susceptibility testing shows all

Shigella species resistance to Sulfamethoxazole,

Amoxycillin and Ciprofloxacin but susceptible to

Ceftriaxone. Other bacteria isolates (Salmonella,

Aeromonas and Yersinia) were found susceptible to

Ciprofloxacin, Sulfamethoxazole and Ceftriaxone but

resistant to Amoxycillin. Diarrheagenic E.coli show

resistance to Amoxycillin but susceptible to

Ciprofloxacin and Ceftriaxone (Table 3).

Table 3: Antibiotic Susceptibility pattern of Bacterial isolates

from both case and control

Isolates AMX CIP SXT CRO NAL

Shigella

(N = 4)

S 1 2

3

*ND

I

1

1

R 3 1 3

Salmonella

(N = 2)

S 2 2 2 2

I

R

Aeromonas

(N =5)

S

4 5 5

I

1

R 1

Yersinia

(N = 1)

S

1 1 1

I

R

EAEC

( N = 19)

S 7 18 14 16

I

1

R 13 1 5 2

EPEC

(N = 2)

S

2

2

I

R 2

2

S = Susceptible, I = Intermediate, R = Resistant

AMX: Amoxycillin, CIP: Ciprofloxacin, SXT:

Sulfamethoxazole, CRO: Ceftriaxone, NAL: Nalidixic acid

* ND - Not done based on previous year data which

showed resistance > 90%

2. Surveillance of Multi Drug

Resistance Tuberculosis

2.1 Culture & Drug Susceptibility Testing

A total of 172 patient sputum samples (169 positive

and 3 negative smears) were received for culture and

Drug Susceptibility Testing (DST) at National TB

Reference Laboratory (NTRL) from various hospitals

(Table 4). From the total, 133 samples were culture

positive and rest still under incubation. Total of 148

extra-pulmonary (EPTB) samples were also received

and processed for MTB culture of which 20 were

culture positive. DST was completed for 30 samples

including EPTB of which nine were MDR-TB cases

(Figure 3).

In addition to samples for culture and DST, NTRL

has also received and processed 133 patient samples

for MDR-TB culture follow-up.

Table 4: Samples received from health centres for culture &

DST

Name of Hospital

No. of

Samples

Received

Name of Hospital

No. of

Samples

Received

Wangdue Hospital 7 Mongar RRH 6

Bali BHU-1 2 Paro Hospital 5

Bumthang Hospital 5 Phuntsholing

Hospital 31

Chukha BHU-I 1 Punakha Hospital 1

Dewathang Military

Hospital 1 Riserboo Hospital 1

Gedu Hospital 3 Samdrupjongkhar

Hospital 8

Gelephu RRH 19 Samtse Hospital 5

Gidakom Hospital 2 Sarpang Hospital 2

Gomtu Hospital 2 Sipsoo Hospital 5

JDWNR Hospital 53 Tashigang

Hospital 1

Lungtenphu Hospital 6 Trongsa Hospital 4



0

20

40

60

80

100

120

140

160

New case(Pulmonary)

Re-treatment(Pulmonary)

Unknown(Pulmonary)

Extra-pulmonaryTB

Nu

mb

er

of

sam

ple

s

Type of TB casesTotal Sample Culture completed (Positive)

DST completed MDR-TB detected

Fig 3: Status of samples processed in NTRL

2.2 MDR-TB cases

Of nine MDR-TB cases, six were from new smear

positive cases, one relapse smear positive and two

extra-pulmonary cases. Distribution of MDR-TB

cases are shown in Table 5. Most of the MDR-TB

cases were reported among the productive age group

(21 - 45 year) and among males (Table 6).

Table 5: MDR-TB case detected from hospitals

Hospital No. of MDR-TB cases

Wangdue (Bajo) Hospital 1

Gelephu RRH 1

JDWNRH 2

Paro Hospital 1

Phuntsholing Hospital 1

Punakha Hospital 1

Sipsu Hospital 2

Grand Total 9

Table 6: Age distribution of MDR-TB cases

Age (Years) MDR-TB

Number (%) Sex (number)

0-1 0 (0) 0

2-4 0 (0) 0

5-14 0 (0) 0

15-29 3(33.4%) M -2; F-1

30-64 5 (55.5%) M -3; F-2

65+ 1(11.1%) M -1

3. Influenza Surveillance

3.1 Influenza Like-Illness Surveillance (ILI) –

Epidemiological Component

Out of total 89,321 OPD visits at seven sentinel sites

(Paro, Punakha, Samtse, Trongsa, Tsirang,

Trashigang and SamdrupJongkhar hospitals); a

cumulative of 2579 ILI visits had been recorded for

this quarter. Average ILI incidence was 29 cases per

1000 outpatient visits (Figure 4). The highest ILI

incidence among sentinel sites was observed in Paro

Hospital (869 cases) followed by Trongsa Hospital

(729 cases).



Fig 4: Average number of ILI cases reported for the 1st Quarter (week 1 to 13); (Data source: Online weekly reporting from

sentinel sites).

ILI cases were commonly observed in age group of

15-29 years (36.84%) (Table 7).

Table 7: Distribution of ILI cases by age groups

Age (Years) ILI cases

Number Proportion (%)

0-1 255 9.89

2-4 320 12.41

5-14 535 20.74

15-29 950 36.84

30-64 434 16.83

65+ 85 3.30

3.2 Influenza Like-Illness Surveillance –

Virological Component

Out of 335 ILI samples received and tested by RT-

PCR, 35.52% (119/335) were positive for

Influenza virus which comprises Influenza A

pandemic 2009 (A/pdm H1) – 78% (93), A/H3

strain -21.5% (25); Flu B- 0.8% (1). The most cases

were detected from 10-13 week (Figure 5).

In the first quarter A/pdm H1 subtype was the most

predominantly circulating influenza virus strain in

Bhutanese population followed by A/H3. Influenza

A/pdm H1 cases were mostly detected from

western region sentinel sites (Figure 6).

The high positivity rate was detected among 15- 29

years age group (38.66%) and was mostly A/pdm

H1 strain (Figure 7).



Fig 5: Influenza virus subtype by week. (Data source: FluNet ( www.who.int/flunet ), GISRS)

Fig 6: Influenza virus subtype distribution by site

http://www.who.int/flunet



Fig 7: Influenza virus subtype and positivity rate by age group

3.3 Severe Acute Respiratory Illness Surveillance-

Epidemiological Component

Out of total 3819 patients admitted in sentinel sites

(JDWNRH, Paro, Punakha, Samtse, GRRH, Trongsa,

Tsirang, MRRH, Trashigang and Samdrupjongkhar

hospitals), 203 SARI cases were recorded for this

quarter. Average SARI incidence was 5 SARI cases

per 100 hospitalized patients (Figure 8). The highest

SARI incidence was observed in Paro Hospital (51

cases) followed by Phuntsholing Hospital (42 cases).

No death was reported from any of the sites. SARI

cases were commonly observed in children of age

group 0-4 years of age (Table 8).

Table 8: SARI case distribution by age groups

Age Cases (Numbers) Proportion (%)

0-1 52 25.62

2-4 48 23.65

5-14 27 13.30

15-29 25 12.35

30-64 29 14.29

65+ 22 10.84

3.4 Severe Acute Respiratory Infection

Surveillance- Virological component

Total of 162 SARI samples were received from 11

sentinels sites with Paro hospital collecting the

highest number of samples (41 samples) followed by

Phuntsholing Hospital (35 samples). The samples

were tested for influenza and other respiratory

viruses like Respiratory syncytial virus (RSV),

human pneumo-metavirus (hMPV) and Adenovirus.

Out of 162 samples, 18.51% samples tested positive

for Influenza Virus, (A/pdm H1- 22 & A/H3-9) and

6.17% positive for (hMPV). However, non tested

positive for Respiratory syncitial Virus (RSV) and

Adeno virus (Figure 9).

The most SARI cases were due to infection with

A/pdm H1 strain and hMPV in children under 5

years of age while it is the influenza A/pdm H1 strain

is the adults (Table 9).



Fig 8: No. of SARI cases reported weekly

Fig 9: Trend of influenza virus and other non-influenza virus



Table 9: Respiratory viruses detected according age groups

Age A/PdmH1

(n=22)

A/H3

(n=9)

hMPV

(n=10)

Total

0-1 4 3 4 11

2_4 4 2 3 9

5_14 0 0 2 2

15-29 4 2 0 6

30-64 9 0 0 9

65+ 1 1 2 4

4. Measles & Rubella Surveillance

Measles and rubella is a national surveillance. In

the 1st quarter 2015, a total of 10 serum specimens

were received from measles and rubella suspected

cases but none of samples tested positive for either

anti-IgM measles or rubella by ELISA (Table 10).

The last confirmed case of measles was in 2012

from Phuntsholing hospital. There were four rubella

cases in 2014.

Table 10: Measles and Rubella Testing Report

5. Acute Encephalitis Syndrome

(AES) Surveillance

Acute Encephalitis Syndrome is sentinel

surveillance. A total of 17 samples were received

and tested for Japanese encephalitis but none of the

samples tested positive for anti-JE IgM by ELISA

(Table 11). Two JE cases were detected in 2014,

each from Trongsa and Punakha. Bhutan falls under

JE belt in the region.



Table 11: Number of samples tested for JE

Hospitals Number of Samples

CSF Result Serum Result

JDWNRH 7 Negative 5 Negative

Mongar RRH 1 Negative

2 Negative

Trashigang

Hospital 0

Negative 1

Negative

S/jongkhar

Hospital 0

Negative 1

Equivocal

Total 8

9

Total Samples 17

6. Dengue Surveillance

Dengue surveillance is sentinel surveillance and the

identified sites are Phuntsholing and Samtse

hospitals. During the 1st quarter, only two samples

were collected from dengue suspected cases where

both tested negative for Dengue non-structural

protein NS1 by ELISA.

Laboratory confirmed dengue cases in 2014 were

also very low (1.4%) compared to 32% lab

confirmed cases in 2013. DENV1 (96%) was the

dominant serotype in 2013 (Table 12).

The surveillance suggests that dengue is endemic in

urban area of Phuntsholing only although dengue

vectors are widely prevalent in other areas of

southern districts.

Table 12: Dengue serotypes (2013-2014)

7. Surveillance on Urban Drinking

Water Quality Monitoring

7.1 Microbiological Report

A total of 533 samples were collected and tested for

faecal coliform from urban areas across the

country. The test results show that 328 samples

were safe for drinking (zero faecal count) and 205

samples were found unsafe (faecal count ranging

from 1CFU to >50 CFU) (Figure 10).

Further, among the 205 unsafe samples, 140

samples are categorized as low health risk, 60

samples as intermediate to high health risk and five

as grossly polluted sample as per the health risk

assessment categories (Figure 11).

Year Assay

No. of

specimens

tested

DENV-

1

DENV-

2

DENV-

3

2013

Nested

RT-

PCR

168 52 2 1

Virus

isolation 55 33 0 0

2014

Nested

RT-

PCR

211 1 1 1

Virus

isolation 3 0 0 0



Figure 10: Microbiological report of 20 districts. Note: CFU: Colony Forming Unit CFU

Figure 11: Categorization of bacteriological report VS health risk.

Note; 0 CFU=Safe water (SW); 1-10 CFU =Low Health Risk (LHR); 11-50 CFU=Intermediate to High Health Risk (IHHR); >50

CFU=Grossly Polluted



7.2 Thimphu Thromdey Physico-Chemical Test Report

In addition to bacteriological test, Public Health Laboratory also conducts testing for important physiochemical

parameters (Residual Chlorine, pH, Turbidity, Total Dissolved Solids & Conductivity) in Thimphu Thromdey at

various sampling points (Figure 12, 13, 14, 15)

Figure 12: Residual Chlorine.

Note: MTP-Motithang Treatment Plant;JTP- Jungshina Treatment Plant; BPT: Break Pressure Tank

6.4 6.6 6.8 7 7.2 7.4 7.6 7.8 8 8.2 8.4

MTP( Raw water)

MTP(Treated water)

BPT R1 Tank

Three tank lower Motithang

Tank above NPPF colony

JTP(Raw water)

JTP(Treated water)

Tank near BCCI Office

Tank above JDWNRH

Tank near Swimming Pool

Changjiji Tank

Changjiji Pump House

pHAcceptable value(6.5-8.5)

Sam

plin

g St

atio

n

Mar

Feb

Jan

Figure 13: pH



Figure 14: Turbidity

Figure 15: Total Dissolve Solids (TDS and Conductivity (CND)

8. External Quality Assessment Programme

8.1 National External Quality Assessment

Scheme on STI/HIV Serology

The main objective of the NEQAS is to identify

the problem associated with various test kits used

to screen or test STIs and HIV in the district

hospitals labs and provide feedbacks to

participating labs on findings. A total of 36

laboratories participated in the 13th proficiency

testing and it was observed that more than one

brand of rapid test kits were used for screening or

testing of STIs and HIV in various hospitals

(Figure 16).



Fig 16: Different test kits used for NEQAS program

Each panel consisted of tests for HIV antibody,

HbsAg, HCV antibody, RPR & TPHA. Of the 36

hospital labs, two labs have used TPHA expired

kit and one lab expired HCV rapid test kit to test

panel samples. Further, 18 labs reported false

positive for HBsAg and test kit used was Hepacard

rapid kit. Similarly nine labs reported false

positive for HBsAg which used SD Bioline rapid

test kit. In total, 27(75%) labs reported false

positive for HBsAg. In addition, three labs

reported false negative for TPHA; the test kit used

was determine TPHA rapid test. Also, two labs

reported false negative and three labs false

positive for HIV (Figure 17).

Fig 17: Problems observed in NEQAS Program

8.2 National External Quality Assessment

Scheme on sputum Microscopy

The 30th round of proficiency testing for TB

microscopy was carried out for 35 hospital

laboratories of which 23 labs achieved an Overall

Agreement Rate (OAR) of 100%, nine labs

achieved 90% and two labs achieved 80% (Table

13). No feedback was received from one of the

labs. No major error was reported while the minor

error observed was 3.71% (Figure 18).

Figure 18: Classification of errors



Table 13: Results of 30th Round Proficiency Testing for TB Microscopy for 35 laboratories.

Sl

No Name of Hospital

Total

Slide HFN HFP LFN LFP QE

Total

errors OAR%

Total

Score

1 Wangdue Hospital 10 0 0 0 0 0 0 100 100

2 Bali BHU-1 10 0 0 0 0 0 0 100 100

3 Bumthang Hospital 10 0 0 0 0 0 0 100 100

4 Chukha BHU-I 10 0 0 0 0 0 0 100 100

5 Dagana BHU-1 10 0 0 0 0 0 0 100 100

6 Dagapela Hospital 10 0 0 0 0 0 0 100 100

7 Damphu Hospital 10 0 0 1 0 0 1 90 95

8 Dewathang Military Hospital 10 0 0 1 0 0 1 90 95

9 Gasa BHU-I* 10 - - - - - - - - - - -

10 Gedu Hospital 10 0 0 1 0 0 1 90 95

11 Gelephu RRH 10 0 0 0 0 0 0 100 100

12 Gidakom Hospital 10 0 0 0 0 0 0 100 100

13 Gomtu Hospital 10 0 0 0 0 0 0 100 100

14 Kanglung BHU-I 10 0 0 0 0 0 0 100 100

15 LhamoyzingkhaBHU-I 10 0 0 0 0 0 0 100 100

16 Lhuentse Hospital 10 0 0 0 0 0 0 100 100

17 Lungtenphu Military Hospital 10 0 0 1 0 0 1 90 95

18 Mongar RRH 10 0 0 0 0 0 0 100 100

19 Paro Hospital 10 0 0 0 0 0 0 100 100

20 Pema Gatshel Hospital 10 0 0 0 1 0 1 90 95

21 JDWNR Hospital 10 0 0 0 0 0 0 100 100

22 Phuntsholing Hospital 10 0 0 1 0 0 1 90 95

23 Punakha Hospital 10 0 0 1 0 0 1 90 95

24 Rangjung BHU-I 10 0 0 1 1 0 2 80 90

25 Riserboo Hospital 10 0 0 1 0 0 1 90 95

26 Samdrupjongkhar Hospital 10 0 0 0 0 0 0 100 100

27 Samtse Hospital 10 0 0 0 0 0 0 100 100

28 Sarpang Hospital 10 0 0 0 0 0 0 100 100

29 Sipsoo Hospital 10 0 0 0 0 0 0 100 100

30 Tashigang Hospital 10 0 0 1 0 1 2 80 90

31 Tashiyangtse Hospital 10 0 0 1 0 0 1 90 95

32 Trongsa Hospital 10 0 0 0 0 0 0 100 100

33 Tsimalakha Hospital 10 0 0 0 0 0 0 100 100

34 Yebilaptsa Hospital 10 0 0 0 0 0 0 100 100

35 Zhemgang BHU-I 10 0 0 0 0 0 0 100 100

*Feedback report not received



9. Summary of Disease Outbreaks Report

Fig 19: Influenza Outbreaks places.

Table 14: Influenza outbreak during the 1st Quarter 2015

Sl. No. Outbreak Date Outbreak Site Dzongkhag Confirmed Outbreak Result

(RT-PCR)

1 04/02/2015 Gaybaykha Locality Wangduephodrang Influenza A/pdmH1

2 02/03/2015 Ramjar Middle school Trashiyangtse Influenza A/H3

3 04/03/2015 Yurung Locality Pemagatshel Influenza A/pdmH1

4 05/03/2015 Mukhung Community Pry

School Mongar Influenza A/pdmH1

5 12/03/2015 Phochu Dumra Lobdra Punakha Influenza A/pdmH1

6 21/03/2015 Zhemgang Higher Secondary

School Zhemgang Influenza A/pdmH1

7 27/03/2015 Langdurbi Community Pry

School Zhemgang Influenza A/pdmH1



10. Summary of National Notifiable Diseases Surveillance

Table 15: National Notifiable Diseases Surveillance Summary during the 1st Quarter 2015

Disease Dzongkhag

Bum Chu Dag Gas Haa Lhu Mon Par Pem Pun Sjk Sam Sar Tph Trg Try Tro Tsi Wan Zhe Total

Anthrax 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Avian Influenza 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Brucellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cholera 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Rubella/CRS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Diphtheria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Dengue 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

DHF 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Shigellosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Human Rabies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Japanese Encephalitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Malaria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Measles 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Bacterial Meningitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Mumps 0 0 0 0 0 0 0 0 0 0 0 17 0 0 0 0 0 0 0 0 17

Nipha Virus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Pertussis 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Plague 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Poliomyelitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

SARS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Small Pox 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Tetanus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Typhoid Fever 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 3

Viral Hepatitis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Scrub Typhus 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 3 0 0 5

first quarter 2015 · giardia lamblia 4 0 entamoeba histolytica 1 0 shigella flexneri 3 01 shigella...

Documents