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IMAI second-level learning programme for district clinicians working at hospitals in limited resource

settings

Participant training manual:

Clinician’s Role in Disease Surveillance and

Case Reporting

This training module is based on guidelines in the IMAI District Clinician Manual: Hospital Care

for Adolescents and Adults

July 2014

Integrated Management of Adolescent and Adult

Illness (IMAI)

2 – CHAPTER 1 Participant manual: Clinician’s role in disease surveillance and case reporting

Participant manual: Clinician’s role in disease surveillance and case reporting CHAPTER 1 - 3

IMAI second-level learning programme for district clinicians working at hospitals in limited resource settings

Participant training manual

Clinician’s Role in Disease Surveillance and Case Reporting

This training course is based on guidelines in the IMAI District Clinician Manual: Hospital Care for Adolescents and Adults

July 2014

Comments to: [email protected]


Table of Contents 1. General concepts of disease surveillance and case

reporting and the clinician’s role

1.1 Priority diseases for integrated disease surveillance…………………………….. 7

Group exercise 1……………………………………………………………………………… 9

1.2 The clinician’s role in immediate reporting of notifiable diseases……………….11

Group exercise 2……………………………………………………………………….……..15

Group exercise 3 (or individual exercise)……………………………………………..……18

1.3 Understand how the clinician’s role fits into IDSR at the health facility…… …18

Class discussion: Reporting notifiable diseases....…………………………………..… .21

Class discussion: Case fatality rate…………………………………………………..…… 22

Class discussion: Hospital emergency response plans………………………………….26

Group exercise 4…………………………………………………………………………… 27

Class discussion: Surveillance goals……………………………………………………….29

Cases 1 to 3…………………………… …………………………………………………30-34

2. Surveillance: Influenza and severe acute respiratory infections (ARI)…………..35

2.1 Principles of clinical surveillance for influenza and ARI……………………….…35

2.2 Role of health workers in clinical surveillance for influenza and ARI………….37

2.3 Use the IMAI DCM to consider the DDx of ARI……………………………………..38

2.4 Laboratory testing for severe ARI…………………………………………………… 39

2.5 Case management and infection control for severe ARI………………………....43

Group exercise 5…………………………………………………………………………….44

Case 4………………………………………………………………………………………...44

2.6 Practical approach to surveillance for ARI in the district hospital…………..…45

Case 5…………………………………………………………………………………………45

Case 6…………………………………………………………………………………………50

3. Viral haemorrhagic fever………………………………………………………………...55

Group exercise 6……………………………………………………………………………60

4. Other priority pathogens with epidemic potential (in development) .............................................

5. Neglected tropical diseases (in development) .................................................................................

6. Cases (mixed) ......................................................................................................................................

APPENDIX A: Immediate case-based report form ............................................................................................ 62

APPENDIX B: IDSR case-based laboratory reporting form ............................................................................. 63

APPENDIX C: Checklist for supervising surveillance and response activities-health facility .................... 64

APPENDIX D: Further training and resources in surveillance for clinicians & managers ........................... 66

APPENDIX E: How to collect a respiratory specimen ...................................................................................... 67

APPENDIX F: Using the laboratory .................................................................................................................... 72


Chapter 1: General concepts of disease surveillance and case reporting and the

clinician’s role

Learning objectives:

1. Understand the priority diseases for integrated disease surveillance 2. Understand the clinician’s role in immediate reporting of notifiable

diseases (event-based surveillance)

Learn how to use the IMAI District Clinician Manual to incorporate surveillance into routine patient care

3. Understand how the clinician’s role fits into IDSR at the facility and their role in outbreak investigation

4. Understand the clinician’s role in indicator-based surveillance

Disease surveillance is the foundation for disease control. This chapter goes through the priority diseases for integrated disease surveillance then the clinician’s role in surveillance activities.

1.1 Priority diseases for integrated disease surveillance

Priority diseases for integrated disease surveillance in the African Region have been recommended because they are:

Required internationally under International Health Regulations (smallpox, poliomyelitis due to wild-type poliovirus, human influenza caused by new subtype, SARS)

Diseases with high epidemic potential to cause serious public health impact due to ability to spread rapidly internationally (cholera, plague, yellow fever, viral haemorrhagic fever)

Principal causes of morbidity and mortality in the region (malaria, pneumonia, diarrhoeal disease, tuberculosis, HIV/AIDS, maternal deaths and injuries)

Non-communicable priorities in the region (high blood pressure, diabetes mellitus, mental health and nutrition)

Effective control and prevention interventions are available for addressing the public health problems they pose (onchocerciasis, trypanosomiasis)

Intervention programs supported by the WHO for prevention and control, eradication or elimination of the diseases exist (Expanded Program on Immunizations, Integrated Management of Childhood Illness).

The following list is from the comprehensive public health surveillance and response systems in African countries, Integrated Disease Surveillance and Response (second


addition 2010, updated with the 2005 International Health Regulations). Next to each disease is listed the section of the DCM relevant to the reportable disease.

Priority diseases, conditions and events for Integrated Disease Surveillance and Response – 2010 Diseases, conditions or events requiring immediate reporting are in italics. [Number indicates the Section in IMAI District Clinician Manual]

Epidemic prone diseases Diseases targeted for eradication or elimination

Other major diseases, events or conditions of public health importance included in this manual

Acute haemorrhagic fever syndrome* [11.46] Anthrax see Section 10.2, 10.6, 10.10 Chikungunya [10.1, 10.13] Cholera [10.7] Dengue [11.9] Diarrhoea with blood (Shigella) [10.7] Measles Meningococcal meningitis [10.10b] Plague [10.5] SARI** (cluster of SARI) [3.2] Typhoid fever [10.7] Yellow fever [10.47] *Ebola, Marburg, Rift Valley, Lassa, Crimean-Congo, West Nile Fever **National programmes may wish to add Influenza-like illnesses to their priority disease list

Buruli ulcer [10.2] Dracunculiasis [10.2] Leprosy [10.2] Lymphatic filariasis [10.4, 11.12] Neonatal tetanus Noma [10.17] Onchocerciasis [10.12] Poliomyelitis

1 (report

acute flaccid paralysis) [10.10] 1Disease specified by

International Health Regulations (2005) for immediate notification

Acute viral hepatitis [11.14] HIV/AIDS (new cases) [9, 13] Injuries (road traffic accidents) [2] Malaria [3.1, 11.25] Maternal deaths Mental health (Epilepsy) [10.11] Rabies (confirmed cases) [11.30] STIs [10.14, 10.15, 10.16] Trachoma [10.12] Trypanosomiasis [11.41, 11.42] Tuberculosis [15]

Diseases or events of international concern

Human influenza due to a new subtype1 [11.17]

SARS1 [3.2]

Smallpox1

Any public health event of international or national concern (infectious, zoonotic, food borne, chemical, radio nuclear, or due to unknown condition).

Classically, surveillance activities at the health care facility include indicator-based surveillance, which is generally collected through monthly or weekly reports, and is dependent on the routine gathering of data. This type of surveillance collects population-based data to identify changes in disease severity, patterns, and antimicrobial resistance and must be an ongoing process in order to detect seasonal variations and unusual patterns or trends. It also provides critical information on burden of disease for non-communicable diseases including accidents, poisonings, and chronic diseases such as diabetes and heart disease. Indicator-based surveillance includes


reporting of notifiable diseases, sentinel surveillance at select health facilities, and laboratory based surveillance. Event-based surveillance1 is the rapid detection, reporting, confirmation, and assessment of public health events, and includes reporting of clusters of disease and rumors of unexplained events. Event-based surveillance relies on immediate reporting, rather than weekly or monthly reports, and is therefore generally better as an early warning system for the timely detection of outbreaks. Data for this type of surveillance often comes from circulating rumors in the community and media. Health workers at the district hospital also play a critical part to an event-based surveillance system, as they are often the first to recognize that there is something unusual about a patient’s presentation or a death. Examples of data reported through event-based surveillance include:

Unexpected deaths in health care workers

Clusters of deaths in a village or family

Deaths from an unusually severe presentation of a routine disease

Presentation of a disease which is unusual or unexpected in the community

Deaths in persons exposed to sick or dead birds Countries have adapted this list according to national priorities and epidemiology. For your country and region all health workers should be familiar with the notifiable diseases:

Diseases where even a single suspected case should be reported urgently (and to whom)

Diseases where a cluster of cases should be reported (and to whom)

How to send reports for notifiable diseases (telephone, radio, mobile phone system, messenger, paper, website)

Group exercise 1

The IDSR table combines notifiable diseases, conditions or events for immediate reporting (in italics) and diseases where the number of cases in a certain time period are routinely reported.

Use the IDSR table to help your facilitator fill out the following table as a group.

1 A guide to establishing event-based surveillance, WHO, 2008.


List the most important notifiable diseases or conditions or events for immediate reporting of a case (this is event-based surveillance).

Start with the ones you know have occurred in your region or country in the last 2 years.

Important causes of morbidity and mortality that are reported monthly or quarterly (these are then used to calculate incidence of disease in your area- this is indicator-based surveillance).

Now put stars next to those which are epidemic-prone.

Circle those diseases targeted for eradication or elimination

In this module, you will learn how these skills that you use in your everyday care of patients can be integrated into both the indicator and event-based surveillance efforts of your hospital and district. The information gained from surveillance:

provides timely information that enable early detection of epidemic and pandemic disease

informs health policy decisions at the local, regional, and national levels

guides vaccine development and monitors for resistance patterns

facilitates prioritization of resources

monitors vulnerable groups at highest risk of severe disease

informs case management and infection control strategies


1.2 The clinician’s role in immediate reporting of notifiable diseases (event-based surveillance)

As the primary health care providers for patients requiring hospitalization in a district, the district hospital clinical team will be first to see patients presenting in unusually large numbers or with unusually severe disease or the first case of a disease that has epidemic potential. In conjunction with community health workers and health centers, information gained from district hospitals is a crucial part of surveillance systems. Surveillance is the systematic collection, analysis, and interpretation of data for use in public health practice. Useful surveillance data is collected and managed in a consistent, timely, and clear manner. The hospital clinical team plays a crucial role in early identification of reportable diseases and should be able to report findings in a consistent, timely, and clear manner, then assist as needed in assisting with outbreak investigation and responding to surveillance feedback. How to use the IMAI District Clinician Manual to incorporate surveillance into routine patient care Throughout this course you have been learning to use the IMAI Quick Check and relevant sections of the District Clinician Manual to rapidly triage and treat patients presenting to the district hospital. You have learned to use the differential diagnosis tables in the DCM to help with clinical case management

In the District Clinician Manual, reportable diseases are marked with a trumpet sign These are communicable diseases that need to be reported to national authorities as their presence has a broader significance to the public. These are usually rare, but are included in the differential diagnosis tables because of the importance of early recognition and of the need to report dangerous pathogens and diseases targeted for elimination. Identifying and reporting notifiable diseases is covered 21.3 of the DCM. Take a look at section 21.3. You will want to take some time after class to review this section. Notifiable diseases with epidemic potential are particularly important to identify promptly and report. Clinicians need to both consider the patient’s signs and symptoms, but also history of exposure and risk factors and whether an outbreak is occurring. The flowchart on the next page incorporates what you have learned so far in Quick Check Essentials and Management of Patients with Septic Shock and Respiratory Distress to identify, manage and report notifiable diseases.


Clinical exam Quick check assessment [IMAI Quick Check module] Detailed exam for signs/symptoms, according to

findings History exposure, risk factors

Local epi awareness: What is happening in your district/nearby? Outbreak? Other unusual clinical cases?

Differential diagnosis (DDx)- what are the possible diagnoses? Further clinical exam

Laboratory tests Point of care Hospital lab Lab tests to send out

How does patient compare to standard case definitions?

Discuss/report if possible notifiable disease

Case management Choice of empirical treatment(s) Standardized management of septic shock, severe

respiratory illness, etc [IMAI Management Septic Shock/Respiratory Distress ]

Clinical monitoring using severely ill patient monitoring form

Infection control: Always use standard precautions. Add additional precautions as appropriate (such as

contact, droplet, aerosol precautions; PPE; isolation)

Reassess: Clinical progression, response to treatments Lab results Further information (discuss with other clinicians,

district staff) Possible/probably diagnoses—

report if notifiable disease


History of exposure/risk factors and local epi awareness Most clinical conditions are usually due to the common causes. It is important to be able to notice changes in disease pattern in patients coming to your hospital, or reported from nearby health centres. History exposure, risk factors If there is an outbreak occurring, or the disease pattern is unusual, ask patients about their history of exposure and risk factors. These vary by disease. Local epi awareness:

What is happening in your district/nearby? Factor in your awareness of what is happening in your community, district, region, country, and cross- border.

Outbreak? Other unusual clinical cases? Differential diagnosis Key notifiable diseases and their clinical and laboratory features are included in the differential diagnosis tables in the DCM, to help district clinicians distinguish notifiable diseases from other diseases with similar presentations. Health staff should learn to consider these notifiable diseases in their differential diagnosis during routine clinical practice.

Differential diagnosis (DDx)- what are the possible diagnoses? Clinical decision-making is centered on a differential diagnosis (abbreviated DDx throughout the manual). Initially, this should be broad, followed by progressive elimination of possibilities without sufficient evidence. The frequency and severity of a disease may influence how diseases within the differential diagnosis table are ranked, and the order in which they are investigated. Differential diagnosis (DDx) tables should be considered in the local context of diseases, both those that are endemic and epidemic in an area. Do further clinical examination and appropriate lab tests. Repeating the physical examination, consulting with clinical mentors, and considering the local diseases epidemiology should all help establish a good DDx and assist in ruling in or out a diagnosis.


Establishing clinical diagnosis using different differential diagnosis tables

1. Use the differential diagnosis tables to establish links between clinical features and possible underlying

diagnoses. 2. Prioritize the list of possible diagnoses from the table based on the conditions most likely to exist in the setting

or to be life threatening. 3. Request and perform specific diagnostic tests in order to support or refute diagnoses from the initial differential

list. 4. Identify patients who need hospitalization. 5. Determine whether clinical findings or diagnostic test results support a condition from the initial differential

diagnosis list. a. If yes, treat accordingly.

i. If treatment was successful, follow the patient as indicated. ii. If treatment was unsuccessful, re-evaluate the patient, modify the differential diagnosis, and return to

step 1. b. If no, re-evaluate the patient, modify the differential diagnosis, and return to step 1.

6. If the diagnosis is uncertain: a. Consider initiating empirical therapy for serious or life-threatening conditions. b. Consider initiating empirical therapy for non-severe conditions when a diagnosis is likely and treatment is

accessible and likely to be effective.

Laboratory tests As the health care worker, you are on the first line of public health surveillance. You are responsible for recognizing potential diseases or conditions of significance for surveillance. You then must report potential diseases through the local or regional reporting system in your hospital. Often you will also need to collect laboratory specimens directly from the patient to confirm a diagnosis. The relevant disease chapters of the DCM and chapter 7 (procedures) and your national laboratory guidance describe procedures for laboratory samples for priority diseases of concern. Why is laboratory testing of specimens necessary for surveillance? Several diseases or conditions may present with similar signs and symptoms. For example influenza can present like many other viral illnesses. The initial presentation of viral haemorrhagic fevers can be very non-specific. Laboratory confirmation is necessary to accurately diagnose illness in an individual patient and to verify the cause (or etiology) of a suspected outbreak.

Laboratory tests In hospital: Point of care testing at bedside Hospital clinical laboratory Public health laboratory/central lab: Lab tests to send out


As a health worker become familiar with the procedures in your hospital for laboratory testing to confirm priority diseases and conditions. It is not always necessary to have these procedures memorized, but you should always know who to contact or where to find the information for the recommended procedure. Sometimes, depending on whether there is a known outbreak, confirmed outbreak, or seasonality the procedures and indications for laboratory testing will change.

For priority diseases and conditions know the following 6 points of information:

1. The diagnostic test for confirming the disease or condition 2. The specimen to be collected 3. When to collect the specimen 4 .How to prepare, store, and transport the specimen 5. When to expect the results 6. Where to go for additional information

Clear documentation by both the health worker and the laboratory are necessary when collecting and processing laboratory specimens for surveillance. The sample IDSR case based laboratory reporting form has 2 parts (see Appendix B). You may use a similar form in your hospital, or your hospital may have a different form that is used. Part 1 should be completed by the referring health worker and a copy should be sent to the lab with the specimen. Part 2, is completed by the lab and return to the district and clinician.

In the next chapters, we will discuss laboratory tests (point of care testing, use of routine hospital laboratory tests, and specific lab tests to send out) for severe acute respiratory infections and for suspect viral haemorrhagic fevers. Home study: Read through Appendix F on lab testing.

Group exercise 2 Case example: how to use the IMAI DCM differential diagnosis tables. Follow along with the case below as a group. Use your IMAI DCM to develop a differential diagnosis using the steps above. History of presenting complaint A 26 year old female presents with fever and vomiting for 4 days. She is brought in by her family because she is now very weak, lethargic, and confused. She has no known sick contacts, but had been visiting relatives in another village the previous week. Past medical history None


Physical exam VS: Temp 40.0 C Pulse 136 BP 110/50 RR 26 SpO2 98% on RA Gen: Pt is weak appearing, opens eyes but not following any commands HEENT: Normal CV: Normal Lungs: Normal Abdomen: Normal Skin: Normal Neuro: Moving all extremities equally, mumbling words 1. First, use the differential diagnosis tables to establish links between clinical

features and possible underlying diagnosis

What clinical features does this patient have? Some of the clinical features are listed below. Then go to the corresponding DDx table in the DCM. You may use DDx lists other than what is listed below. Use the tables and fill in a differential diagnosis list. Fever: Go to section 10.1.2 and review the DDx tables for fever 7 days or less without clinically obvious focus or site (Volume 2 page 22-24). Determine what conditions or diseases from the DDx table should be considered and fill in the table below. Altered consciousness: Go to section 3.4.1 and review the DDx tables for altered consciousness (Volume 1 page 131-134). Determine what conditions or diseases from the DDx table should be considered and fill in the table below.

Differential Diagnosis List In favour


2 Now, prioritize the list of possible diagnoses. In the last column of the table

above try to rank the possibly diagnosis in terms of probability from 1-15. Based on your limited information, some diagnoses may be equally likely. As you get more information you will narrow the differential and you may change the order of your initial ranking. You may also chose to prioritize certain diagnoses higher on the list if they are notifiable diseases or have a high mortality if not treated.

Next, determine what specific diagnostic tests to order. Go to the Quick Check, and sections 10.1.2 and 3.4.1 for reference. List 4 diagnostic tests that you would consider ordering on this patient. Does this patient need hospitalization? What clinical findings or diagnostic test results support a condition from the differential diagnosis list? You had ordered a urinalysis on this patient, which has now returned and shows leukocytes, nitrites, and bacteria. Your other tests have all returned normal. What treatment is indicated?

Is the diagnosis still uncertain?

After 2 days of intravenous antibiotics the patient appears to be improving. The urine culture shows E. coli bacteria. Is the diagnosis still uncertain? If so, reconsider your DDx list.


Group exercise 3 (or individual exercise)

Exercise- work in small groups or individually: Break into clinical team groups. Each team should pick a case description of a patient from the basket. Use the DCM differential diagnosis tables in the IMAI District Clinician Manual, make a list of all the other possible diseases or conditions that should be considered in an initial broad differential diagnosis when a patient presents with these signs and symptoms. What steps would you take to determine if the notifiable disease is more or less likely in your differential diagnosis? What would you do next? Discuss the results as a group with your facilitator.

1.3 Understand how the clinician’s role fits into IDSR at the health facility How do your clinical activities fit into the core IDSR functions and activities in your health facility? Review the IDSR Core Functions and Activities chart


Integrated Disease Surveillance (IDSR) CORE FUNCTIONS AND ACTIVITIES IN HEALTH FACILITIES

STEP 1: IDENTIFY

Use standard case definitions to detect, confirm, and record priority diseases or conditions

Collect and transport specimens for laboratory confirmation

Use local laboratory capacity to confirm cases or initiate confirmation of cases if possible

STEP 2: REPORT

Report case-based information for immediately notifiable diseases

Report summary data to next level

Report laboratory results from screening of sentinel populations

Report laboratory results to next level

STEP 3: ANALYZE AND INTERPRET

Prepare and periodically update graphs, tables, and charts to describe time, person, and place for reported diseases and conditions.

From the analysis, report immediately any disease of condition that

1) Exceeds an action threshold 2) Occurs in locations where it was previously absent 3) Presents unusual trends or patterns

Interpret results, initiate public health actions with local authorities.

STEP 4: INVESTIGATE AND CONFIRM

Take part in investigation of reported outbreaks

Collect, package, store, and transport specimens for laboratory confirmation

STEP 5: RESPOND

Manage cases and contacts according to standard case management guidelines (use the IMAI District Clinician Manual)

Link with contact tracing

Take relevant infection prevention and control measures

STEP 6: COMMUNICATE (FEEDBACK)

Communicate with community members about outcome of reported cases and prevention activities

Risk communication

STEP 7: EVALUATE

Assess community participation

Conduct self assessment on the surveillance and response activities

Monitor and evaluate programme targets and indicators for measuring quality of the surveillance system.

Monitor and evaluate timeliness of response to outbreaks

Monitor and evaluate prevention activities and modify them as needed

STEP 8: PREPARE

Participate in disaster and emergency preparedness and management committees

Participate in Rapid Response training

Prepare hospital- prepare to manage cases and infection control, by season

Conduct risk mapping of potential hazards

Conduct training of community

Participate in simulation exercises.

As the clinician, you may not be involved in all 8 steps of the IDSR core functions and activities, but you are an integral part to the success of the system. The next section will discuss your specific role as a health worker in the surveillance system.


STEP 1: IDENTIFY You have just reviewed how to identify notifiable diseases in the process of doing a differential diagnosis for your patient

STEP 2: REPORT Reliable and timely reporting is necessary for a surveillance system to be effective. There will be certain information that must be reported immediately, weekly, monthly, or quarterly. When to report diseases will depend on specific disease control activities in your district. Immediate reporting is necessary for epidemic prone diseases and other public health events of national concern, or when otherwise required under International Health Regulations. If an immediately reportable disease, condition, or event is suspected:

1. Make the initial report by the fastest means possible (telephone, text, fax, email), and then follow up the verbal report with a written report. The IDSR immediate case-based reporting is provided as an example of a written report. In your hospital you may be directly responsible for making the report to the surveillance officer and completing the form, or there may be someone designated in your hospital to make the report. You need to ensure that the person making the report has all of the necessary clinical information.

2. If a laboratory specimen is required, make sure the patients identifying information, matches the information of the case-based reporting form.

Review the following IDSR form in Appendix A. The information in the form should be collected on patients with suspected immediately notifiable diseases or conditions, or when certain events significant for surveillance are suspected.


CLASS DISCUSSION:

1. List a disease or condition that is considered immediately reportable/notifiable in your hospital.

2. Describe the system in your hospital for reporting these diseases and conditions. 3. Discuss any barriers in your hospital to timely and accurate case reporting. What

can be done to overcome these barriers? 4. Patients may sometimes be recognized during the QUICK CHECK triage, or

when considering the differential diagnosis for severely ill patients with difficult breathing or shock, as having an immediately reportable disease. What would be the system in your hospital to make sure that information is communicated as quickly as possible to the appropriate authorities?

STEP 3: ANALYZE AND INTERPRET As the health care worker, you may not be directly responsible for analyzing and interpreting surveillance data. However you will often receive the information back from the surveillance system and will need to know how to use that information in your clinical practice. Using data, the surveillance system will:

Observe trends over time

Alert health staff about emergent events or unusual patterns

Identifying areas of high risk

Identify characteristics that place a person at high risk for a disease or event. Data analysis will answer the following questions:

Have any priority diseases or public health event of concern been detected during the reporting period, or is an epidemic or unusual public health event suspected?

Of the cases suspected, how many were confirmed?

Where did the cases occur?

How does the current situation, compare to previous observation periods?

Is the trend stable, improving, or worsening?

Is the reported data, actually capturing the entire catchment area?

How timely is the data reported?


Case fatality rate (CFR) When data is analyzed, a case fatality rate is often calculated. The CFR is the number of deaths per the total number of reported cases. This rate is used to indicate whether a case is identified and managed promptly, indicate problems with case management, identify changes in the virulence or drug resistance of a pathogen, and compare case management in different catchment areas and districts. To calculate a CFR:

1. Calculate the total number of deaths 2. Divide the total number of deaths by the total number of reported

cases 3. Multiply the answer times 100

Examples:

There are 50 reported cases of cholera in your district and there are 10 reported deaths from cholera. Calculate the CFR

There are 200 reported cases of influenza in your district and there are 5 reported deaths from influenza. Calculate the CFR.

Class discussion: CFR 1. How have you seen CFR used in your hospital or district? 2. Are there any diseases or conditions for which the CFR is reported

regularly to the health staff? 3. What would an increasing CFR mean? What are some reasons for an

increase in the CFR? 4. What would a decreasing CFR mean? What are some reasons for a

decrease in the CFR? 5. How is monitoring the CFR useful in an outbreak or epidemic situation?

After analyzing and interpreting the data, public health authorities may issue an alert threshold or an epidemic threshold for public health action.

An alert threshold is reached where there is one suspected case (for an epidemic prone disease or a disease targeted for elimination or eradication), or when there is an unexplained increase for any disease or an unusual pattern. An alert threshold usually means that more investigation is needed. The Quick Check triage team should always be aware when there is an alert threshold, since they are the first line of contact for patients with the hospital.

An epidemic threshold triggers a definite public health response when the data indicates that there is a potential epidemic situation. Emergency response


activities may be recommended, and there may be changes in infection control practices based on the epidemic threshold.

STEP 4: INVESTIGATE AND CONFIRM Health workers are often on the front lines of an outbreak investigation or other public health event. The responsibility for investigation will depend on national and local policy. Health staff should be aware of when there is an outbreak investigation in their hospital or district. You should also immediately report any suspected cases, when even one case triggers a response or when there seems to be an unusual number of cases or severity of cases. Rumors of an outbreak may circulate in the community, and result in increased numbers of patients seeking health care. As the health care worker you will need to help control community fears and help communicate reliable information to patients and other staff.

What training in outbreak response have you and your colleagues received?

What needs can you identify in your hospital to be able to investigate and confirm possible outbreak or epidemic situations?

You may identify a patient who meets a case definition during an outbreak investigation. In addition to infection control and case management, also ask the patient or patient’s family the following questions that can assist in the investigation and record the answers:

Where do you live?

When did the symptoms begin?

Who else is sick in your home, school, workplace, village, neighborhood?

Did you attend a funeral or care for someone ill?

Where have you travelled to recently?

Where have you been living during the past 3 weeks prior to the onset of symptoms?

Were you visited by anyone within the last 2 weeks?

Have you been in contact with sick or dead poultry or birds or animals recently?

What vaccines have you received recently?

STEP 5: RESPOND Good outbreak response includes strengthening case management and infection control measures.



respiratory illness, etc [IMAI Management Septic Shock/Respiratory Distress]




As a clinician, your response to an outbreak involves both this individual care of the patient with appropriate infection control, as well as participation in your hospital’s overall response. The emergency department and wards may need to prepare for increased numbers of patients or patients with increased severity of illness. The entire hospital team should work together to ensure:

All clinical staff knows the recommended protocols for case management of outbreak disease.

Clinicians receive results of laboratory confirmation where necessary

An area is identified to accommodate a large number of patients in the event of a large epidemic.

Standard operating procedures are in place including infection control

Infection control precautions are in place: strictly enforce standard precautions for all patients; choose the appropriate additional precautions and provide the PPE and patient isolation required for this (for example, isolation ward, access to personal protective equipment).

o You and your colleagues should always be using standard precautions and should know what additional infection control precautions are needed for each transmissible disease you may encounter. See the Table on the next page on precautions by suspected organisms and the summary of droplet, airborne and contact precautions.

Make necessary medicines, other treatment supplies, and supplies for infections prevention and control available.


Table: Precautions by suspected organisms – examples Additional precautions by suspected organisms – IN ADDITION TO STANDARD PRECAUTIONS

Additional precautions:

Disease or organisms include

Droplet precautions Acute respiratory diseases (ARD) transmitted through large droplets including:

o influenza (seasonal, pandemic) and o ARD with no pathogen identified, no risk factor for

tuberculosis or ARI of potential international concern (influenza-like illness= ILI)

Pneumonic plague

Neisseria meningitides for first 24 hours of antimicrobial therapy

Mumps (infectious parotitis)

Diphtheria- pharyngeal

Pertussis (whooping cough)

Contact precautions Vibrio cholera, Shigella species

Ebola/Marburg, Crimean-Congo haemorrhagic fever

Resistant bacteria (such as methicillin-resistant Staphylococcus)

Clostridium difficile

Different forms of gastroenteritis

Diphtheria- cutaneous

Herpes simplex or localized zoster

Contact plus droplet precautions

• Adenovirus, para-influenza, RSV • Ebola/Marburg, Crimean-Congo haemorrhagic fever with

respiratory symptoms • Avian influenza (e.g. H5N1, H7N9) • SARS, MERS-CoV

Airborne precautions

• Infectious pulmonary TB- especially MDR • Measles • Varicella (chickenpox) (not localized zoster) • ARIs, whenever performing aerosol-generating procedures such

as endotracheal intubation or bronchoscopy

Contact plus airborne

When a novel ARI is identified and the mode of transmission is unknown, it may be prudent to implement the highest level of IPC precautions whenever possible, including the use of particulate respirators, until the mode of transmission is clarified.

No additional - standard precautions only

Common bacterial respiratory infections caused by organisms such as Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia spp., Mycoplasma pneumoniae.

Most blood-borne pathogens including HIV and HBV.

Anthrax

Droplet precautions Additional precautions for infections transmitted by large droplets A respiratory aerosol of certain infections produces large particles or droplets (>5 μm in diameter) that typically remain suspended in the air for a limited period of time and settle within 1 m (3 feet) of the source.


What to do in addition to standard precautions when such droplet transmission is possible.

All health workers for all patient care within 1 meter of the patient should wear a medical mask or surgical mask (tight fitting).

Use single rooms for infectious patients. Otherwise, cohort patients with same suspected etiology. If not possible, place patient beds at least 1 m apart and arranged to keep a distance between patients.

Airborne precautions Additional precautions for infections transmitted by small droplet nuclei Smaller particles (small droplet nuclei ≤5 μm in diameter) evaporate quickly; the resulting dried residues settle slowly from the air, and remain suspended in the air for variable lengths of time. What to do in addition to standard precautions when airborne transmission is possible. Particulate respirator, e.g. N-95 or similar

Use adequately ventilated single rooms (≥12 ACH). If single rooms are not possible, cohort patients with the same diagnosis. Airborne precaution rooms can be naturally or mechanically ventilated, with adequate air exchange rate of at least 12 ACH and controlled direction of air flow.

Contact precautions Additional precautions for infections transmitted by contact Contact transmission can be direct (direct body surface to body surface contact and physical transfer of micro-organisms) or indirect (e.g. contaminated hands or equipment that carry and transfer the micro-organisms). What to do in addition to standard precautions

Gloves and gowns for all patient care.

Use disposable equipment or dedicate equipment for patient care. If equipment must be shared among patients, clean and disinfect it between each patient use.

Use single rooms. Otherwise, cohort patients with the same diagnosis. If not possible, place patient beds at least 1 m apart. For pathogens of potential international concern, a single room is more important.

Class discussion What emergency response plans are in place in your hospital?

Who is responsible for organizing a response in your hospital?


Group exercise 4: There is a cholera epidemic. A 19 year old female presents to your hospital. She is carried in by her family and minimally responsive. When you feels her pulse it with fast and weak.

Would you triage this patient as a Quick Check E, P, or Q?

You assess the patient for dehydration. The patient is lethargic and not able to drink.

How would you classify the patient’s level of dehydration?

The patient weighs 60 kg. Use the IMAI DCM to help guide your management and describe how you would manage this patient.

What type of fluid would you administer and by what route would you administer the fluid?

How much fluid would you give in the first 30 minutes?

How much fluid would you give in the next 2 ½ hours?

What other diseases or conditions would be included in the differential diagnosis?

You are in charge of the casualty ward and expect a large number of cholera patients to be coming into your facility. Think about the actions required for this one patient. Now think about what you will need to do if large numbers of sick patients arrive. Use the IDSR rapid reference guide as a resource.

What actions would you take to prepare?

Should stool specimens be taken from patients? If so, do all patient with suspected cholera need to be tested?

STEP 6: COMMUNICATE During an outbreak investigation clear communication is critical. As the front line health worker you are responsible for communicating potential cases through the surveillance system, receiving communication and feedback on essential public health actions that


need to be implemented, and communicating with the affected community, your patients, and other staff members. Communication can be challenging during an outbreak when information may not be readily available, suspected cases may not be confirmed, and rumors may be circulating. Information summary sheets can be useful to ensure the correct information is communicated to the health staff, and the health staff has supplied accurate information to the public health authorities. In the case of an outbreak, controlling rumors in the community is very important. You, as the health care worker, will often be the first point of contact to identify these rumors. Make sure you communicate them to the appropriate public health authorities, so they can be addressed with public health announcements and bulletins.

STEP 7: EVALUATE Routine evaluation is necessary to determine if the surveillance system is meeting its objectives, and what improvements need to be made. As a member of the health staff, you may not be directly responsible for the evaluation of the surveillance system, but you should become familiar with how the system is evaluated and some of the terminology that is used for evaluation. Most surveillance systems have identified targets and indicators that are used to measure the achievement or progress of a particular program or activity. These indicators may be used based on national goals and with specific plans for improving surveillance in a district. An example of IDSR core indicators includes:

Proportion of health facilities submitting reports on time to the district

Proportion of cases of suspected outbreaks of epidemic-prone diseases notified to the provincial level within 2 days of surpassing the epidemic threshold.

The IDSR Checklist for supervising surveillance and response activities at the health facility is in Appendix xx. As a member of the health staff, what is your role in any of the activities described?


CLASS DISCUSSION:

What are some of the surveillance goals used in your hospital or district?

What targets or indicators are used?

How is that information communicated back to the health staff?

Describe a surveillance objective in your district. Are the goals being met? What are some barriers to meeting the surveillance goals?

STEP 8: PREPARE Preparation is an ongoing process. As a health care worker in the district, preparation involves:

Staying up to date on current case definitions and being able to distinguish notifiable diseases from other diseases with similar presentation

Capacity to provide correct case management- both emergency triage assessment and treatment, using the Quick Check, and correct case management (of both severe and non-severe patients)

Making sure there are adequate supplies both for case management, for priority laboratory tests, and personal protection equipment and other infection prevention and control supplies.

Making sure you understand the system for case reporting and appropriate forms are submitted when necessary

Taking part in disaster preparedness activities

Use standard precautions at all times and additional appropriate infection control interventions as needed.

What are ongoing preparedness activities in your hospital? What more needs to be done? Use the information that you have learned in this course, to help improve preparedness in your district.


CASE EXAMPLES You have been provided with the IDSR rapid reference section for several priority diseases targeted for surveillance by WHO/AFRO (ANNEX) and the IMAI District Clinician Manual as a reference for diagnosis and case management. Divide into small groups and go through the following case examples. You will discuss the answers as a group.

CASE 1:

You are the charge nurse on the adult medical ward. Over the past week, you have had 10 patients admitted with suspected meningitis. Two cases have been confirmed Neisseria meningitidis. You are concerned that there may be a meningitis outbreak in your district and need to update your staff, but have not heard anything from the hospital public health nurse.

1. At triage, what Quick Check emergency or priority signs should prompt screening for meningitis?

2. If a patient with suspected meningitis is identified at triage, what infection control measures should be taken immediately?

3. One of your nurses asks you what is the IDSR standard case definition

they should be using for suspected and confirmed cases of meningitis. What do you tell her?

4. A 23 year old female presents with lethargy, fever, and rash. Neisseria


meningiditis is suspected. In addition to caring for the patient and stabilizing any emergency conditions, you need to report the case to the public health coordinator. What information will you need to gather to fill out the case report form? List all the questions you will want to gather from the patient or family, which have implications for clinical surveillance.

5. List what other diseases or conditions should be included in the differential diagnosis of this patient.

6. You anticipate that there may be more cases of meningitis presenting in

the next few weeks. List 2 medications or supplies may you need to order in increased quantities to care for these patients or protect your staff?


CASE 2:

You are working in the casualty ward and a 26 year old male is brought in by the family. The patient lives in a remote area in the district and the family has traveled almost 8 hours by foot to bring the patient to the hospital. When the patient arrives he is unconscious. The family states that he initially just had a fever and felt very weak, but has become much more ill when they were on the way to the hospital. There have been several deaths in their community in the past 2 weeks that started as fever, so the family was scared to wait until the community health worker came to evaluate the patient at home. When you look at the patient he is in respiratory distress, and has a weak and fast pulse. He is unconscious. You immediately triage the patient as a Quick Check emergency. You notice that the patient has bleeding from the gums and purpura.

1. At triage, what Quick Check emergency signs does this patient have?

2. What immediate emergency treatments does this patient require?

3. If a patient with these symptoms is identified at triage, what infection

control measures should be taken immediately?


4. What is the differential diagnosis for this patient? Use the IMAI DCM to help form a differential diagnosis.

5. You are concerned that your patient may have a viral haemorrhagic fever.

You review the IDSR reference annex for the standard case definition.

What is the standard case definition for a suspected case of viral haemorrhagic fever?

What is the standard case definition for a confirmed case of viral haemorrhagic fever?

6. True of False. It is not necessary to report suspected cases of viral haemorrhagic fever until there are at least 10 cases which are suspected.

7. It is confirmed that your patient has Ebola virus and the public health nurse tells you an action threshold has been issued. Check which of the following actions are necessary:

__ Isolation wards should be established for additional suspected cases. __Patients with Ebola virus only need to be isolated for 1-2 days. __Strict viral haemorrhagic fever infection control practices should be instituted throughout the hospital.


CASE 3: You are working in the maternal ward in and a 28 year old female who is 7 months pregnant is referred from the health center for pre-term labor. She reports contractions and leaking clear fluid starting 1 day ago, and heavy vaginal bleeding today. For the prior 4-5 days she had fever, body aches, generalized weakness, anorexia, sore throat, nausea, vomiting, and diarrhoea. The patient also reports that they have rats in their home and she has been bitten several times. On arrival the patient is very weak and has Quick Check emergency signs of circulation. The blood pressure is 80/40 and the pulse is 120.

1. What first line emergency treatments should be given?

2. List all of the diseases or conditions in your differential diagnosis for this patient?

3. What infection control measures should initially be taken at triage? Does the patient need to be isolated?

4. You work in an area where Lassa fever is endemic, are there any other specific infection control precautions required?

5. If you are concerned for Lassa fever a blood sample can be sent to confirm the diagnosis. True or False?

6. Most patients with Lassa fever have mild illness or are asymptomatic. True or False?


Chapter 2: Surveillance: Influenza and Severe Acute Respiratory Infections

Learning objectives:

1. Understand the basic principles of clinical surveillance for influenza and acute respiratory infections

2. Understand the role of the health worker in clinical surveillance for influenza and acute respiratory infections.

3. Learn how to use the IMAI District Clinician manual to incorporate surveillance into routine care of patient presenting with acute respiratory symptoms.

4. Learn appropriate laboratory testing for severe ARI. 5. Case management and infection control for severe ARI.

2.1 Principles of clinical surveillance for influenza and acute respiratory infections

Respiratory infections are a significant cause of morbidity and mortality in the world. Surveillance to understand the epidemiology and seasonality of acute respiratory infections is essential to implement effective public health strategies for their prevention and control. These strategies include the use of vaccines and antivirals and infection control. Common pathogens causing respiratory infection include:

Streptococcus pneumoniae

Hemophilus influenza b (Hib)

Staphylococcus aureus

Respiratory Syncytial Virus (RSV)

Measles virus

Human parainfluenza virus (PIV-1, PIV-2, PIV-3)

Influenza virus

Varicella virus Respiratory infections can cause significant morbidity and mortality in a community when:

The virus is new to the community (i.e. very few members of the community have been previously exposed to the virus)


An existing virus has mutated and is a new strain There can also be significant morbidity and mortality from respiratory infections in vulnerable groups such as those who are very old and very young, malnourished, or immunosuppressed. Those who are living in close quarters with poor sanitation and hand washing facilities, such as in refugee camps, are also at increased risk. There are also uncommon, severe respiratory infections from bacterial diseases. These include:

Plague

Anthrax

Why surveillance for acute respiratory infections is important in Africa Respiratory infections cause significant morbidity and mortality in Africa particularly among infants and children, and the elderly. Improving the understanding of the epidemiology and seasonality of respiratory infections in Africa, is important for implementing public health strategies such as vaccinations, antivirals for treatment, and infection control. Respiratory infections due to new organisms that have epidemic or pandemic potential are of special concern. An influenza pandemic occurs when a new Influenza A virus emerges with sustained human to human transmission and in populations with limited immunity. Pandemics have occurred in the past in 1918, 1957, and 1968. It is predicted that a new pandemic could kill over 60 million people, most in developing countries. Successful containment of a pandemic depends on early recognition of a new virus

subtype capable of sustained human-to-human transmission. In addition to viral illnesses, each year several countries in Africa report outbreaks of plague and anthrax. Pneumonic plague can spread person-to-person, whereas there has been no documented person-to-person transmission of pulmonary anthrax (and

most cases are cutaneous). Both are notifiable diseases.


2.2 Role of the health worker in clinical surveillance for influenza and acute respiratory infections Community health centers and district hospitals are usually the first point of contact with the health system for patients with severe acute respiratory infections. As the initial point of treatment for these patients, these health facilities are the first place to rapidly identify changes in patterns and epidemiology of respiratory illness and institute public health strategies for prevention, treatment, and control.




Using the Quick Check and ETAT, rapid screening at triage should be used identify patients who may have Influenza like illness (ILI) and Severe Acute Respiratory Infections (SARI). ILI is a subtype of SARI. It is important to identify these patients early in their hospital course, so that precautions can be taken to avoid exposure of others and make sure the patients are given appropriate care. When influenza is occurring, there are often many cases. For routine indicator-based surveillance it is not necessary to recognize every case of influenza, but it is important to recognize trends and unusual levels above expected baseline levels of disease. 2.3 Use the IMAI District Clinician Manual to consider the DDx acute respiratory infections




Discuss/report if possible notifiable disease Consider the differential diagnosis for a patient with a cough and fever (from Section 10.6 in the IMAI DCM). What do the clinical features in your patient suggest are the possible diagnoses? Considering the possibilities may require further clinical exam and additional lab tests.


DDx: Difficult breathing or cough – with fever

Disease or condition In favour

Acute bronchitis Shortness of breath mild, if present Cough may be productive Acute onset Mild or absent fever No chest findings on physical examination except wheezing in asthmatics Normal chest X-ray

Pneumonia Shortness of breath mild to severe Productive cough with bacterial pneumonia and non-productive cough with non-

bacterial pneumonia (but considerable overlap) Acute onset hours to a few days Focal chest pain with deep breaths or coughing Fever and chills Fast breathing (>30 breaths/min) If SBP <90, patient has septic shock (see Section 3.1.5) Focal signs – bronchial breath sounds, crackles, or rales on auscultation With pleural effusion, dullness to percussion and decreased breath sounds over

affected side Chest X-ray may show focal or diffuse infiltrates particularly in non-bacterial

pneumonia

Uncomplicated influenza (may be pandemic or seasonal) see Section 11.17

Influenza known or suspected to be circulating Fever Cough Sore throat Rhinorrhoea or nasal congestion Headache Muscle pain or malaise Gastrointestinal illness such as diarrhoea or vomiting If shortness of breath, consider influenza with pneumonia (below)

Influenza with pneumonia see below and Section 11.17

Influenza known or suspected to be circulating History of influenza-like illness Risk factors: age <2 years or ≥65 years, pregnancy (up to 2 weeks postpartum),

any chronic disease (pulmonary, cardiac, diabetes, metabolic, renal, hepatic, hematologic, or neurologic) or immunosuppression (HIV, malignancy, chemotherapy)

Shortness of breath, pleuritic pain, cough, coloured sputum, fever Rapid respiratory rate Bilateral crackles, possible wheezing Chest X-ray may show focal or diffuse infiltrates Note: Both uncomplicated influenza and influenza pneumonia may be complicated by secondary bacterial pneumonia with features of pneumonia as described above.

Pulmonary tuberculosis see Section 15

Shortness of breath mild to moderate but occasionally severe Possible history of exposure to a person with TB Usually gradual in onset Cough with or without bloody or blood-tinged sputum Weight loss Fever, night sweats, occasionally chills Occasionally, chest pain Xpert MTB/RIF positive (or other nationally- or WHO-approved molecular test)

where available, sputum AFB positive (possible for AFB smear to be negative in patients with smear-negative pulmonary TB) – see Section 15.


Chest X-ray in patients without immune system compromise: unilateral or bilateral upper lobe infiltrates with or without cavitation; pleural effusion; miliary nodular pattern; other nodular opacities and fibrosis. A normal chest X-ray does not exclude TB.

Chest X-ray in patients with advanced immune deficiency (advanced immune system compromise, advanced HIV): non-specific pattern, with patchy infiltrates in the lower and mid lung zones; hilar and mediastinal lymphadenopathy may also be seen. Routine chest X-ray is not indicated for the diagnosis of TB. See Section 15.

Pneumocystis jirovecii pneumonia (PCP)

Shortness of breath mild initially but may become severe Subacute onset – days to weeks Non-productive cough Low grade to moderate fever Fast breathing >30 breaths/minute Nasal flaring Usually no findings on physical examination of the chest Chest X-ray bilateral diffuse infiltrates without lymph node enlargement or pleural

effusion. In mild cases, X-ray may be minimally abnormal or normal. CD4 cell count <200 Hypoxaemia (SpO2 <90) – particularly on exertion

Disseminated fungal

infection (endemic fungi vary from place to place) see Section 11.16

Shortness of breath is mild to moderate Subacute or chronic onset Cough may be productive or non-productive Generally moderate fever Weight loss Mild or no respiratory symptoms Lymphadenopathy and skin lesions may be present Enlargement of liver and spleen Chest X-ray – various abnormalities including focal or diffuse infiltrates, single or

multiple masses or nodules, hilar or mediastinal adenopathy, and pleural effusions

Immune reconstitution inflammatory syndrome

(IRIS) see Section 13

Shortness of breath if the lungs are involved HIV-positive with ART initiated in past 3 months, often with CD4 <50 cells/mm3

at initiation Common in patients with tuberculosis Cough, if present, is generally non-productive Moderate fever is common Physical examination of the chest depend on the manifestations of IRIS Extra thoracic lymphadenopathy commonly increases Usually an increase in CD4 cell count Chest X-ray may show worsening of infiltrates, pleural effusion, and increasing

intra-thoracic lymphadenopathy

Lung abscess Shortness of breath is mild if present Onset is subacute, generally over several weeks Fever is moderate Cough is productive with copious thick, yellow to brown, foul-smelling sputum Poor dentition may be present Chest may reveal crackles and coarse bronchial breath sounds over the involved

area Chest X-ray – focal infiltrate or mass with cavitation Note: Lung abscess is generally the consequence of a necrotizing pneumonia, but may also be secondary to endobronchial obstruction (e.g. from cancer).


Strongyloides hyperinfection see Section 11.36

Shortness of breath moderate or severe Risk factors – use of corticosteroids, other immunosuppressive drugs, or HIV

infection Acute onset Moderate fever Cough usually non-productive but may have blood-tinged sputum Abdominal pain, nausea, vomiting, diarrhoea may be present Skin rash possible Chest usually normal but wheezing may be present. Chest X-ray – diffuse infiltrates Peripheral eosinophilia may be noted Larvae on wet mount and Giemsa stain of sputum

Anthrax see Section 10.2

History of exposure to animals Oropharyngeal anthrax: eschar lesions in mouth, tongue, tonsils, or posterior

pharynx. Symptoms of sore throat, dysphagia, regional lymphadenopathy. Swelling of neck and anterior chest wall.

Inhalation anthrax: fevers, chills, sweats, fatigue, cough, shortness of breath, confusion, nausea and vomiting. Chest X-ray – mediastinal lymphadenopathy plus pleural effusions and pulmonary infiltrates.

Plague see Section 10.5

Sudden onset of fever, chills, headache, severe malaise Chest pain Difficulty breathing Cough with blood-stained sputum or haemoptysis Fulminant course (100% case fatality rate if not treated rapidly) May or may not have painful swelling of lymph nodes

Varicella pneumonia see Section 11.45

Pneumonia may complicate chickenpox in adults, particularly pregnant women and persons who are immunocompromised

Usually presents 1–6 days after the onset of rash Associated with cough, dyspnoea, fever, tachypnoea, and chest tightness,

although chest signs are often minimal The diagnosis is usually based on finding skin lesions characteristic of varicella

(see Sections 10.2 and 11.45) Chest X-ray – diffuse interstitial opacities

If influenza is a possibility, consider:

How does patient compare to standard case definitions? Health workers should become familiar with the case definitions used for surveillance of influenza2. Given that influenza presents with non-specific signs and symptoms similar to the presentation of many viral illnesses, these case definitions will not pick up every case of influenza and will also include some cases that are not caused by influenza. For indicator-based surveillance of influenza it is not necessary that the case definition accurately diagnose all patients. The goal of these surveillance case definitions is to identify trends and patterns necessary to determine the need for public health action.

2 WHO Global Technical Consultation: global standards and tools for influenza surveillance. http://www.who.int/influenza/resources/documents/technical_consulting/en/index/html.


INFLUENZA LIKE ILLNESS (ILI) A person, child or adult with:

measured fever of 38C AND

and cough

with onset within last seven days

SEVERE ACUTE RESPIRATORY INFECTION (SARI) A person, child or adult with:

measured fever of 38C

and cough

with onset within last seven days

and requires hospitalization

If the acute respiratory infection is severe and requires hospitalization, consider if it has any of the special features that suggests it should be reported immediately

:

SARI in health workers

SARI in patients exposed to dead birds or poultry

SARI in unusual clusters (multiple deaths in a village, more than one death in a family, unusually severe disease in a cluster of patients)

Recognizing this cases requires local awareness of what is happening in your district and asking about a history of exposure in unusual cases of severe respiratory infection. As the front-line health worker, there are certain situations where even one case should cause you to alert public health authorities immediately. This event-based surveillance should not wait for weekly or monthly reports, but should be communicated by the fastest means available as it needs to be investigated and confirmed urgently to prevent additional morbidity and mortality. 2.4 Laboratory testing for severe ARI Laboratory testing to determine the specific disease causing pathogen may not be indicated in all patients presenting with an ILI or SARI.

Why is laboratory testing sometimes not always recommended during an ILI disease outbreak? Sometimes routine collection and laboratory testing is only necessary during the beginning of a suspected outbreak. For example, when influenza is detected in a community, public health officials may initially recommend testing to determine the


strain and whether the strain is susceptible to antivirals. Once the strain is confirmed, they may no longer recommend laboratory testing for uncomplicated patients who meet the standard case definition since it is not cost effective and will not alter the clinical care. Another example is that laboratory testing may not be recommended if there is disease outbreak that is endemic to an area. However, if there is a change in the expected pattern of disease, public health authorities may then recommend laboratory testing.

Laboratory testing, however, may be indicated if there is an unusual presentation or pattern of disease, unusually severe disease, or for routine surveillance. Testing should be based on current recommendations in your hospital or region or alerts from public health authorities. When testing is indicated for influenza, the sensitivity and specificity of the test will depend on:

The type and quality of the specimen collected

Transport and storage conditions

The methods used in the laboratory performing the test

The type of test used. Influenza testing can be done using polymerase chain reaction (PCR) and viral culture. For PCR testing the specimens can be positive seven days or more after onset of illness, but it becomes much more difficult to detect the virus after seven days. Viral culture, which allows a detailed characterization of the virus, is most likely to be positive when taken within three days of symptom onset. For most patients oropharyngeal and nasal pharyngeal specimens are preferred to detect ILI. For very sick patients who are intubated, endotracheal tube aspirates or bronchoalveolar lavage should be used to collect the specimen. When collecting the specimen:

Collect and transport in viral transport media

Refrigerate immediately after collected

If the specimen cannot be processed within 48-72 hours, freeze the sample below -70 C. How to collect a respiratory specimen is shown in Appendix E.

2.5 Case management and infection control for severe ARI



respiratory illness, etc [IMAI Management Septic Shock/Respiratory Distress]



contact, droplet, aerosol precautions; PPE; isolation) In the Septic Shock/respiratory distress module in this course, you have learned about case management for severe respiratory distress and how to monitor the patient using the severely ill patient monitoring form. In addition to standard precaution, if you suspect seasonal or pandemic influenza, you should add droplet precautions- wear a medical mask, put a medical mask on the patient when outside his or her room, and use a particulate respiratory during any aerosol-generating procedure. This is more than you would do for a bacterial acute respiratory disease, where standard precaution are sufficient. If there is suspicion of a new influenza virus or SARS, use standard plus droplet plus contact precautions.

Reassess: Clinical progression, response to treatments Lab results Further information (discuss with other clinicians, district staff) Possible/probably diagnoses—


It is important to reassess patients hospitalized with acute respiratory infections. Sometimes a patient admitted with an apparent routine bacterial pneumonia will deteriorate and show clinical signs and lab results suggesting another diagnosis, and possible a notifiable disease. Reconsider the differential diagnosis, consider what other cases are occurring, discuss with other clinicians. The patient may still have a common diagnosis and are not responding due to an underlying condition or an organism not responding to the initial choice of antibiotics.


Group exercise 5:

Look at the Quick Check.

1. List the QC emergency signs that should prompt screening for ILI or SARI.

2. List the QC priority signs that should prompt screening for ILI or SARI.

Detailed additional information on the surveillance and laboratory testing of patients with ILI and SARI can be found in the WHO Global Influenza Surveillance Network: manual for the laboratory diagnostic and virological surveillance of influenza3.

Case 4: Public health authorities in your district have issued an epidemic threshold for a new strain of influenza. You work in the casualty ward of the district hospital.

1. What actions might your hospital now need to now take to respond?

2. What changes in your own clinical practice may be necessary?

3. How would triage using the Quick Check be affected?

3 http://www.who.int/influenza/resources/documents/manual_diagnostics_surveillance_influenza/en/index.html


2.6 Practical approach to surveillance for ARI in the district hospital We have discussed why surveillance is important, and how surveillance is used to monitor acute respiratory infections. Using case examples, we now will discuss a practical approach to surveillance that the health workers in a district hospital can use in their everyday practice when treating patients. Use the stepwise approach outlined in the previous module when going through the following case examples. As the health care worker, you will likely not be responsible for all of the 8 steps, however you should be aware of your role in the process and who is accountable for the other tasks. Use the IMAI DCM and the rapid reference annex as needed for disease specific information.

CASE 5:

You are the head nurse in the adult casualty ward. You are reviewing the admissions for the previous 4 days and notice that 25 adult patients were admitted with a respiratory illness or pneumonia, and 4 of those patients went to the intensive care unit. You decide to look at the previous weeks admissions and note that over the past 2 weeks, the number of patients admitted with respiratory illness has increased. Normally, you would only see about 10 cases of pneumonia admitted per week during this time of the year. Using the 8 step approach to surveillance, information from the IMAI DCM, and the information in the IDSR rapid reference annex, answer the following questions: STEP 1: Identify

You determine that there is potential for an influenza outbreak. You want to make sure that your staff is up to date on the standard surveillance case definitions for ILI and SARI. What are these case definitions?

What steps would you take to re-educate your staff on the case definitions?


One of your nurses asks if they should be collecting respiratory cultures. Currently you have not been routinely collecting respiratory cultures in the casualty ward. How would you determine which patients should be tested and what method of specimen collection would you use?

Your staff member tells you she does not know how to correctly collect a respiratory specimen. List the steps that she needs to follow for one method of collection.

List other diseases or conditions that should be included when you are developing your differential diagnosis for a patient who presents with an ILI.

STEP 2: Report

You realize that you should report your concerns to the public health authorities. Who would you contact and what would be the best method to communicate the information from your hospital?


You decide to start filling out the IDSR case based reporting forms for admitted patients with pneumonia or respiratory illness. Check which of the following points of information should be included on the form:

__ The date the symptoms first began __ The patient’s residence __ HIV status __ Laboratory results __ Vital signs

STEP 3: Analyze and interpret

You receive a report from the public health nurse that an “alert threshold” has been issued for your district for Influenza like illness. Several staff members are concerned and ask you what an “alert threshold” means. What would you tell them?

Review the IDSR rapid reference for influenza like illness. What are 2 reasons that an alert threshold may be issued for ILI?

Now review the IDSR rapid reference for SARI. What are 2 reasons that an alert threshold may be issued for SARI?

STEP 4: Investigate

You decide it is important that your staff is collecting relevant information for an investigation on the increase in influenza like illness in your district. You want to remind your staff of the important questions to ask and decide to have the staff screen all patients with symptoms of ILI or SARI in the casualty ward. List at least 2 important questions you would have your staff ask at all patients meeting the possible case definition of ILI or SARI.


What are some steps you can take in your casualty ward to help assist staff in remember to ask and document answers to these important questions?

STEP 5: Respond

You decide that you need to make sure your standard operating procedures for infection control are up to date. Are there any additional infection control measures you would take in your emergency department at this time?

Patients with suspected ILI or SARI are not currently isolated in your casualty ward and there is no space inside to isolate them. What are some solutions that you can think of to help minimize the exposure of staff and patients with ILI or SARI while getting triaged and being treated in the casualty ward?

STEP 6: Communicate

You have heard rumors circulating in the community that there is a deadly influenza virus circulating and many patients are dying. While you have seen an increase in the number of patients with pneumonia and respiratory illness, and more patients have been admitted to the hospital, there has not been an unusual number of fatalities from ILI or SARI in the past few weeks. You decide that you need to prepare your staff to answer questions about these rumors to patients and other staff members. You decide to prepare a list of possible questions recommended answers to circulate to your staff. Write two questions that you think your staff needs to be prepared to answer. Then write what you feel would be a truthful and clear response for the staff member to answer. Your facilitator will help get you started.


STEP 7: Evaluate

Your hospital has been monitoring the case fatality rate of patients admitted with ILI or SARI and will begin reporting this information on a weekly basis to your staff. One of your staff members ask what the case fatality rate means. What definition would you give for a case fatality rate?

How is a case fatality rate calculated?

STEP 8: Prepare

After several weeks it seems as though the numbers of patients with acute respiratory illness or pneumonia is returning to normal levels for this time of the year, and an alert threshold is no longer in effect. However, you have realized that your department needs to be better prepared for future events. List 1 planning activities that you would propose to your hospital administration your staff takes place in over the next 6 months for influenza emergency preparedness.


CASE 6:

You are the medical officer working in the casualty ward. A 38 year old male presents with fever and severe respiratory distress. The patient lives about 20 km from the hospital on a farm. The man’s wife tells you that two cousins who work on the farm are also sick in their homes with a cough, fever, and diarrhea for the past 2 days. STEP 1: Identify

You have heard about a strain of influenza called H5N1 in other districts in your country, but you have never had a case in your district. You want to review the standard case definition. Review the IDSR rapid reference guide. Does this patient meet the standard case definition for a suspected H5N1 case?

What would be required for a confirmed case of H5N1?

While determining if the patient is a suspected or confirmed case of H5N1, what immediate infection control precautions would you take?

STEP 2: Report

You realize that you should report your concerns to the public health authorities. Who would you contact and what would be the best method to communicate the information from your hospital?

STEP 3: Analyze and interpret

Three days after you report the event an alert threshold is issued for a suspected case of influenza caused by a new subtype or to an unusual event of severe acute respiratory infection. Your patient had died on hospital day 2. List at least 2 actions that staff in your hospital will take in response to this alert threshold. Refer to the IDSR rapid reference annex.


In one week, you are informed that your patient did in fact have confirmed influenza H5N1 and an action threshold has been issued. List at least one activities that would now be required in your hospital or community as a result of this action threshold being issued. Refer to the IDSR rapid reference annex.

STEP 4: Investigate

You are told to collect laboratory specimens on any patients who present with suspected influenza. You also are testing their family members. What type of specimen would be the highest priority to collect?

Ideally within what time from should the specimen for a patient with suspected influenza be tested?

Your colleague has told you to not start antiviral treatment on a very sick patient with suspected influenza until a nasal specimen is collected. However, your hospital has run out of the appropriate culture medium. True or False. You should delay starting treatment until you can locate the culture medium?

STEP 5: Respond

You decide that you need to make sure your standard operating procedures for infection control are up to date. Are there any additional infection control measures you would take in your emergency department at this time?


STEP 6: Communicate

Your hospital has directed you to educate patients about the possibility of H5N1 in the community, and what steps they can take to protect themselves. List two things you would tell your patients regarding H5N1.

STEP 7: Evaluate

After 3 weeks 10 patients have been admitted to the hospital with confirmed H5N1, and 6 of those patients have died. What is the CFR?

STEP 8: Prepare

After six weeks it seems as though the H5N1 outbreak is under control and an action threshold is no longer in effect. However, you have realized that your department needs to be better prepared for future events. List one planning activity that you would propose to your hospital administration your staff takes place in over the next 6 months for emergency preparedness.


Assessment Questions

1. True or false. A blood test is the laboratory test of choice for a patient with suspected influenza.

2. True or false. In 2009 the WHO declared a global pandemic of Influenza H1N1

3. True or false. An influenza virus that is new to a community or that has mutated and is a new strain would be expected to cause a significant number of infections in a community.

4. True or false. The most common form of transmission of Influenza A (H5N1) is through person-to-person contact.

5. True or false. In 2003 SARS caused a significant number of nosocomial infections.


Chapter 3: Viral haemorrhagic fever Viral haemorrhagic fever (VHF) is a general term for a severe illness, sometimes associated with bleeding, that may be caused by a number of viruses. The term is usually applied to disease caused by: 1. Arenaviridae (Lassa, Lujo, Junin, Guanarito, Sabia and Machupo) 2. Bunyaviridae (Crimean-Congo Haemorrhagic Fever - CCHF) 3. Filoviridae (Ebola and Marburg) 4. Flaviviridae (Omsk haemorrhagic fever, Kyasanur forest disease and Alkurma haemorhagic fever) This chapter is focused on specific VHFs-- Ebola, Marburg, CCHF, and Lassa fever -- that occur in Africa and have risk of person-to-person transmission. It does not address the management of other viral infections, such as dengue, Rift Valley Fever and yellow fever, that also have haemorrhagic manifestations, but do not have direct person-to-person transmission. See the relevant Sections in the IMAI DCM for dengue and yellow fever. VHFs can be encountered at any time and require associated preparedness and planning. While VHF outbreaks begin in the community, patients with VHF ultimately present to their local health facility for care and treatment. In the initial stages of an outbreak (before the outbreak has been recognized), patients with VHF present to their local health facility with a constellation of symptoms difficult to differentiate from other common infections (e.g., malaria, typhoid, bacterial sepsis). Thus, without maintaining standard infection prevention and control precautions at all time, and a high level of suspicion for VHF in the differential diagnosis, health staff and other patients are at risk for acquiring infection.




A good surveillance system should keep you aware of whether an outbreak has occurred in your area. You also know what VHFs occur in your country or region (although this can change); for example, Lassa fever has only been reported from West Africa which, until recently, had not experienced an Ebola outbreak. It is difficult to diagnose the first case of VHF in an outbreak.


Prior to an outbreak being identified, the first clue will often be a history of exposure to contacts who have been severely ill or who have died suddenly, or unfortunately it could be a health worker who becomes severely ill with a suggestive clinical presentation after treating a patient If other VHF cases have occurred, it is important to not only do a good clinical assessment but to also assess whether there has been a history of exposure. One of the most important aids in making the diagnosis is eliciting a history of exposure within the potential incubation period (2 to 21 days for Ebola/Marburg; 3 to 7 days for CCHF, 6 to 21 days for Lassa fever.) The diagnosis of VHF is based on 3 components: 1. History of exposure 2. Detailed clinical assessment 3. Laboratory investigations History of exposure

Ebola/Marburg CCHF The most common exposure is to blood or any other

body fluid (e.g. excreta, vomit, sweat) from a known

or suspected Marburg or Ebola case (dead or alive),

usually in providing care or attending a funeral.

People typically most at risk are family members,

caretakers, traditional healers, and those

participating in traditional burial rituals. Health

workers are a recognized high-risk group who

should be questioned about recent patient contact

and unwell colleagues.

Other exposures are:

Contact with infected animals, usually apes and

bats, alive or dead, e.g. via handling or consumption

of infected bush meat, by going into caves

(Marburg), or fields close to fruit trees (Ebola) where

infected bats roost. (Note: the virus is easy to

destroy by heating so well cooked meat is

considered virus free.)

Being breastfed by a woman with Ebola or Marburg

is considered an exposure as Ebola virus has been

shown to be present in breast-milk. As it is unclear

how long it remains present, being breastfed by a

convalescent patient is also considered a risk.

Being the sexual partner of a known or suspected

male case, as the virus remains present in semen

up to 3 months after clinical recovery.

Coming into contact with contaminated items, e.g.

medical material, eating utensils, linens from

infected patients. (Note: the virus cannot survive

very long in non-organic material, but can be

present in material contaminated with body fluids

Farmers, abattoir workers, veterinarians, and health workers are included in the occupational risk groups.

Transmission of the CCHF virus can occur to humans in several ways:

Bite from an infected tick or crushing a tick against the skin. Ixodid (hard) ticks, especially those of the genus, Hyalomma, are both a reservoir and a vector for the CCHF virus. Numerous wild and domestic animals, such as cattle, goats, sheep and hares, serve as amplifying hosts for the virus.

Contact with the blood of an infected animal. Animal herders, livestock workers, and slaughterhouse workers in endemic areas are at risk of CCHF.

Person-to-person transmission through contact with infectious blood or body fluids, in the community or in hospitals.

Documented spread of CCHF has also occurred in hospitals due to improper sterilization of medical equipment, re-use of injection needles, and contamination of medical supplies

Possible horizontal transmission from a

mother to child has been reported. The risk of exposure during breast feeding, however, is unclear


(like needles or other medical material that is

reused, dirty bed sheets...)

Receiving healthcare from a provider who is also

treating Ebola or Marburg patients and who is not

taking appropriate infection control measures.




Discuss/report if possible notifiable disease

Differential diagnosis (DDx)- what are the possible diagnoses? Health workers should consider VHF in any patient with an unknown etiology as part of the differential diagnosis with more common causes of fever in that setting.

Many infectious and even non-infectious diseases can mimic VHF, especially early in the illness. It is very common to misdiagnose VHF, initially diagnosing more common conditions including malaria, bacterial sepsis, meningococcaemia, typhoid). The differential diagnosis of a severe febrile illness should also include African tick-bite fever and other rickettsial illness. The differential diagnosis of fever in adults is large and should be adjusted geographically—see Section 10.3 in IMAI DCM. The presence of certain clinical features can help rule out VHF4:

Haemorrhage is almost never seen in the first few days of illness. Early haemorrhage should suggest Its presence at this early stage should suggest an alternative diagnosis, especially meningococcaemia.

Prominent pulmonary symptoms or productive sputum are not typical of VHF, although secondary bacterial pneumonia can occur later in the illness.

Although conjunctival injection and sub-conjunctival haemorrhage are frequent in VHF, they are not accompanied by itching, discharge or rhinitis. The presence of these symptoms should suggest a more common viral upper respiratory tract infection, adenoviral or bacterial conjunctivitis or allergic rhinitis.

Except for yellow fever, VHF do not usually present with jaundice; this should suggest another diagnosis or a complicating factor.

4 Blumberg L, Enria D, Bausch DG: Viral haemorrhagic fevers, in Manson’s tropical diseases, in press- 2014.


A positive test for malaria does not completely exclude VHF, especially if the patient is not responding to antimalarial drugs, as parasitaemia may be common in holo-endemic areas for malaria.

How does patient compare to standard case definitions? Standard case definitions for VHF have been developed to identify ‘alert’, ‘suspect’, ‘probable’ and ‘confirmed’ cases before and during an outbreak. Once ‘alert’ cases present to the medical personnel, however, the ‘alert’ label should be discarded and a determination made as to whether the person falls into the category of a ‘suspect’, ‘probable’ or ‘confirmed’ case. These case definitions may need further refinement to reflect clinical and epidemiologic features associated with a particular outbreak. (See Appendix A of the VHF pocket guide.) Initial response to a suspected or confirmed case of Ebola/Marbury, Lassa fever or CCHF is summarized in Secton 2.1.3 of the VHF pocket guide. Follow these steps. Report: Notify the district health officer or responsible district surveillance person immediately using the most urgent means possible. Laboratory diagnosis of Ebola/Marburg, Lassa fever or CCHF by sending out specimens to the reference laboratory (in Uganda, this is UVRI in Entebbe). Laboratory diagnosis can be difficult depending on the phase/time of presentation, duration of symptoms and previous exposure. The ability to confirm the diagnosis of VHF also requires highly specialized (with high biosafety infrastructure) reference laboratories that are centrally located. If blood tests have been performed, the following laboratory findings (in combination with the clinical presentation) are suggestive of VHF but not conclusive: thrombocytopenia; elevated hematocrit; and marked leukopenia. To confirm a VHF case, three laboratory tests can be run on blood samples (blood, serum or plasma) collected in patients suspected of having VHF, depending on the time of sample collection relative to the date of disease onset. 1) Polymerase chain reaction (PCR) provides evidence of the virus in the blood or tissues during the acute phase of the clinical disease. In certain circumstances, this test can be replaced by an antigen detection ELISA (it is less sensitive and more broadly cross- reactive); 2) IgM (antibody showing recent infection) during the early convalescence phase of disease (until approximately 8-12 weeks post onset of disease) 3) IgG (antibody showing past infection) persists for several months/ years after the acute phase of the clinical disease. This alone is not suggestive of recent or ongoing infection but can be utilized to confirm acute infection with paired samples showing IgG seroconversion.


Other investigations Due to the potential risk of transmission to laboratory workers, additional blood tests are not to be sent to the routine laboratory until the results of the VHF screen are known and negative. Point of care testing can be performed such as the RDT for malaria and other point of care equipment (such as the i-STAT® System) used by appropriately trained personnel wearing PPE. The latter, however, is unlikely to be available until an outbreak is declared and additional support is provided. The levels of virus increase during the first days of symptoms and this increase correlates with the patient’s degree of infectiousness. Respond: managing the patient and infection control


respiratory illness, etc [IMAI Management Septic Shock/SARI]




Case management of patients with VHF is supportive, with no specific treatments except ribavirin for Lassa fever and CCHF. Supportive management is summarized in the VHF pocket book:

Management of signs and symptoms (fever, pain, bleeding, respiratory distress, diarrhoea, vomiting, dyspepsia, convulsion, signs of hypoglycemia, anxiety, confusion) in Section 3

Management of septic shock: you have already learned this management in the IMAI module on managing severely ill patients with septic shock. (In the IMAI DCM, this is in Section 3.1; in the VHF pocket guide, in Section 4.)

Infection control: caring for a VHF patient requires both standard and contact precautions, with isolation of the patient and use of appropriate PPE; for patients with Ebola or Marburg respiratory symptoms, also use droplet precautions. See the VHF pocket book and wallchart illustrations on how to put on and take off PPE. You will do an exercise practice this.)


Any acute febrile illness not clearly due to a common pathogen or which is unresponsive to initial empirical therapy, should raise concern for VHF. This is especially true if there is unexplained bleeding or rapid deterioration of the patient’s condition.

Group exercise 6: You have just been informed that there is an Ebola outbreak in your district. You are in charge of the casualty area.

1. List 2 initial actions that you would take to prepare your hospital to receive cases

2. How would you isolate patients with suspected Ebola in your hospital?

3. How would you protect yourself and your staff? What new infection control measures may need to be put in place?

4. If a patient presents with signs and symptoms of Ebola, what other diseases or conditions should be considered in the differential diagnosis? Use your DCM differential diagnosis tables to help create a list.

Reassess: Clinical progression, response to treatments Lab results Further information (discuss with other clinicians,

district staff) Possible/probably diagnoses—



Assessment questions

1. What is the definition of surveillance?

2. List the 3 characteristics of good surveillance.

3. List at least 3 reasons why priority diseases for integrated disease surveillance in the African Region have been recommended.

4. What symbol is used to designate a priority disease in the IMAI District Clinician manual?

5. There are 1000 reported cases of cholera in your district and there are 50 reported deaths from cholera. Calculate the CFR.

.

Appendix A: Immediate case-based report form

62 – APPENDIX A Participant manual: Clinician’s role in disease surveillance and case reporting

5 Technical Guideline for Integrated Disease Surveillance and Response in the African Region, WHO-AFRO and CDC, 2010

IDSR Immediate Case-Based Report Form5 Variables / Questions Answers -Case n

1 Reporting Country

2 Reporting Province/Region

3 Reporting District

4 Reporting Site (Health Facility, Camp, Village…)

5 Disease/Event (diagnosis): *

6 In-patient or Out-patient?

7 Date seen at health facility (day/month/year) \___\___\___\

8 Patient Name(s)

9 Date of Birth (day/month/year) \___\___\___\

10 Age (….. Years/……Months/……Days).

11 Sex: M=Male F=Female

12 Patient’s residence: Town/City /Village

13 Neighborhood

14 District of residence

15 Urban/Rural? (U=Urban R=Rural)

16 Address, (cell)phone number … If applicable, name of mother and father if neonate or child

17 Date of onset (day/month/year) of first symptoms \___\___\___\

18 Number of vaccine doses received in the past against the disease being reported

19 Date of last vaccination \___\___\___\

20 Laboratory results

21 Outcome: (Alive, Dead, Transferred out, Lost to follow-up or unknown)

22 Final Classification: Confirmed, Probable, Compatible, Discarded

23 Date health facility notified District (day/month/year) \___\___\___\

24 Date form sent to district (day/month/year) \___\___\___\

25 Record's unique identifier

26 Person completing form: name, function, signature

* Disease/Event (Diagnosis): AFP, Anthrax, Cholera, Bloody Diarrhea, Dracunculiasis, Neonatal Tetanus,

Measles, Meningitis, Yellow fever, Dengue, Chikungunya, Viral Hemorrhagic Fever, Plague, Typhoid fever, Rabies, Smallpox, SARS, SARI, Maternal death, Influenza due to new subtypes, Adverse Effects following

immunization (AEFI), Any other event or disease of public health importance (Specify)

Appendix B: IDSR Case-based Laboratory Reporting Form

0

Participant manual: Clinician’s role in disease surveillance and case reporting APPENDIX B - 63

IDSR case based Laboratory Reporting Form Part I. Referring health worker to complete this form and send a copy to the lab with the

specimen

Variables Answers

1 Date of specimen collection (day/month/year)

2 Suspected Disease or Condition

3 Specimen type *

4 Specimen unique identifier **

5 Patient Name (s)

6 Sex (M= Male F= Female)

7 Age (….. Years/……Months/……Days).

8 Date Specimen sent to lab (day/month/year) \___\___\___\

Part II. Lab to complete this section and return the form to district and clinician

Variables Answers

1 Laboratory Name and location

2 Date lab received specimen (dd/mm/yyyy) \___\___\___\

3 Specimen condition: (Adequate/Not adequate)

4 Type of test(s) performed

5 Final Lab Result(s)

6 Date (dd/mm/yyyy) lab sent results to district \___\___\___\

7 Date Results sent to the clinician (dd/mm/yyyy) \___\___\___\

8 Date district received lab results (dd/mm/yyyy) \___\___\___\

* Blood, Plasma, Serum, Aspirate, CSF, Pus, Saliva, Biopsy, Stool, Uretral/Vaginal discharge, Urine, Sputum, food/water samples ** Same as the patient's identifer in the IDSR immediate case based

reporting form

Appendix C: Checklist for supervising surveillance and response activities at the health facility*

64 – APPENDIX C Participant manual: Clinician’s role in disease surveillance and case reporting

Health Facility:_______________________________________ Date of Supervisory Visit:________________________________________

Participant manual: Clinician’s role in disease surveillance and case reporting APPENDIX C - 65

___________________________________

*Technical Guideline for Integrated Disease Surveillance and Response in the African Region, WHO-AFRO and CDC, 2010

Appendix D: Further training and resources in surveillance for clinicians and managers

66 – APPENDIX D Participant manual: Clinician’s role in disease surveillance and case reporting

Related training and resources

Clinician’s role in disease surveillance and case reporting (this module)

IDSR technical guide—often country adapted Technical guidelines for integrated disease surveillance and response in the African Region. WHO and Centers for Disease Control and Prevention, 2010. Available at http://www.afro.who.int/en/clusters-a-programmes/dpc/integrated-disease-surveillance/ids-publications.html

IDSR District Level Training Course (July 2011). Modules: 0. Introduction 1. Identify cases of priority diseases, conditions and events 2. Report priority diseases, conditions and events 3. Analyze and interpret data 4. Investigate and confirm suspected cases, outbreaks and other events of public health importance 5. Prepare to respond to outbreaks and other public health events 6. Monitor, evaluation and improve surveillance and response 7. Supervise and provide feedback http://www.cdc.gov/globalhealth/healthprotection/ghsb/idsr/tools/training.html eLearning both online and using a CD will soon be available through CDC and WHO AFRO

Comprehensive course for teaching the content of the IDSR technical guidelines. Provides broader training in reporting and outbreak investigation, plotting epidemic curves, etc

VHF pocket guide --MoH Uganda: Clinical management of patients with viral haemorrhagic fever in Uganda: A pocket guide for the font-line health officer, Kampala, December 2013. -- WHO: Clinical Management of patients with viral haemorrhagic fever: A pocket guide for the front-line health worker. Interim emergency guidance- generic draft for West African adaptation, Geneva, April 2014—in English and French.

More specifics on clinical features, laboratory, infection control, case management.

WHO IMAI District Clinical Manual Country adapted if possible

Other training modules within the IMAI second-level learning programme

Appendix D: Further training and resources in surveillance for clinicians and managers

Participant manual: Clinician’s role in disease surveillance and case reporting APPENDIX D - 67

Appendix E: How to collect a respiratory specimen

68 - APPENDIX E Participant manual: Clinician’s role in disease surveillance and case reporting

Materials required:

1. Personal protective equipment (PPE):

PPE should be used according to national or local guidelines and will depend on the

clinical setting and whether cases of SARI or ILI/ARI are being sampled

2. Swabs:

use only sterile dacron or rayon swabs with plastic shafts (see picture below)

calcium alginate or cotton swabs, or swabs with wooden sticks may contain substances

that inactivate some viruses and inhibit PCR testing and should only be used if dacron or

rayon swabs are not available.

1. Tongue depressor (for the collection of throat swabs)

4. Plastic vials:

e.g. cryovial able to accommodate 2–3 ml of VTM

able to withstand temperatures of –70 C to –180 C (liquid nitrogen).

OR

5. VTM:

plastic vials containing 2–3 ml of VTM should be purchased ready made or prepared by

the national influenza laboratory

6. Indelible and alcohol resistant marker pen.

Appendix E: How to collect a respiratory specimen*

Participant manual: Clinician’s role in disease surveillance and case reporting APPENDIX E - 69

Collection of nasal and throat swabs

Standard precautions should always be followed, (i.e. hand hygiene and barrier protections

applied if appropriate – see above). When taking nasal or throat swabs, the swabs must be held

correctly. They should be held between the thumb and the first and second fingers with the shaft

protruding beyond the web of the thumb (like a pencil) (Fig. 2) and not between the thumb and

forefinger with the base in the palm of the hand (Fig. 3). The main reason for this is that if the

patient makes a movement in reaction to the swabbing, the swab will slide out of harms way if

held the first way (Fig. 4 – with the patient represented by the open gloved hand of the operator)

but not if held in the second way (Fig. 5). In this case discomfort would be caused and the patient

could be injured. In addition, control over the swab is much greater if it is held correctly.


Collection of posterior pharyngeal swabs (throat swabs):52

1. Hold the swab and with a sweeping motion, swab the posterior pharyngeal wall and

tonsilar pillars (see figure below).

– Have the subject say “aahh” to elevate the uvula.

– Hold the tongue out of the way with a tongue depressor (N.B. This procedure can

induce the gag reflex).

– Avoid swabbing the soft palate and do not touch the tongue with the swab tip.

Participant manual: Clinician’s role in disease surveillance and case reporting APPENDIX E - 71

2. Place the swab immediately into a sterile vial containing VTM.

3. Break the applicator stick off near the tip to permit closure of the lid. Plastic swab

handles usually have a weak point in them to allow them to be broken off for insertion

into a specimen tube. Others have a handle made of a brittle plastic that will snap easily.

If the shaft cannot easily be broken off so that it is short enough to fit into a small tube,

such as a cryovial, it will have to be cut. To do this:

– cut the shaft with scissors, taking care not to touch the tip;

– allow the tip to slide into the VTM and then cap the tube (do not let cut portions

of the bag or wrap fall into the tube);

– sterilize the cutting edge of the scissors by the use of flame (e.g. by the use of a

spirit burner, a Bunsen burner or another suitable heat source);

– allow scissors to cool before reuse.

4. Label the specimen container (the cap should not be marked as it may be switched during

handling) with: 52 For cases of SARI, or suspected infections with novel influenza viruses, consider collecting duplicate throat and

nasal swabs

72

– the unique identifier

– the specimen date

– the type of specimen in the tube (e.g. nasal swab, throat swab etc.).

Nasal swab collection

Sending clinical data with the sample When collecting laboratory sample, the following clinical data should also be recorded and provided.

Unique patient identifier

Sex

Age

Body temperature at presentation

Date of symptom onset

Date of hospitalization (SARI only)

Date of specimen collected

Seasonal influenza vaccination status

Antiviral use for present illness

Pregnancy status

Presence of chronic pre-existing medical illness such as o Chronic respiratory, cardiac, liver, renal, neuromuscular or neurological

disease


o Asthma o Diabetes o Immunodeficiency including HIV o Chronic hematological disease (such as Sickle Cell Disease)

When possible you should also try to collect and record the following information:

Signs and symptoms of illness

Smoking history

Infection with HIV or AIDS

Infection with TB and status of infection (latent or active)

Patient height and weight

Ethnicity or if patient belongs to disadvantaged minority group.

Appendix F: Using laboratory

Participant manual: Clinician’s role in disease surveillance and case reporting APPENDIX F - 73

Why is laboratory testing of specimens necessary for surveillance? Several diseases or conditions may present with similar signs and symptoms. For example influenza can present like many other viral illnesses. The initial presentation of viral haemorrhagic fevers can be very non-specific. Laboratory confirmation is necessary to accurately diagnose illness in an individual patient and to verify the cause (or etiology) of a suspected outbreak. Who is responsible for laboratory testing? Laboratory testing is the responsibility of everyone who comes in contact with the specimen, not just the laboratory staff. The health care worker who collects the specimen must make the decision that it is indicated to test the patient and collect the specimen according to specifications, or the test may not produce reliable results. Specimens must be clearly labeled with the patient information. The health care worker must then make sure the test is stored and transported correctly and in a timely manner, or the results may also be inaccurate. The laboratory team must process the specimen correctly, and communicate the results in a timely manner to health care staff and through the surveillance system. Why are laboratory tests not always accurate? Many results can affect the reliability of a laboratory test or make the test difficult to interpret. For example:

Specimen may be collected inappropriately

Delay in transport and processing may result in bacterial overgrowth in the collected specimen

Use of wrong transport or storage media, resulting in reduced viability of the suspected organism.

Why is laboratory testing sometimes not always recommended during a disease outbreak? Sometimes routine collection and laboratory testing is only necessary during the beginning of a suspected outbreak. For example, when influenza is detected in a community, public health officials may initially recommend testing to determine the strain and whether the strain is susceptible to antivirals. Once the strain is confirmed, they may no longer recommend laboratory testing for uncomplicated patients who meet the standard case definition since it is not cost effective and will not alter the clinical care. Another example is that laboratory testing may not be recommended if there is disease outbreak that is endemic to an area. However, if there is a change in the expected pattern of disease public health authorities may then recommend laboratory testing.

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