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I N T E G RAT E D D I SE A S E S U RV E I L L A NC E MINIST RY OF HEALT H A ND FAMILY W ELFARE

H E A LT H W O R K E R S ’ O P ER AT I O N S M A N UA L
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INDEX
Sl. No 1.0 1.1 1.2 2.0 2.1 2.2 2.3 3.0 4.0 5.0 5.1 6.0 7.0 8.0 I. II. III. IV. V. Page number Abbreviations 3 Introduction 4 What is surveillance? ……………………………......................... 4 Why surveillance? ………………………………......................... 4 Integrated Disease Surveillance Project 5 Syndromes under surveillance ……………………………........... 5 Types of surveillance under IDSP ………………......................... 6 Which are the reporting units? ……………………………........... 7 Data Collection . ................................. 7 Flow of Information .. ......................... 8 Laboratory Confirmation ............... 9 Biosafety ……..………………………............................................ 10 Outbreak Response .......................... 10 Inter-sectoral Collaboration .. ........... 10 Conclusion ..................,...................... 10 Annexure I: Syndromes Under Surveillance ........ 12 Syndrome of Fever …………………………………………………. 12 Syndrome of Cough (with or without fever) ...……………………. 16 Syndrome of Watery Diarrhoea ...…………………………………. 18 Syndrome of Jaundice ……………………………………………… 22 Syndrome of Unusual Events Causing Death or Hospitalization 25 Glossary of terms 27 Topic

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alert the higher authorities and take action within the limits of their capacity. both in the Government and Private sector. 3 .ABBREVIATIONS AFP ARI BDO CDC CEO CFR CHC DH DSU ESI IDSP IEC JE MO MP NGO OPD ORI ORS ORT OT PHC RRT RT SPP TB Acute Flaccid Paralysis Acute Respiratory Infection Block Development Officer Centers for Disease Control and Prevention Chief Education Officer Case Fatality Ratio Community Health Center District Hospital District Surveillance Unit Employee State Insurance Integrated Disease Surveillance Project Information Education Communication Japanese Encephalitis Medical Officer Malarial Parasite Non Governmental Organization Out Patients Department Outbreak response immunization Oral Rehydration Salts Oral Rehydration Therapy Orthotoludine Primary Health Center Rapid Response Team Radical Treatment Sentinel Private Practitioner Tuberculosis This manual is intended for the use of the most peripheral workers in the health system. It should help them identify cases.

The course of an epidemic is dependent on how early the outbreak is identified and how effectively specific control measures are applied.0 Integrated Disease Surveillance Project Integrated Disease Surveillance Project (IDSP) is a decentralized. the alertness for identification of early warning signals and the capacity for initiating recommended specific interventions in a timely manner are important to achieve the above objectives. • Analysis and interpretation of data. non-governmental agencies and the community 4 .2 Why surveillance? Surveillance is an important component of public health measures. and • Feed back and dissemination of results. is negligible.0 Introduction 1. Scarce resources are often wasted in undertaking such measures after the outbreak has already peaked and the outcome of such measures in limiting the spread of the outbreak. laboratory). It is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. and in reducing the number of cases and deaths. precautionary measures can be taken within the existing health infrastructure and service delivery to reduce risks of outbreaks and to minimize the scale of the outbreak if it occurs. • Response – a link to public health program specially actions for prevention and control. the co-operation of other government departments. the credibility of the health services is greatly improved. When outbreaks occur or when the risk of such outbreaks his high. clinical.1. The effectiveness with which national programs are implemented and monitored. state based surveillance programme in the country. All outbreaks cannot be predicted or prevented. However. The epidemiological impact of the outbreak control measures can be expected to be significant only if these measures are applied in time. • Investigation and confirmation (Epidemiological. The key output of a good surveillance system is the early detection of outbreaks. 2. By preventing outbreaks. Action may be in the form of improvement of services when gaps are identified or outbreak response when an outbreak is detected. It is also expected to provide essential data to monitor progress of on-going disease control programmes and help allocate health resources more efficiently. The six main steps in surveillance are: • Detection and notification of health event. Surveillance helps the health services keep a close watch on health events occurring in the community and detect outbreaks that may be occurring so that corrective action can be taken immediately. • Collection of data.1 What is surveillance? Surveillance is collecting data on disease conditions so that necessary action can be taken. 1.

4. Viral outbreaks 2. and partnership with private health sector. There are many surveillance systems currently in the country. Bleeding from skin or mucus membrane v. strengthening of laboratories. Typhoid. The main components in this surveillance system would be: 1) surveillance of diseases. emerging diseases. Fever with or without localising signs Malaria. Measles Tuberculosis Polio Cholera Hepatitis. Such help will be more forthcoming if mechanisms for interactions have been developed before the onset of an outbreak. Less than seven days duration without any localizing signs ii. Fever more than seven days with or without localizing signs Cough more than three weeks duration Acute Flaccid Paralysis Diarrhoea Jaundice Unusual Events causing death or hospitalization 2. capacity building of health staff at various levels. With Rash iii. Leptospirosis Plague.often becomes necessary. Unusual events causing death or hospitalization 5 . The frequency of the occurrence of epidemics is an indication of the inadequacy of the surveillance system and preparedness to identify and control outbreaks in a timely manner. 1. provision of computers at the District Surveillance Unit to enable rapid transmission of surveillance data. Diarrhoea 5. Efforts will be made under IDSP to converge surveillance under various national disease programs in to a single surveillance system under IDSP. Jaundice 6. 6. Cough more than 3 weeks 3. These syndromes are intended to pick up all priority diseases listed under regular surveillance at the level of the community under IDSP. 3. With altered sensorium or convulsions iv. 2. Dengue. Acute Flaccid Paralysis 4. Japanese Encephalitis. 5.1 Syndromes under Surveillance: The paramedical health staff will undertake disease surveillance based on broad categories of clinical presentation. The following clinical syndromes will be under surveillance in IDSP: 1. The Integrated Disease Surveillance system will be operational all over the country and will help the health services to improve the alertness of the health services to potential outbreaks. Fever i.

For e. The medical diagnosis of a condition. Syndrome is group of symptoms and/or signs attributable to particular disease condition (e.g.2 Types of surveillance under IDSP: Depending on the level of expertise of the health staff. Confirmed: Clinical diagnosis confirmed by an appropriate laboratory test.g. loose motions. vomiting. based on presenting symptoms and clinical signs will be conducted only at the level of Medical Officers (such as those at Primary. Symptoms. Under IDSP. Syndromic surveillance is defined as the surveillance of diseases based on the presenting symptom/s (and not the disease attributable to the syndrome). skin rash.g. fever with skin rash indicative of measles). fever. Village Volunteers and Non-formal Practitioners will conduct syndromic surveillance.) Signs are findings on examination of patients e. disease surveillance under IDSP will be of the following three categories. headache. yellow discoloration (jaundice). Presumptive: Diagnosis made on typical history and clinical examination by medical officers. cough etc. signs and syndrome Symptom is complaint perceived by the patient or identified by the examiner (e. Dispensaries and Hospitals) or qualified medical practitioners. 6 .2. the Health Workers.g. The cases identified through the presenting symptoms are classified as ‘suspect cases’ of a certain disease condition. a case of fever with rash will be classified under the syndrome ‘fever with rash’ and not as measles. Syndromic: Diagnosis made on the basis of history and clinical pattern by paramedical personnel and/or members of the community. Community Health Centers.

Medical colleges. this information has to be transferred onto the suspect case reporting format (Form S). The peripheral health workers will be provided a register in which they will note down the syndromes that are under surveillance as and when they come to know of this during their routine visits to the village and urban wards. Urban Hospitals. sentinel hospitals.0 Data collection The health workers are the most important personnel for syndromic surveillance. The health worker. The health worker would be expected to record the number of these syndromes seen by her/him each week and report it to the next level on a weekly basis. Every Monday. The reporting units are the sub-centers of PHC and urban health centers. The MO PHC will retain one copy of the form S and 7 . ESI / Railway / Medical college hospitals Sentinel Private nursing homes. The reports from the Urban Health Center will be forwarded to the Municipal Health Officer. The Health Workers are the most peripheral workers at the subcentres and are the primary reporting units in the surveillance system. On a weekly basis.0 Flow of information: The health workers (and other peripheral reporting units such as the village volunteer and non-formal provider) should register all patients seen by them (either at the Subcentre or during home visits) into their register for syndromic surveillance. 4. The Municipal Health Officer will then forward the reports to the District Surveillance Officer. Village volunteers from the Panchayat. District Sentinel Private Hospitals practitioners (SPPs) and Sentinel hospitals. this information will be translated into a summary sheet (form S) and given to the Medical officer in charge of the PHC / Urban Health Center. This will be immediately forwarded to the District Surveillance Officer. local private practitioners (including practitioners of Indian Systems of Medicine) and non-formal health providers may be incorporated as reporting units for syndromic surveillance.2. after proper training. PHCs. Private and NGO laboratories Rural Urban 3. Reporting units for disease surveillance Public health sector Private health sector Sub-centers. the HW should collect the reports from them and submit it to the PHC (without delay in sending the subcenter report to the PHC). CHCs. The register will contain the verifiable information which can be counter-checked by the supervisory staff under IDSP at PHC/CHC and District levels. If there are Sentinel Private Practitioners in his/her area who form a part of the reporting system. village volunteer or other providers will submit form S to the PHC Medical Officer every Monday.3 Which are the reporting units? A reporting unit is one that generates the data and feeds it into the surveillance system.

Pvt. P. and entered into the reporting form. Practioners Nursing Homes Private Hospitals Private Labs.U. Other than patients coming to the subcenter.C. the HW may also hear about cases in the community from key informants..S.H. Feedback If the HW has referred patients for further investigation.S. Sub-Centres Programme Officers P. D. Med. she should find out from the Medical Officer at the PHC about the outcome of the referral.forward the remaining copy to the District Surveillance Officer immediately on Monday or latest by Tuesday. in the process of collecting the forms from them. 8 . S. Corporate Hospitals Transmission of data Once the data is collated.s C. The data from the periphery that will be provided to the PHC will be used for action.H. Weekly Information Flow under IDSP C.C. Army etc.U. then the HW should ensure that the form S reaches the PHC every Monday. she should share her diagnosis and action with them. However. the HW should ensure that his/her forms do not get delayed in reaching the MO PHC. This may be done either manually or by telephone where possible.U. The HW must verify these cases before reporting.Col.s Dist.Hosp.S.Lab Other Hospitals: ESI. Municipal Rly.H. it is the responsibility of the HW to collect the form S from them and forward them to the PHC. If there are Sentinel Private Practitioners in a subcentre area. If the HW has received information about cases from key informants.

Transportation boxes should be securely fastened. This must be supervised by the MP PHC or the laboratory technician at the PHCs. 9 .1 Biosafety measures The HW must follow precautionary measures while collecting samples from at the periphery.1: Action to be taken by the HW in the field Syndrome Only Fever Action Blood Smear for all patients Inform PHC MO immediately to arrange for collection of stool samples Two samples of stools taken at interval of 24 hours and transported to the MO PHC in reverse cold chain Take sample of stools in a filter paper or in a sterile bottle and send it by reverse cold chain to the nearest District Laboratory (within two hours) or use Cary-Blair medium for transport of the sample Acute Flaccid Paralysis Loose watery stools with dehydration in an adult Fever with rash Fever with altered sensorium Fever with bleeding Fever more than 7 days Cough for more than three weeks Unusual severe syndromes Referred to the MO PHC for specific lab action 5.0 Laboratory confirmation While the HW is expected to see and report cases. 4. Keep absorbent cotton inside the carrier. he/she is also required to send specimens of cases presenting certain symptoms to the laboratory for confirmation. Transportation 1. Decontaminate used syringes by immersing in 10% bleach. Table 5. In case of spills – wipe the surface with 10% bleach. Recommended to use autodestruct syringes. Blood samples – Use disposable syringe/needles 2. Collection 1. Discard used needles into sharp boxes 3. The table below summarizes the types of samples to be sent to the laboratory as part of routine surveillance activity and as a part of outbreak response.5. autoclaving and then discarding.

If cold chain is required. ensure that there are ice packs. case fatality rate of the disease and the prevalence of the problem in the community. many outbreaks in the community can be prevented which. Once a disease condition has crossed this threshold. 7. In the case of fever or AFP. the health worker as a part of the outbreak response will inform the Panchayat office and the locally active NGOs regarding possible outbreaks in the community (if any). will improve the credibility of his/her services. he/she should attempt to identify and build rapport with key informants in each village who will inform him/her of the health events as and when they occur.0 Conclusion The HW is the eye and the ear and the most important personal of the Health Services and plays a very crucial part in the early detection of outbreaks in the community.0 Outbreak response The role of the HW is not simply to collect and transmit data. 6. 8. Do not re-use the same cold chain box to transport vaccines.0 Inter-sectoral coordination For an effective outbreak response it is important to involve members of the community and members of non-health departments/sectors. Therefore. The trigger levels are dependent on the outbreak/epidemic potential. She/he should also be alert to outbreaks so that they can be detected early and an effective response can be taken. These community based informants would improve the alertness of the surveillance system and should stimulate the health services to identify and respond immediately to potential outbreaks. Other than the HW’s own services. 10 . the HW should also take the responsibility of collecting the appropriate sample. Preset trigger levels for diseases have been identified with specific responses for various levels of the health system. If the HW works sincerely on surveillance.2. Loose wet ice should not be used. the HW must take the appropriate action which is specified in the annexure I (page 11). Thresholds for outbreaks are given in annexure I (page 11).

a patient is considered to be suffering from fever. they should record it in their register for syndromic surveillance. While entering the diagnosis for fever.Annexure I: Syndromes under surveillance I. fever with muscle pain. Measles. care must be taken to record it as one of the following categories: • Only fever • Fever with rash • Fever with altered consciousness or convulsions • Fever with bleeding • Fever more than 7 days These registers for syndromic surveillance are the source of data from which the Syndromic Reporting Form (form S) will be filled by the HW on a weekly basis.g.b Syndrome Definition All new patients with fever should be classified as follows: a) Fever less than seven days with: Ø Ø Ø Ø Ø Rash and running nose or conjunctivitis (suspected Measles) Altered sensorium (suspected JE) Convulsions (suspected JE) Bleeding from skin. mucus membrane. While the last two are not common. JE and Dengue. Syndrome of Fever Diseases under Surveillance: Malaria/ Typhoid / Measles / Japanese Encephalitis (JE) / Dengue I. sex. I. vomiting blood or passing fresh blood through nose or ear or black motion (suspected dengue) With none of the above (suspected malaria) b) Fever more than seven days (suspected typhoid) Trigger 1 : More than two cases with similar symptoms (as mentioned above) in the village (1000 Population) Note: While there may be other accompanying symptoms e. I. if his/her main symptom is that of fever.c Recording information at reporting unit Whenever the staff in the reporting unit sees a patient with fever. Typhoid. age. The disease conditions of public health interest are Malaria. the syndrome and date of onset. This includes simple details such as name. This would include patients who come to the reporting unit or as seen during their field visits. 11 .a Why surveillance for fever? Fever is the most common presenting symptom among patients at the periphery. the HW needs to keep them under surveillance so that they are picked up early to identify impending outbreaks. fever with cough. address.

then the HW should immediately take the necessary action. If the threshold is crossed. Thresholds – • Sudden/gradual increase in the number of cases of fever over the past three weeks • Two or more cases of fever with rash in one week • Two or more cases of fever with altered consciousness or convulsions • Two or more cases of fever with bleeding • Two or more cases of fever more than seven days 12 .I.d Analysis The HWs should do a preliminary analysis of their data.

Strengthen routine measles immunization services. Vector surveillance 6. 4. IEC for community awareness* None 1. 2. Presumptive / RT for malaria 3. Refer the case to PHC 6. Give vitamin A 2. Antipyretics 3. Refer the case to CHC/District Hospital 4.f Detailed Surveillance Action: Syndrome Trigger event (in a village or urban ward for 1000 population approx) Recommended Surveillance Actions Lab action A) Fever less than 7 days duration a) Only fever 2 or more cases b) With rash 2 or more similar cases c) Altered consciousness or convulsions 2 or more similar cases Slides for MP 1. Inform MO PHC. Check measles immunisation status of cases 4. Inform MO PHC 7. Collect slide for MP. Slides for MP 2. IEC for community awareness* * Regarding mosquito breeding sites. including Vitamin A Slides for MP 1. 3. anti-larval measures and personal protection from mosquito bites (such as use of bed-nets) 13 . Search for similar cases 5.I. Inform MO PHC 5. Give paracetamol.

CONCLUSION Remember that increasing cases of fever in the community could be the initial signs of an outbreak of malaria or dengue. 3.d) Fever with bleeding 2 or more similar cases 1. 14 . Give paracetamol. 4.Train local person about water Chlorination / Community awareness about safe water and personal hygiene. Give anti malarial treatment Inform MO PHC. 3. Collect slide for MP. 5. Lab action B. Paracetamol Refer the case to CHC/DH Inform MO PHC Vector surveillance IEC for community awareness Slides for MP Syndrome Trigger event (in a village or urban ward for 1000 population) Recommended Surveillance Actions 1. Conduct appropriate chlorination of all drinking water sources 5. 2. Fever more than 7 2 or more similar days Slides for MP Once typhoid fever is confirmed 1. 2. 3. IEC . 6. Collect slide for MP. So be alert to the trends. Collect water sample and send it to PHC for H2S testing and to district labs for MPN count. The main focus should be to pick up warning signals of outbreaks at an early stage before it spreads. Check TCL stock. Orthotoludine testing of drinking water sources to check for residual chlorine level. 4. 2. 4.

Suspect ARI (common among children less than five years) b) Long duration cough (Cough of more than or equal to 3 weeks) . However. and. then she should take the necessary action. ranging from the common upper respiratory tract infection to cancer of the lung.d Analysis and action The HW should do a preliminary analysis of their data. fever and breathlessness. Thus the symptom of cough is divided into two broad categories: 1) Short duration cough (less than three weeks). II. Adults (more than or equal to five years) with cough for more than three weeks should be suspected to be suffering from TB. Syndrome of Cough (with or without fever) Diseases under Surveillance: Tuberculosis / Acute Respiratory Infections II. age. These register for syndromic surveillance is the source of data from which the Syndromic Reporting Form S is filled by the HW on a weekly basis. care must taken to record it as either short duration cough or long duration cough (as mentioned above) .c Recording at Reporting Unit Whenever the HW sees a patient with cough during the field visits or at the sub center. II. if his/her main symptom is that of cough. address. 15 .a Why surveillance of cough? Cough is a common symptom.g. These Patients will be divided into two categories: a) Short duration cough (Cough less than 3 weeks) . while children (less than five years) with cough less than three weeks should be suspected to be suffering from ARI. he/she should record it in the register for syndromic surveillance. Tuberculosis and Acute Respiratory Infections among children are the major public health problems. especially among children. While entering the diagnosis for cough.II. sex.Suspect Tuberculosis Note: While there may be other accompanying symptoms e.b Syndrome definition: All new patients with cough as the main presenting symptom should be included. II. 2) Long duration cough (more than three weeks). THRESHOLD (increase in number of cases during last 3 weeks) Cough less than 3 weeks duration Cough more than 3 weeks duration RESPONSE Alert the Medical Officer about a potential outbreak Refer the patient to the Medical officer for further investigation. This should include simple details such as name. a patient is considered as one suffering from cough. syndrome and date of onset. There are many causes of cough. If the threshold is crossed.

16 . So be alert to trends.e Conclusion Remember that increasing cases of cough in the community may be the initial signs of a measles outbreak or an outbreak of whooping cough. Also try and pick up suspect TB cases as early as possible before they transmit the infection to others.II.

Thus it is important to keep a strict vigil on the cases of diarrhoea – to check whether they are increasing in number or whether there are deaths occurring due to diarrhoea in the community. they should record it in their register for syndromic surveillance. especially among children. sex. They would be further divided into less than five years of age and equal to or more than five years of age and by sex (male and female). all diarrhea cases would be divided into two categories – diarrhea with dehydration and diarrhoea without dehydration. 17 . While sporadic cases are not alarming from the public health point of view.a Why surveillance for Diarrhoea? Diarrhoea is one of the most common symptoms faced by health workers at the periphery. This would include patients who come to the reporting unit or as seen during their field visits. Deaths due to diarrhoea and dehydration in adults (> 5 years) should alert the health workers about the possibility of cholera and appropriate action should be taken as given below. Syndrome of Watery Diarrhoea Diseases under surveillance – Acute Diarrhoeal Diseases. The total duration of illness should be less than 14 days. This should include simple details such as name. Trigger: 1) More than 10 houses with at least one case of diarrhoea each in a village or urban ward within a week. there is a danger of diarrhoea attaining outbreak situation in a short period of time. care must taken to record it as one of the following categories. address. • Acute diarrhea with dehydration • Acute diarrhea without dehydration The register for syndromic surveillance is the source of data from which the Syndromic Reporting Form S is filled by the HW on a weekly basis. or 2) Single case of severe dehydration or death in a patient more than or equal to 5 years with diarrhoea. or 3) A single death due to severe dehydration following diarrhoea. It has a high death rate. Preventing diarrhoeal outbreaks will improve the image of the health services and the health workers in the periphery. and cases of cholera is one of them. especially in areas where sanitation is poor. Outbreaks of diarrhoea reflect poorly on the effectiveness of the health services. While entering the diagnosis for diarrhea. Whenever the Health Worker sees a patient with diarrhea during field visit or at the subcenter. Those cases of diarrhoea which last more than seven days should be labeled as chronic diarrhea (for surveillance purposes).c Reporting Details As the main aim of surveillance is to detect potential outbreak situations. syndrome and date of onset. III.III. III.b Syndrome Definition Syndrome of Acute Diarrhoeal Diseases: Any new case of watery diarrhoea (passage of even one large profuse watery stools in the past 24 hours) with or without dehydration. age. cholera III.

If the threshold is crossed. ORS – 100 ml/kg/day • If worsened or increased – Refer to PHC/CHC. III. Thresholds – • • A single case of severe dehydration / death in a patient of more than or equal to 5 years of age More than 10 houses with at least one case of diarrhoea each in a village or urban ward within a week. III. This is in the form of Oral Rehydration Therapy.III. 18 . then she/he should take the necessary action.f Conclusion Remember that diarrhoea can spread very rapidly in a short time.g) III. Diarrhoea with dehydration • 75 ml / kg of ORS in the first 4 hours.g Annexure i) Case management: Rehydration therapy is the key treatment for diarrhoea. • Reassess dehydration • If same – continue for another 4 hours • If rehydrated.d Analysis The HWs should do a preliminary analysis of their data. Search for more diarrhoea cases in the community and prepare line listing of cases Alert the MO PHC immediately. Appearance of diarrhoea cases should be is a warning signal of a potential outbreak.e Response Depending on the threshold. the HW should take the following action: THRESHOLD ACTION/RESPONSE A single case of diarrhoea with severe Distribute ORS to the cases including dehydration / death of a patient who is other vulnerable families more than 5 years old with diarrhea Refer cases with severe dehydration to More than 10 houses having at least the nearest PHC one case of diarrhea each in a village or urban ward within a week. (Details of Action/Response – Refer to III.

These include • IEC on food. providing safe drinking water is the most accepted method of control. vi) If diarrhoea outbreak occurs: vi. • Chlorine tablets may be distributed to all households so that they may chlorinate their drinking water themselves.ii) Epidemiological investigation o Active search for all new cases in that area. • Health education of the community to boil drinking water if feasible may be resorted to. o Line listing of cases. • Importance of washing of hands after defecating and before eating must be emphasised. vi. Residual chlorine should be ensured before this water is used. the health department should be involved in this measure and should advise the water supply department about the areas to be targeted. However. Discourage consumption of cut fruits and raw vegetables like salads without thorough washing with safe water. The food must be freshly prepared and served hot. Provision of safe water is the responsibility of the department of water supply and should be coordinated by the BDO / CEO / Collector. Sale of food items must be strictly monitored and food should not be exposed to houseflies. personal and sanitary hygiene • Use of sanitary toilets wherever possible • Avoid defecation near water sources. o Refers cases of dehydration to the PHC o Intimate the local practitioners about the probable outbreak v) Safe drinking water: In an outbreak of cholera. b) Food sanitation: Ensure proper hygiene and sanitatary precautions while preparing and distributing food. a) Sanitary disposal of human waste: During an outbreak the community has to be educated on the need for observing basic sanitary practices. 19 . This would include: • Immediate provision of safe drinking water . o Information to MO PHC / CHC iii) Collection of lab specimens o Collect stool specimens and send to PHC for Cholera isolation o Water samples for bacteriological analysis iv) Prevention of further cases / deaths o Provision of safe drinking water by disinfection of drinking water sources o IEC to promote food and personal hygienic measures o Distribution of ORS packets to the vulnerable families. Proper washing of hands by food handlers is essential for food safety.steps must be taken to provide properly treated or other wise safe water to the community for all purposes (drinking and cooking). • All water sources in the community should be chlorinated with bleaching powder.

In the urban areas. • Label the samples. Vii. importance of safe water. it would be advisable to store in a refrigerator and transport under reverse cold conditions. time and place of collection. • If C-B media is not available. • Put the containers in separate polythene bags to prevent leakage and cross contamination. Ensure that it is moist and fecally stained. Send the samples to the nearest District Lab. hygienic food practices and personal hygiene. the samples need to be sent to the nearest designated lab that may be a Private lab 20 . collect from 5 – 10 patients. vii) Stool Collection: vii. This specimen then should be sent to the nearest lab as soon as possible. introduce the swab well into the rectum (2 – 4 cms deep) and rotate by 90*. The label should contain the o Patient’s name o Unique ID number o Specimen type. date. pour out /scoop specimen with spoon and fill upto the half the container • If stool is not available. • If stool is available. These should be transported immediately to the District laboratory for confirmation. Vibrio cholera can be isolated from the media if transported and plated within 7 days. c) Health Education: Health education is the most effective prophylactic measure and should be mainly directed at early reporting and prompt treatment. Ensure that the sample reaches the lab within 2 hours. a) Purpose: To confirm cases of cholera.vi. o Name/ initials of collector. While cold chain is not necessary. b) Procedure: • Collection of specimens before the patient receives antibiotics • In the event of an outbreak. So stools samples should be taken from adult patients who have diarrhoea and severe dehydration. then the specimen (or even filter paper soaked in stool) can be placed in a sterile container and transported under reverse cold chain conditions (2* – 8* C). • Put specimen / swab into the Cary-Blair transport medium which has been previously cooled for one hour.

IV. but it has the potential for developing into an outbreak situation. • anorexia. While entering the diagnosis for jaundice. they should record it in their register for syndromic surveillance. Thresholds – • If there are more than 2 cases of jaundice in a village or an urban ward (approximately 1000 population) within a week. sex. IV. care must taken to record it as one of the following categories.IV. If the threshold is crossed. address. age. To differentiate this type of jaundice from others of lesser public health importance. syndrome and date of onset.c) Reporting details Whenever the HW sees a patient with jaundice during the field visits or at the subcenter. There are many causes of Jaundice of which Hepatitis A and E virus and Hepatitis B virus and Leptospirosis are the diseases that are of public health importance and may occur as outbreaks. Viral Hepatitis E and Leptospirosis.a) Why surveillance for jaundice? Jaundice is not a common symptom in the village level. surveillance will focus only on jaundice of less than four weeks duration. This should include simple details such as name. • A single case of death due to acute jaundice (jaundice of less than 4 weeks) 21 .d) Analysis The HWs should do a preliminary analysis of their data. then he/she should take the necessary action. malaise. Trigger: More than two cases of Jaundice in different houses irrespective of age in a village/urban ward or approximately 1000 population.b) Syndrome Definition Clinical Description: A case with an acute illness (less than 4 weeks) and with the following symptoms: • jaundice. IV. The register for syndromic surveillance is the source of data from which the Syndromic Reporting Form S is filled by the HW on a weekly basis. • Jaundice of less than 4 weeks • Jaundice of more than 4 weeks. extreme fatigue and • pain in the right upper abdomen. IV. Syndrome of Jaundice Diseases Under Surveillance: Acute Viral Hepatitis A. dark urine.

IV. the health department should be involved in this measure and should advise the water supply department about the areas to be targetted. who should be referred immediately to the district level. and if Hepatitis A or E is suspected. • Health education of the community to boil drinking water if feasible may be resorted to. Provision of safe water is the responsibility of the dept of water supply and should be co-ordinated by the BDO / CEO / Collector. providing safe drinking water is the most accepted method of control. PHC about a different households irrespective of age potential outbreak per thousand population in a village or ward Active search for more cases in the community. • All water sources in the community should be chlorinated with bleaching powder. location and A single case of death due to acute symptoms jaundice (jaundice of less than 4 weeks) Active search for pregnant women with jaundice. take all action listed under diarrhoea outbreak.f Conclusion Remember that jaundice is an uncommon but important problem in the community.IV. Most community members prefer to treat jaundice with traditional medicines. the MPW should take the following action: Threshold Response More than 2 cases of Jaundice in Alert Medical Officer.e) Response Depending on the threshold. ii) Sanitary disposal of human waste: During an outbreak the community has to be educated on the need for observing basic sanitary practices. so they do not usually approach the allopathic system for treatment. Line listing of these cases by name. age. This would include: • Immediate provision of safe drinking water . Chlorine tablets may be distributed to all households so that they may chlorinate their drinking water themselves.g Annexure i) Safe drinking water: In an outbreak of jaundice. However. These include • Using of sanitary toilets wherever possible 22 .steps must be taken to provide properly treated or other wise safe water to the community for all purposes (drinking and cooking). multiple cases may indicate problems due to contaminated water supply. NOTE: If an outbreak of Hepatitis A or E occurs. IV. While a single case may be of no public health significance. Residual chlorine should be ensured before this water is used. Thus a single case of jaundice should alert the MPW about potential cases in the community and she should make efforts to trace them. sex.

23 . Sale of cut fruits and eating of raw vegetables like salads without thorough washing with safe water should be discouraged. Also washing should not be done with 10 m of a water source. iv) Health Education: Health education is the most effective prophylactic measure and should be mainly directed at early reporting and prompt treatment. iii) Food sanitation: Steps should be taken to ensure proper hygiene and sanitation while preparing and distribution of food. The food should be freshly prepared and served hot. Sale of food items must be strictly monitored and food should not be exposed to houseflies. importance of safe water.• • • If they resort to open-air defecating then they must be instructed to ensure that they are not next to a water source. that they cover the faeces with mud mixed with slaked lime. The importance of washing of hands after defecating must be emphasized. Proper washing of hands by food handlers is essential for food safety. Washing of patient’s soiled linen and clothes should be done only after soaking them in a solution of bleaching powder. hygienic food practices and personal hygiene.

he/she should record it in the register for syndromic surveillance. age. Today is a period of bioterrorism and chemical warfare that pose a threat to the health of the community.c) Definitions • Hospitalization and Death are self explanatory and do not require any specific definition. 24 .a) Why surveillance of unusual syndromes? While most common illnesses fit into the syndromic approach.b) Syndrome definition Syndrome Description: The sudden occurrence of unusual events. sex. • Altered Consciousness is defined as not able to recognize relatives and not to be aware regarding time or place. mucus membrane. in a geographical region. V. Syndrome of Unusual Events Causing Death or Hospitalization V. syndrome and date of onset. address. Examples given above. V.V. • Breathing Difficulty: When ever patients complain of severe breathlessness associated with rapid respiration • Bleeding from skin. So any unusual illness in the community causing either deaths or affecting large populations should be brought to the notice of higher authorities immediately. • Convulsion is defined for the syndrome as any patient admitted or died following involuntary muscular spasms with or without loss of consciousness. Some of the symptoms may be: • Convulsions • Alteration in consciousness • Breathing Difficulty / Respiratory distress • Bleeding • Paralysis Trigger: Two cases of death or hospitalisation due to an unusual symptom/s. causing death or hospitalization and which does not conform with the standard case/syndrome definitions discussed earlier in the manual. The register for syndromic surveillance is the source of data from which the Syndromic Reporting Form S is filled by the HW on a weekly basis.d) Reporting details Whenever the HW sees a patient with unusual syndromes during field visit or at the subcenter. V. vomiting blood or passing fresh blood or black motion • Paralysis: Severe muscle weakness leading to difficulty in using any of the limbs. This should include simple details such as name. the health workers should be alert for uncommon events in the community also.

then line list them according to their age. snake bites. V. This also indicated effective surveillance in a given area. location. then he/she should take the necessary action. Thresholds – • Two or more similar cases of unusual symptoms Care should be taken to ensure as much as possible that it is a health event that is unusual. If the threshold is crossed.V. V. the HW should take the following action: Threshold Two cases of death/hospitalization due to unusual symptoms. This is the ultimate test of a surveillance system and all levels of health workers should be alert to this. • Convulsions • Alteration in consciousness • Breathing Difficulty / Respiratory • Bleeding • Paralysis Action Refer the patients to the District Hospital immediately Inform the MO of the PHC immediately Active search for similar cases in the community.f) Response Depending on the threshold.e) Analysis The HW should do a preliminary analysis of their data. 25 . unnoticed head injury etc. Some cases that may be confused as an unusual events are suicide. homicide. If there are such cases. clinical details and date of onset of symptoms and refer them to District Hospital. sex.g) Conclusion Remember that unusual syndromes are the best way of picking up the presence of new agents in the community.

to list a few. Threshold . Also. Non formal practitioners at the village level etc have been referred to as Health Worker (HW). a single case of measles is a trigger for a measles outbreak that should set into action. a warning signal has been set under every disease to identify a potential outbreak situation. Key informants – These are members of the community that are knowledgeable about the community. there is a risk of an outbreak of that disease. For e. Trigger level – Under IDSP. This warning signal is referred to as the trigger level. Outbreak/epidemic potential – It is the nature of diseases that are highly communicable by virtue of their nature of transmission that makes them prone to reach outbreak situations rapidly. Auxiliary Nurse Midwife. especially in rural areas. especially in rural areas Health Worker (M/F) – For consistency and convenience. Anganwadi Workers. Multi Purpose Worker. it’s composition. when a disease reaches this threshold level.g. 26 . the control measures. school teachers or members of local NGOs. Health Assistant. which will serve as a trigger for action. Lady Health Visitor. Health Supervisor. Village Volunteers.Every disease needs a basic number of cases in order to sustain the transmission to other vulnerables in the population. all peripheral staff of the health system such as Health Workers. health problems etc and are capable of providing information to the HW regarding health events in the community.Glossary of terms Non formal practitioner – This refers to the practitioners who are not medically qualified but provide health care at the community level. Key informants could be panchayat members.