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Case Definitions
and Standard Procedures
for Collection and Transportation of
Human Infectious Disease's Samples
including Prevention & Control
Disease Early Warning System
Updated in June 2009
A joint program of
the Ministry of Health,
the National Institute of Health and
the World Health Organization
Prevention and Control of Communicable Diseases remains a daunting challenge for the healthcare systems across the globe. In addition to the commonly prevalent illnesses in various geographical regions, the emerging and re-emerging diseases call for a really concerted and coordinated effort on part of all stakeholders. The Infectious diseases may be airborne (diphtheria, measles, whooping cough, influenza, SARS and meningococcal meningitis), some spread through contaminated food or water (poliomyelitis, typhoid fever, acute watery diarrhoea/cholera and hepatitis A&E), some by insects (malaria, classical dengue fever and plague), while others are transmitted through parenteral routes (hepatitis B & C and HIV) or mainly by contamination with infected blood as in Crimean Congo Haemorrhagic Fever. Sexual contact is another route for infectious disease' transmission as is the case for HIV and hepatitis B infections. Utilization of devices contaminated with infected soil or dirt may also constitute a source of infection from tetanus. Considering their potential harmful impact, all of the above mentioned diseases are included in the Disease Early Warning System with specific case definitions in this handbook. The hallmark of the infectious diseases is their ability to cause outbreaks rendering populations vulnerable to increased morbidity and mortality. Their effective control depends upon improved detection, early recognition and warning through notification, outbreak verification and effective response. Such national and joint efforts indeed form an effective partnership to investigate and contain those outbreaks that could spread wide and require concerted action. WHO is assisting several priority disease control programmes in Pakistan and lends technical support for the national disease surveillance & response initiatives so as to reduce the significant burden attributed to these infections. This brief publication is part of the joint efforts aimed at improving the case detection and management capacity of the health professionals. The use of definitions is a necessary step in providing accurate and timely information about important disease outbreaks. The National Institute of Health and the Ministry of Health, Government of Pakistan are commended for this field guide on case definitions that will contribute both to the specificity of case reports as well as the cost-effectiveness of disease control strategic interventions. Khalif Bile Mohamud, MD, PhD WHO Representative in Pakistan Being in a stage of epidemic transition, Pakistan is faced with the public health challenges posed by the communicable as well as non-communicable diseases. Despite improvements in the recent years, the prevalent illiteracy, limited access to safe water and sanitation facilities, continued environmental degradation, non-equitable health resources and infrastructure demand great deal of vigilance on part of healthcare professionals working at all levels of the healthcare delivery system in order to mitigate the associated public health threats. The handbook "Case Definitions and Standard Procedures for Collection / Transportation of Human Infectious Disease Samples" is an improved version of the Case Definitions Booklet published by the Epidemic Investigation Cell, Public Health Laboratories Division, National Institute of Health as an integral component of the Disease Early Warning System (DEWS) tools in order to assist the healthcare professionals in timely recognition, reporting and management of epidemic prone diseases. Based on the operational needs of the public health field staff, significant additions have been made to the earlier editions printed in 2001, 2002, 2005 and 2006. The current 5th addition also includes two new diseases i.e. Severe Acute Respiratory Syndrome (SARS) and Scabies. SARS is a new viral respiratory disease that made its global appearance in 2002 whereas Scabies has emerged as a major problem particularly in the situations involving internal displacement of the population. Additionally, pertinent information has also been added to assist in timely and proper collection and transportation of human samples, which would greatly help in accurate lab results for appropriate interventions. For expedient detection and reporting of outbreaks, this booklet should be used in conjunction with the DEWS manual and the Weekly Watch Chart. According to the definitions herein, the newly reported case of a disease can be suspected, probable or confirmed. When immediate laboratory confirmation is not available, it is recommended that the "syndromic-based" suspected and / or probable case definitions must be used for outbreak detection and response without waiting for laboratory results. Whenever laboratory investigations are required, utmost care must be undertaken to collect appropriate sample followed by its efficient transmission. The necessary epidemiological information must invariably be conveyed along with the request form enabling the laboratory staff to process the patient's sample without delay. It is earnestly hoped that this document would augment the good judgment of physicians and other health officials and serve to reduce morbidity and mortality associated with the epidemic prone diseases in Pakistan. Dr. Birjees Mazher Kazi Executive Director National Institute of Health, Islamabad TABLE OF CONTENTS
Acute Watery Diarrhoea / Cholera Crimean Congo Haemorrhagic Fever (CCHF) Dengue Fever (DF) Acute Viral Hepatitis Human Immunodeficiency Virus (HIV) 11. Meningococcal Meningitis 13. Human Plague 14. Poliomyelitis 15. Severe Acute Respiratory Syndrome (SARS) 17. Neonatal Tetanus 18. Tuberculosis 19. Typhoid Fever Acute Watery Diarrhoea / Cholera

Infectious agent:
Bacterium - Vibrio cholerae
Mode of transmission:
Faecal-oral route, contaminated water and food.

Incubation period:
Usually between 1 and 5 days

Alert Threshold:
One case of suspected AWD/ Cholera is an alert must be
Outbreak threshold
One confirmed case of Cholera is an outbreak.

Case Definition:
Suspected case:
• In an area where the disease is not known to be present:
severe dehydration or death from acute watery diarrhoea in a patient aged 5 years or more. • For management of cases of acute watery diarrhoea in an area where there is a cholera epidemic, cholera should be suspected in all patients with acute watery diarrhoea. Confirmed case: Any suspected case confirmed by laboratory through isolation of Vibrio cholerae 01 or 0139 from stool in any patient with diarrhoea. Specimen Collection: • Collect at least two rectal or fresh stools sample /swabs during active diarrhoea period (preferably as soon as possible after onset of illness). • Transport in Cary-Blair transport medium or alkaline peptone water or cold chain. • Each sample accompanying a complete lab request form with brief history of the patient may be sent by overnight mail. Management:
• Cholera can be treated by immediate replacement of the fluid and salts, which are lost throughout diarrhoea period. • Patients can be treated with ORS, a pre-packaged mixture of sugar and salts in water and drunk in large amounts. • Even in cholera, intravenous electrolyte solutions should be used only for the initial rehydration of severely dehydrated patients, including those who are in shock. Ringer's lactate solution (Hartmann's solution for injection) is the preferred fluid for intravenous rehydration. Its composition is suitable for treating patients of all ages and with all types of diarrhoea. Plain glucose solutions are ineffective and should not be used. • After vomiting stops, 500 ml fluid should then be given orally every hour. Total fluid requirements can be in excess of 50 litres over a period of 2-5 days. • Food should be given after 3-4 hours of treatment, when rehydration is completed. Breast-feeding of infants and young children should be continued. • The choice of antibiotic should take into account local patterns of resistance to antibiotics. The sensitivity patterns in Pakistan show that Vibrio cholera 01 is sensitive to Doxycycline, Ciprofloxacin, Norfloxacin, Tobramycin, and Tetracycline. Methods of control:
a) Preventive measures:
The only sure means of protection against severe GE including
cholera epidemics is ensuring adequate safe drinking water
supply and sanitation. To make water safe for drinking, when the
water source has been contaminated, either boil the water or
chlorinate it. Bringing water to a vigorous, rolling boil and keep it
boiling for one minute will kill Vibrio choleras 01 and most other
organisms that cause diarrhoea.
Making water safe by chlorination:
To make water safe by chlorination, first make a stock solution of
33 gm (3 tablespoons) of bleaching powder in one litre of water
and store it in a brown bottle. Then put 3 drops (0.6 ml) of stock
solution in one litre of water or 6 ml in 10 litres of water or 60 ml in
100 litres. Wait 30 minutes before drinking or using the water.
Good sanitation to avoid the contamination of clean water sources
can markedly reduce the risk of transmission of intestinal
pathogens, including cholera vibrios. High priority should be given
to observing the basic principles of sanitary human waste disposal
at appropriate distance from water source and supply. When large
groups of people congregate for fairs, funerals, religious festivals,
etc., particular care must be taken to ensure the safe disposal of human waste & provision of adequate facilities for hand washing. Hygiene and Food Safety: • Wash hands thoroughly with soap after defecating, or after contact with faecal matter, and before preparing or eating food, or feeding children. • Handle and prepare food in a way that reduces the risk of contamination (e.g. cooked food and eating utensils should be kept separate from uncooked foods and potentially contaminated utensils and crockery). • Avoid raw food, except those undamaged fruits and vegetables from which the peel can be removed in a hygienic manner. • Cook food until it is hot throughout. • Eat food while it is still hot, or reheat it thoroughly before • Wash & thoroughly dry all cooking & serving utensils after use. Breast feeding: • Continue breast-feeding in ill children as it may reduce the severity of gastroenteritis. b)Control of patient, contacts and the immediate environment:
• Report of epidemic to the local health authority. • Investigation of contacts and source of infection should be sought out in certain high-risk populations and antigen excretors in outbreak situation. c) Epidemic measures:
• Search for vehicles of transmission and source on epidemiological basis. References:
1. World Health Organization, 2004 Guidelines for Drinking-Water Quality. Geneva: World Health Organization. 2. Van Zijl WJ, 1966. Studies on diarrhoeal diseases in seven countries by the WHO dirrhoeal disease advisory team. Bull World Health Organ 35: 24-261. 3. Hoque BA, Hallman K, Levy J, Bouis H, Ali N. Khan F, Khanam S Kabir M, Hossain S, Shah Alam M, 2006 Rural Drinking water at supply and household levels: Quality and management. Int J Hyg Environ Health 209: 451-461. 4. Kosek M, Bern C, Guerrant RL, 2003. The global Burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 81: 197-204. 5. Pruss-Ustun A et al. Safe water better health—costs, benefites and sustainability of interventions to protect and promote health. Geneva, World Health Organization, 2008. 6. WHO and UNICEF joint monitoring programme for water supply and sanitation. Water for life: making it happen. Geneva: World Health Organization, 2005. 7. Diarrhoea and acute respiratory infections prevalence and risk factors among under-five children in Iraq in 2000. Seter Siziya, Adamson S Muula, and Emmanuel Rudatsikira, Riv Ital Pediatr. 2009; 35(1): 8. Published online 2009 April 25. doi: 10.1186/1824-7288-35-8. PMCID: PMC2687547 8. Acute childhood diarrhoea in northern Ghana: epidemiological, clinical and microbiological characteristics. Klaus Reither, Ralf Ignatius, Thomas Weitzel, Andrew Seidu-Korkor, Louis Anyidoho, Eiman Saad, Andrea Djie-Maletz, Peter Ziniel, Felicia Amoo-Sakyi, Francis Danikuu, Stephen Danour, Rowland N Otchwemah, Eckart Schreier, Ulrich Bienzle, Klaus Stark, and Frank P Mockenhaupt BMC Infect Dis. 2007; 7: 104. Published online 2007 September 6. doi: 10.1186/1471-2334-7-104. PMCID: PMC2018704 9. Management of infectious diarrhoea. A C Casburn-Jones and M J G 10.1136/gut.2003.022103. PMCID: PMC1774945 10. Acute dehydrating disease caused by Vibrio cholerae serogroups O1 and O139 induce increases in innate cells and inflammatory mediators at the mucosal surface of the gut. F Qadri, T R Bhuiyan, K K Dutta, R Raqib, M S Alam, N H Alam, A-M Svennerholm, and M M Mathan. Gut. 2004 January; 53(1): 62–69. PMCID: PMC1773936 11. Management of bloody diarrhoea in children in primary care, M Stephen Murphy. BMJ. 2008 May 3; 336(7651): 1010–1015. doi: 0.1136/bmj.39542.440417.BE. PMCID: PMC2364807 Crimean Congo Haemorrhagic Fever

Infectious Agent:
Nairovirus group, Bunyaviridae family

Mode of transmission:
Tick-borne (Hyalomma genus); also direct contact with blood /
tissue of infected people, blood / tissue of infected domestic
animals (butchering) or the grinding of infected ticks.

Incubation period:
Incubation period is usually 1 to 3 days, with a maximum of 9
days. The incubation period following contact with infected blood
or tissues is usually 5 to 6 days, with a documented maximum of
13 days.

Alert Threshold:
One probable case is an alert and requires an immediate

Outbreak threshold
One confirmed case is an outbreak
Case Definition:
Suspected Cases:
Patient with sudden onset of illness with high-grade fever over
38.5°C for more than 72 hrs and less than 10 days, especially in
CCHF endemic area and among those in contact with sheep or
other livestock (shepherds, butchers, and animal handlers). Note
that fever is usually associated with headache and muscle pains
and does not respond to antibiotic or anti-malarial treatment.
Probable case:
Suspected case with acute history of febrile illness 10 days or
less, AND any two of the following: thrombocytopenia less than
50,000 /mm3, petechial or purpuric rash, epistaxis, haematemesis,
haemoptysis, blood in stools, ecchymosis, gum bleeding, other
haemorrhagic symptom - AND no known predisposing host factors
for haemorrhagic manifestations.
Confirmed case:
Probable case with positive diagnosis of CCHF in blood sample,
performed in specially equipped high bio-safety level laboratories.
Positive diagnosis includes any of the following:
• Confirmation of presence of IgG or IgM antibodies in serum by
ELISA or any method. • Detection of viral nucleic acid by PCR in specimen or isolation Specimen Collection: • Collect 5 ml of blood and separate serum for analysis of CCHF virus after centrifuge, observing strict safety precautions. If centrifuge is not available, store the blood specimens in a refrigerator until a clot is formed; then remove the serum and pipette it into an empty sterile tube (using a Pasteur pipette). • Transport serum specimens to the lab in triple packing with ice packs or frozen with dry ice along with a prominent Bio Hazard label and complete lab request form with brief history of the patient. Management:
• A suspected case of CCHF should be managed by diagnosing and treating for other likely causes of fever. If there is no response to anti-malarial and antibiotic treatment, the patient's platelet count should be checked and examined in view of the criteria mentioned above for "probable CCHF". All specimens of blood or tissues taken for diagnostic purposes should be collected and handled using universal safety precautions. • If the case meets the criteria for probable CCHF, begin isolation precautions, alert health facility staff, report the case immediately, draw blood samples for CCHF diagnostic confirmation and start treatment protocol below without waiting for confirmation. Patients with probable or confirmed CCHF should be isolated and cared for using barrier-nursing techniques – masks, goggles, gloves, gowns and proper removal and disposal of contaminated articles. Treatment Protocol General supportive therapy is the mainstay of patient management in CCHF. Intensive monitoring to guide volume and blood component replacement is recommended. If the patient meets the case definition for probable CCHF, oral ribavirin treatment protocol needs to be initiated immediately with the consent of the patient/ relatives and strictly in consultation with the attending physician. Oral Ribavirin: 2 gm loading dose 4 gm/day in 4 divided doses (6 hourly) for 4 days 2 gm/day in 4 divided doses for 6 days Please note that pregnancy should be absolutely prevented (whether female or male partner is victim) within six months of completing a course of ribavirin. Prophylaxis Protocol • In case of known direct contact with the blood or secretions of a probable or confirmed case such as needle stick injury or contact with mucous membranes such as eye or mouth, do baseline blood studies and start the person on the ribavirin protocol above in consultation with physician. • Household or other contacts of the case who may have had the same exposure to infected ticks or animals, or who recall indirect contact with case body fluids should be monitored for 14 days from the date of last contact with the patient or other source of infection by taking the temperature twice daily. If the patient develops a temperature of 38.5° C or greater, headache and muscle pains, he/she would be considered a probable case and should be admitted to hospital and started on ribavirin treatment as mentioned above.
Methods of control:
a) Preventive measures:
• Educate public about the mode of transmission through tick
bites, handling ticks and handling and butchering animals and the means for personal protection. • Tick control with acaricide (chemicals intended to kill ticks) is a realistic option for well-managed livestock production facilities. Animal dipping in an insecticide solution is recommended. • Avoid tick-infested areas when feasible. To minimize exposure, wear light colored clothing covering legs and arms. • Persons who work with animals in the endemic areas should take practical measures to protect themselves. They include the use of repellents on the skin (e.g. DEET) and clothing (e.g. permethrin) to prevent tick bites and wearing gloves or other protective clothing to prevent skin contact with infected tissues or blood. • In case of death of CCHF patient, family should be informed to follow safe burial practices. Please see EIC Publication: Guidelines for Management, Prevention and Control of CCHF. • Hospitals should maintain stock of Ribavirin. • Bio-safety is the key to avoid nosocomial infection. Patients with suspected or confirmed CCHF should be isolated and
cared for using barrier-nursing techniques to prevent
transmission of infection to health workers. Please see EIC Publication: Guidelines for Management, Prevention and Control of CCHF.

1. Kakar, F. 2004. Presentation at WHO Inter-Country Meeting on Emerging Infectious Diseases, Beirut, 6-8 April 2004. 2. Chin J. 2000. Control of Communicable Diseases Manual. Am Pub Health Assoc, seventh edition; Washington DC. p 54. 3. Athar MN, Baqai HZ, Ahmad M, Khalid MA, Bashir N, Ahmad AM, Balouch AH, Bashir K. 2003. Short Report: Crimean-Congo Hemorrhagic Fever outbreak in Rawalpindi, Pakistan, February 2002. Am J Trop Med Hyg 69(3): 284-287. 4. Lee GR, et al. (eds.) 1998. Wintrobe's Clinical Hematology. Part V Disorders of Hemostasis and Coagulation. Acquired Coagulation Disorders. NY: Lippincott. pp. 1739-1749. 5. Pantanowitz L. 2003. Mechanisms of thrombocytopenia in tick-borne diseases. The Internet Journal of Infectious Diseases. Volume 2, Number 2., accessed 18 October 2004. 6. An outbreak of Crimean-Congo hemorrhagic fever in western Anatolia, Turkey. Ertugrul B, Uyar Y, Yavas K, Turan C, Oncu S, Saylak O, Carhan A, Ozturk B, Erol N, Sakarya S. Int J Infect Dis. 2009 Apr 29. PMID: 19409826 7. Ecology of the Crimean-Congo Hemorrhagic Fever Endemic Area in Albania. Papa A, Velo E, Papadimitriou E, Cahani G, Kota M, Bino S. Vector Borne Zoonotic Dis. 2009 Apr 29. PMID: 19402760 8. Crimean Congo haemorrhagic fever, precautions and ribavirin prophylaxis: A case report. Tutuncu EE, Gurbuz Y, Ozturk B, Kuscu F, Sencan I. Scand J Infect Dis. 2009;41(5):378-80. PMID: 19343611 9. The role of ribavirin in the therapy of Crimean-Congo hemorrhagic fever: early use is promising. Tasdelen Fisgin N, Ergonul O, Doganci L, Tulek N. Eur J Clin Microbiol Infect Dis. 2009 Mar 20. PMID: 19301047 10. Crimean-Congo hemorrhagic fever in Greece: a public health perspective. Maltezou HC, Papa A, Tsiodras S, Dalla V, Maltezos E, Antoniadis A. Int J Infect Dis. 2009 Jan 18. PMID: 19155182 Dengue Fever
Classical and Haemorrhagic
Infectious Agent:
Flavivirus group

Mode of transmission:
Bite of infective mosquitoes, principally Aedes aegypti (day biting
Incubation period:
From 3 to 14 days
Alert Threshold:
One probable case is an alert and requires an immediate

Outbreak threshold
One confirmed case is an outbreak
Case Definition:
Suspected case:
Any person with acute febrile illness of two to seven days duration
AND two or more of the following symptoms: Headache, retro-
manifestations and leucopoenia. Probable Case: Any suspected case, which occurs in an area where an outbreak of Dengue exists, with laboratory-confirmed cases and presence of the vector. Confirmed Case: Any suspected case confirmed by laboratory isolation of the virus or by the IgM-ELISA test or by PCR. Probable Dengue Haemorrhagic Fever: A probable or confirmed case of dengue AND any two of the following: thrombocytopenia less than 100,000 /mm3, petechial or purpuric rash, epistaxis, haematemesis, haemoptysis, blood in stools, ecchymosis, gum bleeding, other haemorrhagic symptom - AND no known predisposing host factors for haemorrhagic manifestations. Specimen Collection: • Collect 5 ml of blood 5 days after on set of fever and separate serum for analysis after centrifuge. • Transport serum specimens along with complete lab request form with brief history of the patient. Management:
• Supportive treatment - there is no specific therapeutic agent. • Severe pains can be relieved by paracetamol but occasionally opiates are required. • Prevent access of day biting mosquitoes by screening patient or using a bed net. • Fluid replacement and corticosteroids are indicated in the haemorrhagic variety. • Take universal safety precautions to prevent contamination with blood or secretions. • Investigate contacts - determine place of residence of patient for 2 weeks before onset of illness. Prevention:
• Conduct community survey to determine density of vector mosquitoes and identify and destroy mosquito larval habitats and breeding sites such as old tyres, old water containers, etc. • Protect against day biting mosquitoes including use of screening, protective clothing and repellents. References
1. "Dengue Haemorrhagic Fever" – diagnosis, treatment, prevention and control; 2nd Edition, WHO, Geneva, 1997 WHO/SEARO, New Delhi 3. Disease surveillance and outbreak prevention and control of dengue 4. Dengue history in the eastern Mediterranean Region, page 61-67, 5. Paul RE, Petal AY, Mirza S, Fisher-Hoch SP, Luby SP. Department of Community Health Sciences, Agha Khan University, Karachi. Expansion of epidemic dengue viral infection to Pakistan 6. Qureshi JA, Notta NJ, Salahuddin N, Zamman V, Khan JA. An epidemic of dengue fever in Karachi – Associate clinical manifestations, journal of Pakistan Medical Association, 1997 July; 47 (7): 178-81 7. Dengue prevention and control, (Provisional agenda item 13.14 of the fifty-fifth World Health Assembly, March 2002 Dengue/Dengue Haemorrhagic Fever" WHO/SEARO, New Delhi 1998 9. Integrated vector management in the EMR, A training manual, WHO- 10. Chemical methods for the control of arthropod vectors and pests of public health importance, WHO, Geneva, 1984 11. Guidelines for the treatment of dengue/dengue haemorrhagic fever in small hospitals, WHO/SEARO 1999 12. Manson's Tropical Diseases, page 728 Fifth Edition 13. Skylark Sports and Travel Medicine 14. An Epidemic of Dengue Fever in Karachi. Associated Clinical Manifestations: Jazibeh A. Qureshi, Nasreen J. Notta, Naseem Salahudin5, Viqar Zaman J. Pak. Med Assoc: Vol 47, No 7, July 1997 15. Khawar Saleem and Irfan Sheikh,: Journal of the college of physicians and surgeons Pakistan 2008, Vol 18(10): 608-611 Dengue Fever- Information Sheet World Health Organization October 9, 2006 16. Rosen L. The global importance and epidemiology of Dengue Infection and disease in T. Pang and Pathmansthen, R. eds. Proceedings of International Conference, Dengue Haemorrhagic Fever Kualalumpur, Malaysia 1984, pp.1.6 17. Changing Pattern and outcome of Dengue Infection; Report from a teriary care hospital in Pakistan. Muhammad Wassay, Roomasa Channa, Maliha Jumani, Aafia Zafar. Department of Neurology, Agha Khan University Karachi. JPMA-58:488;2008 On the Final Size of Epidemics with Seasonality. Bacaër N, Gomes MG. Bull Math Biol. 2009 May 28. PMID: 19475453 18. High potential risk of dengue transmission during the hot-dry season in Nha Trang City, Vietnam. Tsuzuki A, Duoc VT, Higa Y, Yen NT, Takagi M. Acta Trop. 2009 May 22. PMID: 19467217 19. Clinical evolution of dengue in hospitalized patients. González AL, Martínez RA, Villar LA. Biomedica. 2008 Dec;28(4):531-43. Spanish. PMID: 19462558 20. Community beliefs and practices about dengue in Puerto Rico. Pérez-Guerra CL, Zielinski-Gutierrez E, Vargas-Torres D, Clark GG. Rev Panam Salud Publica. 2009 Mar;25(3):218-226. PMID: 19454149 21. Early clinical and biological features of severe clinical manifestations of dengue in Vietnamese adults. Binh PT, Matheus S, Huong VT, Deparis X, Marechal V.J Clin Virol. 2009 May 16. PMID: 19451025 22. Aedes albopictus, an arbovirus vector: From the darkness to the light. Paupy C, Delatte H, Bagny L, Corbel V, Fontenille D. Microbes Infect. 2009 May 18. [Epub ahead of print] PMID: 19450706 Diphtheria
Infectious agent:
Bacterium: Corynebacterium diphtheriae
Mode of transmission:
Contact (usually direct, rarely indirect) with the respiratory droplets
of a case or carrier; or
In rare cases, the disease may be transmitted though foodstuffs
(raw milk has served as a vehicle).
Incubation period:
Usually 2-5 days, occasionally longer.
Alert Threshold:
One suspected, probable or confirmed case is an alert and
requires an immediate investigation.

Outbreak threshold
One confirmed case is an outbreak
Case Definition:
Probable case:
An acute illness characterized by an adherent membrane on the
tonsils, pharynx and/or nose and any one of the following:
laryngitis, pharyngitis or tonsillitis.
Confirmed case:
A confirmed case is a probable case who has been laboratory
confirmed or linked epidemiologically to a laboratory confirmed
case. At least one of the following criteria is used for diagnosing a
confirmed case:
• The isolation of Corynebacterium diphtheriae from a clinical
• A four fold or greater rise in serum antibody (but only if both serum samples were obtained before the administration of diphtheria toxoid or antitoxin). Note that asymptomatic persons with positive C. diphtheriae cultures (i.e. asymptomatic carriers) should not be reported as probable or confirmed diphtheria cases. Specimen Collection: • Collect nasopharyngeal samples by using alginate swabs and throat culture by using cotton swabs. • Collect 5ml of clotted blood or serum (acute and convalescent phase) for serological diagnosis. • Transport in routine bacteriological transport media (Amies transport medium). Case Management:
• Do not wait for laboratory results before starting treatment/
control activities. • Diphtheria antitoxin I/M (20 000 to 100 000 units) in a single dose, immediately after throat swabs have been taken; plus
Procaine penicillin G I/M (25 000 to 50 000 units/kg/day for
children; 1 200 000 units/kg/day for adults in 2 divided doses)
or parenteral erythromycin (40-50 mg/kg/d with a maximum of
2 g/d) until the patient can swallow; then;
• Oral penicillin V (125-250 mg) in 4 doses a day, or erythromycin (40-50 mg/kg/day) in divided doses. Antibiotic treatment should be continued for total of 14 days. • Note: Clinical diphtheria does not necessarily confer natural immunity, and patients should thus be vaccinated before discharge from a health facility with either primary or booster doses. Contacts: • All close contacts, regardless of vaccination status, should have nose and throat cultures, receive a single dose of benzathine penicillin I/M (600 000 units for children < 6; 1.2 million units for 6 or older) or a 7-10 day course of erythromycin (PO), and remain under surveillance for 7 days. Those who handle milk or work with school children should remain at home until culture results are available. If culture is positive, give antibiotics as for patients above. Prevention and control:
• Give priority to immunization of population at risk in areas not yet affected where the outbreak is likely to spread. Repeat immunization one month later to provide at least 2 doses to recipients. • Vaccine containing diphtheria toxoid (preferably Td – tetanus- diphtheria) should be given. • To ensure safety of injection during immunization, employ proper techniques, use auto destroyable syringes and safety boxes for safe disposal of used sharps. • Vaccination consists of DPT 3 doses of 0.5 ml each/IM administered to the children less than one year of age according to the following schedule: 1st dose at age six weeks; 2nd dose at age ten weeks; 3rd dose at age fourteen weeks.
1. Communicable Disease Control in Emergencies - A Field Manual
2. Control of Diphtheria, Tetanus, Pertussis, Haemophilus influenzae type b (Hib), and Hepatitis B: Field Guide was designed by the Pan American professionals and field staff involved in the Expanded Program on Immunization (EPI) with a quick reference tool for these five diseases and the vaccines used to prevent them. 2005, approx. 87 pp., ISBN 92 75 11604 0 Code: SP 604. 3. IIZUKA, Hideyo; FURUTA, Joana Akiko and OLIVEIRA, Edison P. Tavares de. Diphtheria: immunity in an infant population in the city of S. Paulo, SP, Brazil. Rev. Saúde Pública [online]. 1980, v. 14, n. 4, pp. 462-468. ISSN 0034-8910. 4. Communicable Disease Control in Emergencies a Field Manual: MA Connolly/ CDS/2005.27 2005 World Health Organization 5. Monitoring equity in immunization coverage: Enrique Delamonica, Alberto Minujin, & Jama Gulaid /384 Bulletin of the World Health Organization May 2005, 83 (5) Acute Viral Hepatitis
Infectious agent:
Hepatitis means inflammation of liver and the most common
cause of acute hepatitis is infection with one of 4 viruses, called
hepatitis A, B, C, and E.
Mode of transmission:
• Hepatitis A virus (HAV) is spread through faecal-oral route, especially contaminated water and food. It is usually a mild, self-limited disease but may cause relapsing hepatitis for up to one year in 15% of cases. Infections occur early in life in areas where sanitation is poor and living conditions are crowded. • Hepatitis E virus (HEV) is transmitted by faecal-oral route similar to hepatitis A with faecally contaminated drinking water being the usual vehicle. HEV causes generally a mild self-limiting illness with no long-term sequelae, infecting mainly young adults, 15 to 30 years of age. However, the disease is especially severe in pregnant females in the third trimester with a case fatality reaching 20% in this group. It may also cause abortion, premature delivery, or death of a live-born baby soon after birth. HEV is a major cause of outbreaks and sporadic cases of viral-infections. • Hepatitis B virus (HBV) is transmitted by contact with blood or body fluids of an infected person in the same way as human immunodeficiency virus (HIV). Modes of transmission for Hepatitis B virus are vertical (from mother to baby at the time of delivery); unsafe injections (use and re-use of un-sterilized needles/syringes/drips etc.); blood transfusions, and sexual or household contact with an infected person. Chronic infection develops in about 90% of infants infected during the first year of life and 40% of children infected between 1 to 4 years of age. In Pakistan HBV is endemic and is one of the major causes of chronic hepatitis, liver cirrhosis and liver cancer. • Hepatitis D virus (HDV) mechanisms of transmission are similar to those of hepatitis B virus. HDV affects only those who have hepatitis B virus either as co-infection or super-infection of HBV and increases risk of severe acute disease and progression to chronic hepatitis. • Hepatitis C virus (HCV) is transmitted primarily by direct contact with human blood through un-screened transfusions, re-use of inadequately sterilized needles, syringes or other medical equipment, or through needle-sharing among drug-users. Sexual and perinatal transmission may also occur, although less frequently as compared to HBV. In Pakistan HCV is also endemic in some areas and contributes to chronic hepatitis, liver cirrhosis and primary liver cancer. • All of the hepatitis viruses can cause an acute disease with symptoms lasting several weeks including yellowness of the skin and eyes (jaundice); darker colour of urine; extreme fatigue; nausea; vomiting and abdominal pain. It can take several months to a year for a patient to feel fit again. Incubation period:
Hepatitis A (15 to 50 days, average 30 days), Hepatitis B (45 to
180 days, average 75 days, as short as 2 weeks to the
appearance of HBsAg), Hepatitis C (2 weeks to 6 months, most
commonly within 2 months), Hepatitis D (approximately 2-10
weeks) and Hepatitis E (2 to 9 weeks).
Alert Threshold:
A cluster of 3-5 cases in one location is an alert and requires

Outbreak threshold

A cluster of 8-10 cases in one location is an outbreak Case Definition
Suspected case viral hepatitis syndrome:
An acute illness with discrete onset of symptoms of jaundice, dark
urine, anorexia, malaise, extreme fatigue, and right upper
aminotransferase level >2.5 times the upper limit. Note: Most early childhood infections and a variable proportion of adult infections are asymptomatic. Confirmed case: A suspected case that meets the clinical case definition AND is laboratory confirmed for: • Hepatitis A: Anti-HAV IgM antibodies (anti-Hepatitis A virus immunoglobulin M) positive • Hepatitis B: Positive test of any: HBsAg (Hepatitis B surface antigen), Anti-HBs, Anti-HBc (antibody to Hepatitis B core antigen), HBeAg (Hepatitis B e antigen, indicates infectivity of patient), or Anti-HBe. • Hepatitis D: HDV-Ag (Hepatitis D antigen) positive • Hepatitis C: Anti-HCV (anti-Hepatitis C virus antibodies) • Hepatitis E: Anti-HEV immunoglobulin M (IgM) positive • For Hepatitis A only: a case compatible with the clinical description, in a person who has an epidemiological link with a laboratory-confirmed case of hepatitis A, e.g., household contact with an infected person during the 15-50 days before the onset of symptoms. Specimen Collection: • Collect 5 ml blood during acute phase of illness observing all safety precautions. • Separate serum by centrifugation technique or keep the blood sample refrigerated until the clot is formed and retracted completely. Separate serum in a tube. • Transport serum specimens either refrigerated (for serology) or frozen (for antigen detection by PCR) with complete lab request form. Specimens can be refrigerated by placing them in an insulated box with ice or frozen refrigerant packs. Frozen specimens can be kept frozen by shipping them on dry ice. • Batch the specimens and send by overnight mail. Management:
There is no specific management for acute uncomplicated
hepatitis but general supportive measures can be helpful in the
earlier recovery of the disease like bed rest, fluid replacement,
nutritional support etc. It is also important to avoid all the
hepatotoxic drugs during the illness. Alpha interferon and
Lamivudine are available therapeutic options for patients with
chronic hepatitis B and C. However, it is important to note that the
management of chronic hepatitis requires specialist consultation.
Hepatitis A and E:
• While no vaccine is available yet against Hepatitis E, an
effective inactivated hepatitis A vaccine is available both for adults and children aged 2 years or older. The vaccine is administered I/M with a recommended vaccination schedule of 0, 1, and 6-12 months. • As almost all HAV and HEV infections are spread by the faecal-oral route, good personal hygiene including frequent and proper hand washing after bowel practices and before food preparation, avoiding drinking water and/or ice of unknown purity and avoiding eating uncooked fruits or vegetables that are not peeled, high quality standards for public water supplies and proper disposal of sanitary waste are important measures to reduce the risk of disease transmission. For HAV post-exposure prophylaxis of non-vaccinated people, the passive administration of IG can modify the symptoms of infection, provided it is given within 2 weeks of exposure. Hepatitis B, C and D: • Hepatitis B virus has become a vaccine-preventable disease and both serum-derived and recombinant hepatitis B vaccines are safe and immunogenic. This vaccine is available in Pakistan as an integral part of the EPI schedule, with a standard administered I/M to the infant concurrently with DPT vaccination at weeks 6, 10 and 14. This schedule is consistent with the insignificant risk of perinatal transmission in the country. • No vaccines exist against HCV or HDV; however, vaccination against HBV of patients who are not chronic HBV carriers also provide protection against HDV infection. All measures aimed at preventing the transmission of HBV will prevent the transmission of hepatitis D and HBV-HDV co-infection or super infection. • For the prevention of HBV and HCV, implement and maintain infection control practices in health care settings, including appropriate sterilization of medical and dental equipment, screening and testing of blood and organ donors, and virus inactivation of plasma derived products; promote behaviour change among the general public and health care workers to reduce overuse of injections, use safe injection practices and build public awareness for safe and protected sex. HBV, HDV and HCV are not spread by contaminated food or water, and cannot be spread casually in the workplace. • For post-exposure prophylaxis or suspected perinatal transmission, Hepatitis B Immune Globulin (HBIG) 0.5 ml I/M is effective, followed by vaccine 1 and 6 months later. Comment
Persons who have chronic hepatitis should not be reported as
having acute viral hepatitis unless they have evidence of an acute
illness compatible with viral hepatitis (with the exception of
perinatal hepatitis B infection). Up to 20% of acute hepatitis C
cases will be anti-HCV negative when reported and will be
classified as non-A, non-B hepatitis because some have not yet
sero-converted and others remain negative even with prolonged
follow-up. Available serologic tests for anti-HCV do not distinguish
between acute and chronic or past infection. Thus, other causes
of acute hepatitis should be excluded for anti-HCV positive
patients who have an acute illness compatible with viral hepatitis.

1. Surveillance for acute viral hepatitis - United States, 2007.Daniels D,
Grytdal S, Wasley A; Centers for Disease Control and Prevention (CDC). MMWR Surveill Summ. 2009 May 22;58(3):1-27. PMID: 19478727 2. Epidemiology of Hepatitis E Virus in the United States: Results from the Third National Health and Nutrition Examination Survey, 1988-1994. Kuniholm MH, Purcell RH, McQuillan GM, Engle RE, Wasley A, Nelson KE. J Infect Dis. 2009 May 27. PMID: 19473098 3. Viral load, antibody titers and recombinant open reading frame 2 protein-induced TH1/TH2 cytokines and cellular immune responses in self-limiting and fulminant hepatitis e. Saravanabalaji S, Tripathy AS, Dhoot RR, Chadha MS, Kakrani AL, Arankalle VA. Intervirology. 2009;52(2):78-85. Epub 2009 Apr 28. PMID: 19401616 4. Molecular epidemiology of hepatitis E virus in Hong Kong. Tai AL, Cheng PK, Ip SM, Wong RM, Lim WW. J Med Virol. 2009 Jun;81(6):1062-8. PMID: 19382265 5. Hepatitis E virus in patients with unexplained hepatitis in Finland. Kantala T, Maunula L, von Bonsdorff CH, Peltomaa J, Lappalainen M. J Clin Virol. 2009 Apr 17. PMID: 9376741 6. An individual-based model of hepatitis A transmission. Ajelli M, Merler S. J Theor Biol. 2009 Apr 8. PMID: 19361529 [ Human Immunodeficiency Virus (HIV)
Infectious Agent:
Human Immunodeficiency Virus (HIV)

Mode of transmission:

1. Sexual intercourse (vaginal or anal) with an infected partner, especially in presence of a concurrent ulcerative or non-ulcerative sexually transmitted infection (STI); or 2. Contaminated needles (injecting drug users, needle-stick injuries, injections), 3. Transfusion of infected blood or blood products; or 4. Infected mother to her child during pregnancy, labour and delivery or through breast-feeding. Incubation period:
May be variable. On an average, time from HIV infection to clinical
AIDS is 8 to 10 years, though AIDS may be manifested in less
than 2 years or be delayed in onset beyond 10 years. Incubation
times are shortened in resource poor settings and in older
patients. They can be prolonged by provision of primary
prophylaxis for opportunistic infections or anti-retroviral treatment.

Case Definition:
Suspected case:
Not applicable.
Note: Sentinel sites should focus on testing high risk groups which
include patients seeking treatment for sexually transmitted
diseases, users of intravenous drugs, commercial sex workers
seeking health treatment, etc. Cases suspected at first level care
facility should be referred to second level care facility for
Confirmed case:
In 1997, UNAIDS and WHO issued revised recommendations for
the selection and use of HIV antibody tests. For diagnosis of HIV
infection following strategy is used
• If the sample is reactive with the first assay (A), test with
second assay (B). • If it is non reactive with the second assay, consider it to be "Indeterminate". • If serum is reactive in the second assay, test with the third • If non-reactive in the third assay, consider it to be "Indeterminate". If the serum is reactive in the third assay, report it to be HIV antibody positive. Specimen Collection: • Collect 5ml blood/serum sample observing all safety • For sero-diagnosis the specimen can be refrigerated at 4oC and transported to lab. • For antigen detection by PCR samples should immediately be freezed if delay is anticipated. • Transport specimens with complete lab request form and BioHazard label and send by overnight mail. Management:
In case of a confirmed case with HIV infection or AIDS, he/she
should receive counselling and be referred to tertiary level care
facility for treatment of virus and opportunistic infections such as
TB and for follow up.
Primary Prevention:
Prior to development of HIV infection, prevention focuses on
modifying the risk behaviours of persons in the community through
"behaviour change communication" (BCC).
Secondary Prevention:
Counselling: HIV Positive individuals must be counselled to lead
as normal a life as possible, but to take strict precautions
regarding sexual intercourse, disposal of used needles and other
sharps, and avoiding donating blood. Family and social contacts
must be reassured that the infection does not spread by casual
1. Reported care quality in federal Ryan White HIV/AIDS Program supported networks of HIV/AIDS care. Hirschhorn LR, Landers S, McInnes DK, Malitz F, Ding L, Joyce R, Cleary PD. AIDS Care. 2009 May 29:1-9. PMID: 19484615 2. Surveillance for acute viral hepatitis - United States, 2007. Daniels D, Grytdal S, Wasley A; Centers for Disease Control and Prevention (CDC). MMWR Surveill Summ. 2009 May 22;58(3):1-27. PMID: 19478727 3. A Qualitative Exploration of HIV/AIDS Health Care Services in Indian Prisons. Guin S. J Correct Health Care. 2009 May 7. PMID: 19477802 4. Shortage of healthcare workers in developing countries--Africa. Naicker S, Plange-Rhule J, Tutt RC, Eastwood JB. Ethn Dis. 2009 Spring;19(1 Suppl 1):S1-60-4. PMID: 19484878 Influenza
Infectious Agent:
Myxovirus group (Influenza virus) type A, B and C.
Mode of transmission:
Inhaling infected droplets from the air; spreads from person to
Incubation period:
24-28 hours.
Alert Threshold:
One suspected case is an alert and requires an immediate

Outbreak threshold

One confirmed case is an outbreak Case Definition:
Suspected Case:
Any person with sudden onset of fever greater than
39ºCentigrade, AND sore throat or cough in the absence of
another known cause. Headache, myalgias, and prostration are
often present.
Confirmed Case:
Any suspected case with laboratory confirmation by isolation of
virus in culture, by IFAT or by serologic test demonstrating a rise
in specific antibody titer.
Specimen Collection:
• Collect throat and nasal swabs and nasopharyngeal aspirates
from patient and tracheal aspirate or broncho-alveolar lavage fluid from intubated patients place immediately in Viral Transport Medium (VTM). • Collect 5ml blood or serum for serology (acute and convalescent if possible). • Transport specimens' bottles and tubes in upright position and secured in a screw cap container or in a rack in a transport box having enough absorbent paper around them to soak up all the liquid in case of spillage. • Sample for virus isolation collected in VTM can be taken to lab within 4 days, kept at +4oC and frozen at -70oC on arrival in lab if stored. • In the absence of freezers or VTM, ethanol preserved swabs are a possible alternative. Storage of such specimens at 4oC (in a standard refrigerator) is better than at room temperature. • Blood/serum samples should be frozen at -70oC for PCR and at -20oC or lower for antibody determination but can also be stored at +4oC for about one week. • Specimens for influenza virus isolation should not be stored or transported in dry ice unless they are sealed, taped and double plastic-bagged as CO2 (dry ice) can rapidly inactivate the virus if it gains access to the specimens. Management:
• The goal of treatment is to alleviate the symptoms. Antibiotics are not effective against viruses. Bed rest is advisable until the fever is subsided. • A mild analgesic such as paracetamol 0.5 - 1 g every 4-6 hours usually relieves the headache and generalized pains and warm fluids help to relieve the discomfort of the symptoms. • Pholcodine 5-10 mg 3-4 times daily may be used to suppress unproductive cough. • Specific treatment of complications such as bronchitis and pneumonia may be necessary. Prevention:
• Good ventilation of public buildings; • Avoidance of crowded places during an epidemic; • Encourage sufferer to cover their faces with a mask or handkerchief when coughing and sneezing; • Annual winter vaccination (Anti influenza vaccine) is recommended for patients suffering from chronic pulmonary, cardiac or renal disease. • For older individuals who have been exposed to the virus, the drug amantadine may be given to prevent them from actually getting the flu. This may also be used for treatment. References:

1. The development of a non-contact screening system for rapid medical inspection at a quarantine depot using a laser Doppler blood-flow meter, microwave radar and infrared thermography. Matsui T, Suzuki S, Ujikawa K, Usui T, Gotoh S, Sugamata M, Abe S. J Med Eng Technol. 2009 May 29:1-7. PMID: 19484686 2. Lay perceptions of the pandemic influenza threat. Raude J, Setbon M. Eur J Epidemiol. 2009 May 30. PMID: 19484363 3. MicroRNA-mediated species-specific attenuation of influenza A virus. Perez JT, Pham AM, Lorini MH, Chua MA, Steel J, Tenoever BR. Nat Biotechnol. 2009 May 31 4. Influenza A (H1N1): A new e-pidemic. Vilella A, Trilla A. Med Clin (Barc). 2009 May 30;132(20):783-784. Spanish. No abstract available. PMID: 19480889 5. Cluster of new influenza A(H1N1) cases in travellers returning from Scotland to Greece - community transmission within the European Union. Panagiotopoulos T, Bonovas S, Danis K, Iliopoulos D, Dedoukou X, Pavli A, Smeti P, Mentis A, Kossivakis A, Melidou A, Diza E, Chatzidimitriou D, Koratzanis E, Michailides S, Passalidou E, Kollaras P, Nikolaides P, Tsiodras S. Euro Surveill. 2009 May 28;14(21). pii: 19226. PMID: 19480814 6. Hospitalized patients with novel influenza A (H1N1) virus infection - California, April-May, 2009. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2009 May 22;58(19):536-41 PMID: 19478723 7. New influenza A(H1N1) virus infections in France, April - May 2009. New influenza A(H1N1) investigation teams . Euro Surveill. 2009 May 28;14(21). pii: 19221. PMID: 19480813 Infectious agent:
Trypanasomatidae, Leishmanania: L. donovani and L. infantum may cause visceral
leishmaniasis while L. tropica and L. major may cause cutaneous

Mode of transmission:
Spread by the bite of the sandfly. The sand fly bites on the skin
and the protozoan is transmitted to the blood stream. If animals
are the primary host reservoir, it is called zoonotic leishmaniasis; if
humans are the primary host reservoir, it is called anthroponotic

Incubation period:
Considered to be at least a week but may extend up to several
months. For zoonotic type it is considered to be about 4 months
and for the anthroponotic type it ranges from 6-12 months

Alert Threshold:
One suspected case is an alert and requires an immediate
Outbreak threshold
One confirmed case is an outbreak
Case Definition:
Two types of leishmaniasis occur in Pakistan: - cutaneous and
Suspected case • In cutaneous leishmaniasis there are lesions on the face, neck, arms, and legs, which begin as nodules and turn into skin ulcers, eventually healing but leaving a depressed scar. • In visceral leishmaniasis, the parasite invades the spleen, liver, bone marrow, and lymph nodes. Symptoms include mainly irregular fever, splenomegaly and weight loss; also fatigue, enlargement of the lymph nodes and the liver, secondary infections such as pneumonia, and it can be fatal if left untreated. Confirmed case Suspected cases with positive parasitological evidence from a stained smear by microscopy or culture from the lesion. Specimen Collection:
Cutaneous Leishmaniasis:
• Skin biopsy is the standard dermatologic technique for
obtaining specimen. • Slit-skin preparation or aspiration from the edge of the lesion by a well-trained staff is the alternate. • No preservatives are required for examining LD bodies in patient's sample or for leishmania culture. Visceral leishmaniasis:
• Collect 5ml clotted blood or serum for serologic studies.
• Splenic or bone marrow aspirate collected in a tube with
anticoagulant is required for demonstration of amastigotes. • Specimen can be transported at room temperature without
Intra-lesional Treatment:
treatment Patient' Calculate
dose (mls) / day
means carefully infiltrating the area around the lesion Antimony)
and the base, with a fine gauge (25g) needle and injecting the Glucantime / antimony under pressure as Treatments are every week up to five times. Systemic (intra-muscular) treatment: Injections should be given daily (with a break of one day for a week-end) for 14 days into the upper, outer quadrant of the buttock, alternating sides. If the response is poor by the 14th day, the treatment can be continued for 7 more days. Here is a table showing the correct doses for Glucantime and Pentostam on a scale based on a simplified formula relating body weight to surface area whereby a 20 Kg child receives 20 mg/kg of antimony. Prevention:
• Prevention of ACL is very similar to malaria, as sand flies bite
at night and indoors, permethrin treated bed nets, etc. Sandflies are generally more sensitive than mosquitoes to insecticide, i.e. residual spraying of indoor rooms (vector control). • Use of insecticide is unlikely to work in prevention of Zoonotic Cutaneous, as the sand fly vector tends to bite outdoors, so the most effective strategy is to poison or dig up the burrows of reservoir rodents. For more information, please consult the MoH/NIH/WHO publication (2002) called "Guidelines for the treatment and prevention of Cutaneous Leishmaniasis in Pakistan".

1. Tayeh A, Jalouk L, Al- Khiami AM. A cutaneous leishmaniasis control trial using pyrethroid-impregnated bednets in villages near Aleppo, Syria. WHO/Leish/97.41, August 1997. 2. Reyburn H. A guide to the treatment of cutaneous leishmaniasis in Afghanistan and Pakistan. 2002; Peshawar: Health Net International. 3. Momeni AZ, Javaheri AM. Clinical picture of cutaneous leishmaniasis in Isfahan, Iran. Int J Dermatol. 1994; 33(4):260-265. 4. Dogra J. Cutaneous leishmaniasis in India: evaluation of oral drugs (dapsone vs itraconazole). Europ J Dermatol. 1992; 2:568-569. 5. Wallace MR, Hale BR, Utz GC, et al. Endemic infectious disease of Afghanistan. Clin Infect Dis. 2002; 34:171-207. 6. A new focus of cutaneous leishmaniasis in the central area of Paraná State, southern Brazil. Soccol VT, Castro EA, Schühli GS, de Carvalho Y, Marques E, Pereira ED, Alcantara FD, Machado AM, Kowalthuk W, Membrive N, Luz E. Acta Trop. 2009 May 28. 7. Cutaneous leishmaniasis in Tunisia: discovery of leishmania infantum in south of the country. Masmoudi A, Ben Salah H, Meziou TJ, Bouzid L, Maalej S, Akrout F, Bouassida S, Baba H, Turki H, Zahaf A. Tunis Med. 2008 May;86(5):512-3. 8. Cutaneous leishmaniasis caused by Leishmania (L.) major infection in Sindh province, Pakistan. Bhutto AM, Soomro FR, Baloch JH, Matsumoto J, Uezato H, Hashiguchi Y, Katakura K. Acta Trop. 2009 May 22. 9. Sand fly salivary proteins induce strong cellular immunity in a natural reservoir of visceral leishmaniasis with adverse consequences for Leishmania. Collin N, Gomes R, Teixeira C, Cheng L, Laughinghouse A, Ward JM, Elnaiem DE, Fischer L, Valenzuela JG, Kamhawi S. PLoS Pathog. 2009 May;5(5):e1000441. Epub 2009 May 22. 10. Mucosal leishmaniasis: description of case management approaches and analysis of risk factors for treatment failure in a cohort of 140 patients in Brazil. Amato VS, Tuon FF, Imamura R, de Camargo RA, Duarte MI, Amato Neto V. J Eur Acad Dermatol Venereol. 2009 Apr 30. Infectious agent:
Protozoan parasite Plasmodium falciparum which is the most life
threatening form of the disease and Plasmodium vivax which
causes the less severe form of the disease.
Mode of transmission:
Bite of infected female Anopheles mosquito. May also be rarely
transmitted by injection of infected blood (transfusion malaria).
Incubation period:
Average incubation period for P. falciparum is 12 days and for P.
vivax is 13-17 days
Alert Threshold:
1.5 times the mean of cases in the previous three weeks, by
reporting sit, is an alert and requires investigation.

Outbreak threshold

Clustering of cases in a particular locality on alert investigation. Case Definition:
Suspected case of uncomplicated malaria:
• History of recent fever (may be continuous or irregular in
beginning), chills, headache, body aches, weakness, anaemia, hepato-splenomegaly. (In falciparum infection the fever may be continuous with bouts of high peaks.) Suspected case of severe or complicated malaria: • Only Falciparum malaria can develop into severe malaria if not treated promptly, especially in children and pregnant women. • History of fever with prostration (inability to sit), altered (followed by coma), difficulty in breathing, low urinary output or dark urine, severe anaemia, abnormal bleeding, and hypoglycaemia. (The parasites may not be visible in peripheral smears, as they are sequestrated in the capillaries). Probable case: A suspected case with history of same type of manifestation in other members of the household; or in the same patient in the past. Confirmed case: Clinical case, which is confirmed by: • Laboratory diagnosis of malarial parasites in peripheral blood • Parasite antigens by immunodiagnostic test kit. Specimen Collection: • Collect 3-5ml blood in a tube with anticoagulant (EDTA) for demonstration of malarial parasites in peripheral blood film. • Sample may also be used to demonstrate parasite antigen by immunodiagnostic test kit. • Transport the specimen at room temperature preventing sample spillage or damage to the tubes. Management:
Early diagnosis and treatment especially in children and pregnant
women is essential. The management requires the following
Clinical Malaria:
First line drug: Chloroquine (each tab. Contains with 150 mg base
+ 5 ml syrup with 50 mg base), three-day course with the following
doses: Day Zero, 10 mg/kg body weight, Day One, 10 mg/kg body
weight and Day two, 5mg/kg body weight:
Second Line drug: Sulfadoxine + pyrimethamine, (each tab. or 5
ml. Syrup. contains 500 mg S, & 25mg P). Dose = 25 mg of
Sulfadoxine /kg body weight (single dose) (up to maximum adult
dose of 3 tabs).
Vivax Malaria:
First line drug: Chloroquine (no resistance has been reported to
Chloroquine in vivax malaria).
Uncomplicated Falciparum Malaria: First line drug: Chloroquine
(dose as above).
Second line drug: Sulfadoxine/ pyrimethamine (dose as above).
Third line: Quinine (each tab. with 600 mg. of the salt). Dose 10
mg /kg body wt. 3 times daily for 7 days
Severe or complicated Falciparum Malaria:
Give the first dose of Chloroquine or of quinine orally if possible,
bring down the temperature and shift the patient to a hospital with
intensive care facilities.
Radical Treatment:
Vivax: (for prevention of relapse) Primaquine tab. - 0.25 mg/kg
daily for 5 days.
Falciparum: (as an anti-gametocide) Primaquine tab. - 0.25 mg/kg
daily for 3 days.
• Do not give primaquine to pregnant women and children below
2 years of age, and it is advisable to do a Glucose 6-Phosphate dehydrogenase test before giving this drug. Give primaquine preferably after the patient has recovered from the acute illness. • Do not give undiluted chloroquine or quinine by I/M or I/V route, as it can cause sudden cardiac arrest, especially in children. • Do not give Sulfadoxine/ pyrimethamine to children below 2 months of age or during first trimester of pregnancy. • Halofantrine (Halfan) is potentially a cardio-toxic drug and should be used under strict government control, according to WHO recommendations. Prevention:
• Promote personal protection measures like wearing long sleeves and trousers outside the houses in the evening. Use of repellent creams and sprays. Avoidance of nighttime outside activities. • Screen windows and use of mosquito nets. • Use mosquito's coils or vaporizing mat containing a pyrethrin. • Destroy breeding places of mosquitoes by filling in ditches where water stands or stagnates. • Use bed-nets (preferably insecticide impregnated nets) in highly endemic area especially for high-risk groups (pregnant women & children). • Control of anopheline mosquitoes, especially by spraying of houses with residual insecticides aerosol has reduced or abolished the risk of malaria. • Insecticide spray, which is costly and hazardous to the environment, is recommended only in emergency situations with insecticides like Deltamethrine, and larvicides like Temephos. • Prompt diagnosis and treatment of cases to prevent spread of References:
1. Protecting infants against measles in England and Wales: a review. Manikkavasagan G, Ramsay M. Arch Dis Child. 2009 May 19. [Epub ahead of print] PMID: 19457878 2. A measles outbreak in the Irish traveller ethnic group after attending a funeral in England, March-June 2007. Cohuet S, Bukasa A, Heathcock R, White J, Brown K, Ramsay M, Fraser G. Epidemiol Infect. 2009 May 27:1-7. 3. Epidemiological and molecular studies of measles at different clusters in hokkaido district, Japan, 2007. Nagano H, Jinushi M,
Tanabe H, Yamaguchi R, Okano M. Jpn J Infect Dis. 2009 May;
4. Laboratory diagnosis of measles and rubella infection. Nakayama T. Vaccine. 2009 May 21;27(24):3228-9. Epub 2009 Feb 28. PMID: 19446196 5. Vaccine coverage for 10-11 year-old children in Finistère, France in 2004: comparison with national average. Thébaud V, Lietard C, Ktaiche D. Sante Publique. 2009 Jan-Feb;21(1):55-64. French. PMID: 19425520 6. Cold War, deadly fevers: Malaria eradication in Mexico 1955-1975. Rodriguez J. Glob Public Health. 2009 May 27:1-3. [Epub ahead of print] No abstract available. PMID: 19479592 7. Regulatory elements within the prodomain of falcipain-2, a cysteine protease of the malaria parasite Plasmodium falciparum. Pandey KC, Barkan DT, Sali A, Rosenthal PJ. PLoS ONE. 2009 May 27;4(5):e5694. 8. Potential of integrated continuous surveys and quality management to support monitoring, evaluation, and the scale-up of health interventions in developing countries. Rowe AK. Am J Trop Med Hyg. 2009 Jun;80(6):971-9. 9. Effect of malaria rapid diagnostic tests on the management of uncomplicated malaria with artemether-lumefantrine in kenya: a cluster randomized trial. Skarbinski J, Ouma PO, Causer LM, Kariuki SK, Barnwell JW, Alaii JA, de Oliveira AM, Zurovac D, Larson BA, Snow RW, Rowe AK, Laserson KF, Akhwale WS, Slutsker L, Hamel MJ. Am J Trop Med Hyg. 2009 Jun;80(6):919-26. 10. Marked increase in child survival after four years of intensive malaria control. Kleinschmidt I, Schwabe C, Benavente L, Torrez M, Ridl FC, Segura JL, Ehmer P, Nchama GN. Am J Trop Med Hyg. 2009 Jun;80(6):882-8. PMID: 19478243 Infectious agent:
Measles virus, a member of the genus Morbillivirus in the family
Mode of transmission:
Spread via airborne droplets or
Direct contact with nasal or throat secretions of an infected
patients or
Direct contact with items infected with such nasal or throat
Incubation period:
It is considered to be on an average of 10-12 days after exposure
to infection with a maximum range of 7-18 days.
Alert Threshold:
One case of measles is an alert and requires an investigation.

Outbreak threshold

Five or more cases in one location is an outbreak Case Definition:
Suspected Case
A patient presenting with complaints of fever with rash should be
investigated as a suspected case of measles.
Probable Case
A probable case is characterized by the following symptoms:
• Fever > 38.3ºC (101ºF)
• Cough, coryza (i.e. runny nose), or conjunctivitis (i.e. red eyes)
• Generalized maculopapular rash (non-vesicular type) for at
least 3 days, usually lasting 5-6 days. The rash begins at the hairline, and then involves the face and upper neck. During the next three days, gradually proceeds downward and outward, reaching extremities last and being less pronounced on hands and feet. Rash fades in the same order that it appears, from head to feet. • Koplik's spots may occur 1-2 days before rash to 1-2 days after rash. They appear as pinpoint, depressed blue white spots on bright red background on the buccal mucosa. Confirmed Case Measles case is confirmed by the laboratory, in the absence of recent (1-14 days) immunization with measles-containing vaccine, with one of the following: • Isolation of measles virus from an appropriate clinical • Significant rise (about 4 fold) in measles specific antibody titer between acute and convalescent sera OR • Positive serologic test for measles IgM antibody using a recommended assay Clinical measles in a person who is epidemiologically linked to a laboratory-confirmed case is also considered to be a confirmed case Specimen Collection: • Collect throat swab in Viral Transport Medium (VTM) for detection of measles virus as soon as possible after the onset of rash and 5ml blood, centrifuged for serum separation at 3000 rpm for 5 minutes. • Store serum at 4 to 8oC for not more than 48 hours. Do not freeze the whole blood. • If centrifugation is not possible, blood should be kept in refrigerator until there is complete retraction of the clot from the serum. • Carefully remove the serum and transfer aseptically to a sterile • Transport the specimens in zip lock plastic bags with complete request form along with the cold chain Management:
For uncomplicated cases:
Give Vitamin A and advise to treat the child at home if no
complications develop (control fever, treat mouth ulcers, provide
nutritional feeding)
For complicated cases:
• Refer to health facility
• Ensure that 2 doses of Vitamin A are given
• Clean eyes and treat with 1% tetracycline eye ointment
• Clean ear discharge and treat with antibiotics
• Treat malnutrition and diarrhoea with sufficient fluids and high
• Treat pneumonia with antibiotics • Refer suspected encephalitis to hospital Prevention:
• Immunize the population at risk as soon as possible. Children who are vaccinated against measles before 9 months of age must receive a second measles vaccination. This should be given at nine months with at least one month between first and second vaccination. Any child who received measles vaccine should also receive Oral Polio Vaccine. • The priority is to immunize children 6 months to 5 years old, regardless of vaccination status or history of disease. Expansion to older children is of less priority and should be based on evidence of high susceptibility among this age group. • All children 6 months - 5 years of age should also receive prophylactic Vitamin A supplementation. If evidence of clinical vitamin A deficiency in older age groups, treatment with Vitamin A should be initiated as per WHO guidelines. • To ensure safety of injection during immunization, auto destructible syringes and safety boxes are recommended. Safe disposal of used sharps should be ensured. Meningococcal Meningitis Infectious agent:
Caused by diplococcal Neisseria meningitidis with serotypes A, C,
Y, or W-135. Note that meningococcal meningitis is the main
cause of epidemic meningitis. Majority of cases are in children
under age five and case fatality is between 5-15%.
Mode of transmission:
It is transmitted by direct contact with respiratory droplets from
nose and throat of infected people.
Incubation period:
Varies from 2 to 10 days, and most commonly is between 3-4
Alert Threshold:
One case is an alert and requires investigation.
Outbreak threshold
Two confirmed cases from the same location is an outbreak. Case Definition:
Suspected case
Any person with acute illness that demonstrates:
• Sudden onset of fever (> 38.5 º C rectal or > 38 º C axillary),
AND one or more of the following: neck stiffness, altered consciousness, other meningeal sign or petechial or purpural rash. • In-patient under one year of age, when fever is accompanied by a bulging fontanelle. Probable case A suspected case of meningococcal meningitis with turbid CSF, OR, link to a confirmed case. Confirmed case A suspected or probable case with positive CSF antigen detection for Neisseria meningitides; or, A culture positive result from CSF and /or blood sample with identification of Neisseria meningitidis. Specimen Collection: • Collect 2-3 ml of CSF under aseptic measures through lumber puncture in a sterile screw-capped container for chemical analysis, latex particle agglutination test and culture for Neisseria meningitides. • Blood samples should directly be inoculated in blood culture • Transport the specimen immediately (within a maximum of one hour) to the lab. If delay is anticipated, sample should be inoculated in Trans Isolate Medium (TIM). Management:
The following antimicrobial therapy must be started immediately:
• Penicillin G, 4 million. 6 hourly I.V. up to 24 million units/day in
• Ceftriaxone 2 grams I.V. b.i.d. per day. • Chloramphenical in penicillin allergic patients, 100 mg/kg/day I.V. up to 4 grams /day. Other antimicrobials should be considered depending upon availability of local sensitivity patterns. • Mannitol I.V. can be used if signs of raised intra-cranial pressure are present. • Sometimes systematic corticosteroids are also indicated. • Treatment of convulsions with diazepam. • General supportive measures are important. Prevention:
• Household and other close contacts of patients with meningococcal infections, especially children, should be given Rifampicine 600 mg twice daily for 2 days. Children under one year are given 5-mg/Kg body weight 12 hourly and those over 12 months 10 mg/kg 12 body weight hourly. In case of contraindication, Ceftriaxone single dose of 250 mg for adults and 125 mg for children. • An effective tetravalent capsular polysaccharide vaccines (containing A, C, Y and W-135 polysaccharides) is available to prevent meningococcal infections but is contraindicated in those under age 2 and pregnant women. Tetravalent vaccine should be administered to all intimate contacts of index cases at the start of chemoprophylaxis. Its immunity lasts for 3 years; a booster dose is advised every year. • The risk of the disease is often seasonal; one subcutaneous injection is advisable at minimum.

1. Epidemiology of Pertussis and Haemophilus influenzae type b Disease in Canada With Exclusive Use of a Diphtheria-Tetanus-Acellular Pertussis-Inactivated Poliovirus-Haemophilus influenzae type b Pediatric Combination Vaccine and an Adolescent-Adult Vaccine: Implications for Disease Prevention in the United States. Greenberg DP, Doemland M, Bettinger JA, Scheifele DW, Halperin SA, Waters V, Kandola K; for the IMPACT Investigators. Pediatr Infect Dis J. 2009 May 11. PMID: 19436236 2. Neonatal pertussis in Africa: A case report. Nagalo K. Arch Pediatr. 2009 May 5. [Epub ahead of print] French. PMID: 19423306 3. Pertussis vaccination in newborns. Ulloa-Gutierrez R. Expert Rev Vaccines. 2009 Feb;8(2):153-7. PMID: 19196195 4. Response to an education program for parents about adult pertussis vaccination. Tam PY, Visintainer P, Fisher D. Infect Control Hosp Epidemiol. 2009 Jun;30(6):589-92. PMID: 19419326 5. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. N Engl J Med. 2009 May 7;360(19):1981-8. PMID: 19420367 6. Vaccine coverage for 10-11 year-old children in Finistère, France in 2004: comparison with national average. Thébaud V, Lietard C, Ktaiche D. Sante Publique. 2009 Jan-Feb;21(1):55-64. French. PMID: 19425520 Pertussis
(Whooping Cough)
Infectious agent:
Bacterium- Bordetella pertussis
Mode of transmission:
Primarily by direct contact with respiratory droplets of infected
person by the airborne route. Most frequently the infection is
brought within a home by an older sibling and sometimes by a
Incubation period:
7-14 days
Case Definition:
Suspected case:
A person with a cough lasting at least 2 weeks with one of the
Paroxysms (i.e. fits) of coughing; or
Inspiratory "whoop"; or
Post-tussive vomiting (i.e. vomiting immediately after coughing)
AND without other apparent cause
Confirmed case:
A confirmed case is a suspected case that is laboratory confirmed
or linked epidemiologically to a laboratory confirmed case.
The criteria used for laboratory diagnosis are:
• The isolation of Bordetella pertussis; or
• The presence of IgG or IgA directed toward pertussis toxin
(PT) or filamentous haemaglutinin antigen (FHA) or PCR positive. Specimen Collection: • Collect duplicate nasopharyngeal specimen using calcium alginate swabs on fine flexible wire. • Bronchial or nasopharyngeal secretions/aspirates may provide superior specimens for culture. • Collect throat swabs in addition to the nasopharyngeal swabs for isolation of organism on culture. • Direct plating at bedside of the patients on a freshly prepared Bordet Gengou (BG) medium is the most reliable method for culturing Bordetella. • In absence of direct plating the Reagan Lowe (RL) transport medium may be used for sample transportation, which is stable for 2 months if refrigerated. Management:
Young infants particularly those younger than 6 months of age
should be hospitalized and mild cases require only supportive
• Erythromycin 30-50 mg/kg body weight (in two to four divided
doses) a day for 14 days to prevent bacteriologic relapse. • Methadone (cough suppressant) may be helpful in controlling the severity of paroxysms When the illness is of long duration and vomiting is frequent, skilled nursing will be required to maintain nutrition, especially in infants and young children. Seriously ill infants should be kept in a darkened, quiet room and disturbed as little as possible, since any disturbance can precipitate serious paroxysmal spells with anoxia. Specific attention must be devoted to the maintenance of proper water and electrolyte balance, adequate nutrition and sufficient oxygenation. Prevention:
All household and close contacts, irrespective of age or
immunization status, should receive chemoprophylaxis with
erythromycin 40-50 mg/kg per day in four divided doses for 14
Active immunization:
Vaccination consists of 3 doses of 0.5 ml each/IM administered to
the children less than one year of age according to the following
weeks interval in EPI: 1st dose at the age of six weeks; 2nd dose
at the age often weeks; 3rd dose at the age of fourteen weeks.
Passive immunization is unreliable and is not recommended.
Human Plague
Infectious agent:
Bacterium - Yersinia pestis
Mode of transmission:
Bite of infected fleas especially Xenopsilla cheopis (rat fleas).
Person to person transmission is rare but possible through direct
exposure to infected tissues, or respiratory droplets for the
pneumonic form.
Incubation period:
Ranges from 1 to 7 days

Alert Threshold:
One probable case is an alert and requires an immediate

Outbreak threshold
One confirmed case is an outbreak
Case Definition:
Suspected case:
A case characterized by rapid onset of fever, chills, headache,
severe malaise, prostration together with the following symptoms,
depending upon whether it is the bubonic or the pneumonic form:
• Bubonic form: Extreme painful swelling of lymph glands
• Pneumonic form: Cough with blood-stained sputum, chest pain, difficulty in breathing Probable case: A probable case is a suspected case with: • A positive FA test for Yersinia pestis in clinical specimen; or • PHA test, with antibody titre of > 1:10, specific for the F1 antigen of Y. pestis as determined by HI; or an epidemiological link with a confirmed case. Confirmed case: A confirmed case is a suspected or probable case laboratory- confirmed by: • Isolation by culture of Y. pestis from buboes, cerebrospinal fluid or sputum; or • PHA test demonstrating a four fold change in antibody titre, specific for F1 antigen of Y. pestis (HI test) in paired sera. Note: Case report universally required by International Health Regulations. Specimen Collection: • Specimens best suited for culturing include: fluid aspirated from bubo, sputum and blood (multiple), lymph node, bone marrow and lung tissues • Serum taken during the early and late stages of infection can be examined to confirm infection. • Rapid dipstick tests have been validated for field use to quickly screen for Y. pestis antigen. • The specimens (except blood/serum) may be placed in Cary- Blair (enteric) transport media. In the absence of CBT, any sterile container may be used for transportation to the laboratory as quickly as possible. Management:
• Streptomycin is the most effective antibiotic against Y. pestis and the drug of choice for treatment of plague, particularly the pneumonic form. • Standard patient-care precautions should be applied to management of all suspected plague patients. These include prescribed procedures for hand washing, wearing of latex gloves, gowns, and protective devices to protect mucous membranes of the eye, nose and mouth during those procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. • Isolation is necessary only in case of pneumonic form Prevention:
This largely depends on preventing biting by fleas carrying plague.
• Rats should be controlled.
• Powder containing 1.5% dieldrin or 2% Aldrin should be
applied to household floor and blown into rat holes kill all the fleas and remain active for 9-12 weeks. • In endemic areas people should avoid handling and skinning Patients should be isolated and attendants must wear gowns, masks and gloves. Health personnel conducting laboratory tests or post-mortem exam should take strict precautions. Persons in close contact with pneumonic plague patients should receive antibiotic prophylactic therapy (tetracycline 2g daily or chloramphenicol for a week) within 6 days if they have: • Been exposed to Y. pestis-infected fleas • Had direct contact with body fluids or tissues of a Y. pestis- • Been exposed during a laboratory accident to known infectious Immunization:
Worldwide, live attenuated and formalin-killed Y. pestis vaccines
are available for human use. They however do not protect against
primary pneumonic plague.
In general, immunizing communities is not feasible; further
immunization is of little use during human plague outbreaks, since
a month or more is required to develop a protective immune
The vaccine is indicated for persons whose work routinely brings
them into close contact with Y. pestis, such as laboratory
technicians in plague reference laboratories and persons studying
infected rodent colonies.

1. Identification of flea blood meals using multiplexed real-time
polymerase chain reaction targeting mitochondrial gene fragments. Woods ME, Montenieri JA, Eisen RJ, Zeidner NS, Borchert JN, Laudisoit A, Babi N, Atiku LA, Enscore RE, Gage KL. Am J Trop Med Hyg. 2009 Jun;80(6):998-1003. PMID: 19478265 Immunochromatographic Tests for the Detection of Yersinia pestis Antibodies in Humans and Reservoirs. Rajerison M, Dartevelle S, Ralafiarisoa LA, Bitam I, Tuyet DT, Andrianaivoarimanana V, Nato F, Rahalison L. PLoS Negl Trop Dis. 2009;3(4):e421. Epub 2009 Apr 28. PMID: 19399164 3. Effects of the removal of large herbivores on fleas of small mammals. McCauley DJ, Keesing F, Young T, Dittmar K. J Vector Ecol. 2008 Dec;33(2):263-8. PMID: 19263845 4. Plant-derived recombinant F1, V, and F1-V fusion antigens of Yersinia pestis activate human cells of the innate and adaptive immune system. Del Prete G, Santi L, Andrianaivoarimanana V, Amedei A, Domarle O, D' Elios MM, Arntzen CJ, Rahalison L, Mason HS. Int J Immunopathol Pharmacol. 2009 Jan-Mar;22(1):133-43. PMID: 19309560 5. Chloroplast-derived vaccine antigens and biopharmaceuticals: expression, folding, assembly and functionality. Chebolu S, Daniell H. Curr Top Microbiol Immunol. 2009;332:33-54. PMID: 19401820 Infectious agent:
Enterovirus subgroup, family Picornaviridae, having three related
serotypes 1, 2 and 3, each capable of causing paralysis and
infection with one does not confer protection against the other two
Mode of Transmission:
Poliovirus is transmitted person-to-person most frequently through
the fecal-oral route. It replicates after entry into mouth in pharynx,
GI Tract and local lymphatics. Through viraemia, it reaches central
nervous system and spread along nerve fibers.
Poliovirus is highly infectious and cases are most infectious from 7
to 10 days before and after paralysis onset
Incubation period:
10 - 21 days.
Humans are the only known reservoir.
Alert Threshold:
One case is an alert requires an immediate notification and
sample for confirmation.

Outbreak threshold

One confirmed case is an outbreak. Case Definition:
Suspected case [acute flaccid paralysis (AFP)]:
Any child under 15 years of age with recent onset of floppy
weakness of any cause including Guillian-Barre Syndrome or any
person of any age with a paralytic illness, in whom poliomyelitis is
Confirmed Poliomyelitis cases as per Virological Classification
"An AFP case, from which, the wild poliovirus is cultured". This
definition is applied if a country programme has non-polio AFP
rate of 1/100,000 children under 15 years of age, two adequate
specimens collected from at least 60% of all AFP cases and all
specimens processed in a WHO-accredited laboratory. Adequate
stool specimens are two stools collected at least 24 hours apart, within 14 days of onset of paralysis, and arriving lab with proper documentation, maintained reverse cold chain, sufficient quantity for laboratory analysis without drying or leakage. Compatible case: A case of acute flaccid paralysis (AFP) in which a diagnosis of poliomyelitis cannot be excluded with confidence based on all available clinical and epidemiological information in the absence of good viral cultures, by the Expert Review Committee. Discarded case: A discarded case is an AFP case, which is neither diagnosed as confirmed nor compatible with a polio case definition. Specimen Collection: • Collect 2 stool samples about 8 grams each (about the size of the tip of thumb) at an interval of 24 to 48 hours for virus isolation as soon as possible or within 14 days of onset of illness in a clean, leak proof, screw-capped container, preferably in a transport medium like Minimal Essential Medium or Eagle's medium. • Seal the container with tape. • Place samples immediately after collection in refrigerator at 2- 8oC or in a cold box with frozen ice packs. • Transport specimens to the lab maintaining cold chain with duly filled request form within 72 hours after collection. • The set of specimens from a single patient should be placed in a single plastic bag just large enough to hold both the containers. Management:
Management depends on the severity of infection and includes
recognition of disease and extent of damage it has caused.
Management in different phases is as below: -
Inapparant Poliovirus Infection without symptoms (90-95%
Infection is not apparent and there are no symptoms. Infected
person with virus shed virus in stool, and are able to transmit the
virus to others.
Abortive Poliovirus Infection (4 8% of infection)
This has non-specific illness with three syndromes observed
usually: - upper respiratory tract infection (sore throat and low
grade fever), gastrointestinal disturbances (nausea, vomiting, abdominal pain, constipation or, rarely, diarrhoea), and influenza-like Illness. These syndromes are difficult to distinguish from other viral illnesses. Treatment is Symptomatic and recovery is rapid and complete. Nonparalytic poliomyelitis (l-2% of poliovirus infection) Non-paralytic aseptic meningitis may cause stiffness of neck, back and/or legs, usually following several days of prodromal symptoms. Increased or abnormal sensations can also occur. Symptoms last from 2 to 10 days and typically there is complete recovery. Paralytic Poliovirus Infection (<1% of infection) Poliovirus invades and replicates in motor neurons of the anterior horn and brain stem resulting in cell destruction and causing the typical clinical manifestations of poliomyelitis. The actual clinical signs depend on which region of the central nervous system is affected. There could be Spinal polio, most common, Bulbar Polio and Bulbo-spinal Polio. Of paralytic cases, as many as 5-10% is fatal, 10% recover completely and the remainder may have partial recovery with residual paralysis/ weakness Spinal paralysis Results from the infection of the lower motor neurons and typically affects only one leg having acute flaccid paralysis. Paralytic illness usually starts 1 to 10 days after prodromal symptoms. Progression to maximum paralysis is rapid (24 days). Paralysis is usually associated with fever and muscle pain and spasms that rarely continue after the temperature has returned to normal. Spinal paralysis is typically asymmetric (i.e. one side affected to a greater degree than the other), more severe proximally than distally, and deep tendon reflexes are absent or diminished. There is no sensory loss or change in cognition. Treatment includes bed rest, symptomatic treatment, Orthopaedic/ re-constructive surgery and rehabilitation physical and social. Bulbar Poliomyelitis: - This is more serious and involves neurons in the brainstem and, therefore, affects breathing. Encephalitis results from the infection of the brain itself; it makes up 1% of all cases and is usually fatal. Treatment is artificial breathing, if breathing muscles affected and other treatment same as above for paralytic polio. Prevention:
All children aged 0-59 months should be vaccinated with Oral
Polio Vaccine (OPV) through routine and supplementary
immunization activity, such as National Immunization days (NIDs)
regardless of vaccination status.

1. Coverage of recommended vaccines in children at 7-8 years of age
in Flanders, Belgium. Theeten H, Vandermeulen C, Roelants M, Hoppenbrouwers K, Depoorter AM, Van Damme P. Acta Paediatr. 2009 May 7. PMID: 19432835 2. Polio eradication remains a challenge. Falleiros-Carvalho LH. Vaccine. 2009 May 11;27(21):2731-2. Epub 2009 Jan 29. No abstract available. PMID: 19428885
3. Seroprevalence of anti-polio antibodies in a population 7 months to
39 years of age in Uruguay: Implications for future polio vaccination strategies. Pírez MC, Olivera I, Diabarboure H, Montano A, Barañano R, Badía F, Bonnet MC. Vaccine. 2009 May 5;27(20):2689-94. Epub 2009 Feb 24. PMID: 19428880 4. Vaccine-derived poliovirus (VDPV): Impact on poliomyelitis eradication. Minor P. Vaccine. 2009 May 5;27(20):2649-52. Epub 2009 Mar 3. PMID: 19428874 5. Vaccine coverage for 10-11 year-old children in Finistère, France in 2004: comparison with national average Thébaud V, Lietard C, Ktaiche D. Sante Publique. 2009 Jan-Feb;21(1):55-64. French. PMID: 19425520 6. Why polio has not been eradicated in India despite many remedial interventions? Paul Y. Vaccine. 2009 Jun 8;27(28):3700-3. Epub 2009 Apr 16. PMID: 19464552 Severe Acute Respiratory Syndrome
Infectious agent
Severe Acute Respiratory Syndrome (SARS) is an acute viral
infection of respiratory tract, first recognized on 26th February
2003 in Hanoi, Viet Nam. Out of 8,447 persons infected that year,
811 died (9.6% CFR) in 33 countries in Asia, Europe, Middle East,
North, Central and South America. The infectious agent has been
presumptively identified as a novel Coronavirus, provisionally
named as SARS-CoV.
Mode of transmission
SARS is primarily transmitted through inhalation of aerosol and/or
droplet infection of an affected individual but also by direct contact
through contaminated hands, surfaces and body fluids.
Incubation Period
Up to 10 days
Clinical picture
Initially flu-like symptoms, rapid onset of high-grade fever (>38°C) followed by muscle aches, headache, sore throat. In some cases, there may be bilateral pneumonia, progressing to acute respiratory distress requiring assisted breathing on respirator. It may be associated with other symptoms like loss of appetite, malaise, confusion, rash and diarrhoea. Early lab findings may include thrombocytopenia and leucopoenia. Case definition
Suspected case
1. A person presenting after 1st November 2002 with history of:
• High grade fever (>38ºC) AND
• Cough or breathing difficulty AND
• One or more exposures during the 10 days prior to the onset
o Close contact with a person who is a suspect or probable o History of travel, to an area with recent local transmission o Residing in an area with recent local transmission of 2. A person with an unexplained acute respiratory illness resulting in death after 1st November 2002, but on whom no autopsy has been performed AND • One or more of the following exposures during 10 days prior to onset of symptoms: o Close contact with a person who is a suspect or probable History of travel to an area with recent local transmission Residing in an area with recent local transmission of Suggested laboratory investigations in a suspected case of SARS require the collection and safe transport of the following specimens to the reference laboratory; • Throat and/or nasopharyngeal swab • Bronchial lavage • Blood culture • Urine specimen • Blood for complete examination and serology Probable Case • A suspect case with radiographic evidence of infiltrates consistent with pneumonia or respiratory distress syndrome (RDS) or chest X-ray. • A suspect case of SARS that is positive for SARS coronavirus by one or more assays. ELISA, IFA and RT-PCR have been developed but have not been evaluated for routine use. • A suspect case with autopsy findings consistent with the pathology of RDS without an identifiable cause. Prevention and Control measures
Care and management of cases
• Good supportive care including intensive therapy has been
shown to improve the prognosis. • No vaccine or chemoprophylaxis is available yet. • Antibiotics attributed no clinical improvement. • Ribavirin, an antiviral agent, used intravenously in combination with corticosteroids clinically improved some critically ill patients in Hong Kong. Management of suspected case • Patients with suspected SARS symptoms should be isolated and cared for using barrier-nursing techniques and by providing surgical mask to the patient. • Detailed clinical, contact and travel history including occurrence of acute respiratory diseases in contact persons during the last 10 days. • X-ray chest (CXR) and complete blood count. • If CXR is normal, discharge the patient with advice to seek medical care if respiratory symptoms worsen, use best personal hygiene, avoid public areas and transportation, confine at home until well. If CXR demonstrates unilateral or bilateral infiltrates with or without interstitial infiltrations, see management of probable case. Management of probable case • Hospitalize under isolation or cohorted with other SARS • Lab investigation to exclude known cause of atypical Urine examination. Complete blood picture. Blood for culture and serology. Specimens should be collected on alternate days and investigated in the laboratories with proper containment facilities (BL3). Throat and/or nasopharyngeal swabs and cold agglutinin. Bronchoalveolar lavage. Post-mortem examination as appropriate. • CXR as clinically indicated. • Treat as clinically indicated (symptomatic treatment). • Broad-spectrum antibiotics have not appeared to be proven effective in halting SARS progression to date. • Intravenous Ribavirin in combination with corticosteroids has been shown effective in some cases. Management of contact of suspected and probable cases • Reassure. • Record name and contact in detail. • Advise to seek medical assistance in the event fever or respiratory symptoms worsen, and immediately report to the health authority. • Do not report to the work until advised by the physician.
• Minimize contact with family members and friends.
• Avoid public places.

1. Hospitalization for Ambulatory-care-sensitive Conditions in Taiwan
Following the SARS Outbreak: A Population-based Interrupted Time Series Study. Huang YT, Lee YC, Hsiao CJ. J Formos Med Assoc. 2009 May;108(5):386-94. PMID: 19443292 2. Therapies for coronaviruses. Part I of II -- viral entry inhibitors. Tong TR. Expert Opin Ther Pat. 2009 Mar;19(3):357-67. Jack D Weiler Hospital, Montefiore Medical Center, Department of Pathology, Bronx, NY 10461, USA. 3. Development of a non-contact screening system for rapid medical inspection at a quarantine depot using a laser Doppler blood-flow meter, microwave radar and infrared thermography. 4. Matsui T, Suzuki S, Ujikawa K, Usui T, Gotoh S, Sugamata M, Badarch Z, Abe S. J Med Eng Technol. 2009 May 26:1-7. PMID: 19440915 5. Characterization of a highly conserved domain within the SARS coronavirus spike protein S2 domain with characteristics of a viral fusion peptide. Madu IG, Roth SL, Belouzard S, Whittaker GR. J Virol. 2009 May 13. PMID: 19439480 6. On the Final Size of Epidemics with Seasonality. Bacaër N, Gomes MG. IRD (Institut de Recherche pour le Développement), 32 avenue Henri Varagnat, 93143, Bondy, France, : Bull Math Biol. 2009 May 28 7. Development of a non-contact screening system for rapid medical inspection at a quarantine depot using a laser Doppler blood-flow meter, microwave radar and infrared thermography. 8. Matsui T, Suzuki S, Ujikawa K, Usui T, Gotoh S, Sugamata M, Badarch Z, Abe S. J Med Eng Technol. 2009 May 26:1-7. Department Metropolitan University, Hino, Tokyo, Japan. Infectious agent:
Sarcoptes scabiei mite
Mode of transmission:
Skin contact with an infected person or contact with towels,
bedclothes and undergarments contaminated by infested persons
with in last 4-5 days. The mites cannot jump or fly. Adult scabies
mites can survive off the skin for up to 48 hours in indoor
Incubation period:
Ranges from 2 to 6 weeks before itching occurs in a person not
previously exposed. Symptoms develop more quickly if a person
is re-exposed, often with in one to 4 days.
Alert Threshold:
Case count greater than 1.5 times the mean number of cases over
the previous 3 weeks requires investigation.

Outbreak threshold

To be determined by trend. Case Definition:
Skin infection characterized by rash or lesions and intense itching
especially at night. Lesions prominent around finger webs, wrists,
elbows, axillaries, beltlines, thighs, external genitalia, nipples,
abdomen, lower portion of buttocks, head, neck, palm and soles of
infants may be involved.
• Application of permethrin cream (2 days) or lotion (3days) is treatment of choice. • It should be applied to all cutaneous surfaces, particularly the hands, fingernails, waist and genitalia at bedtime after taking shower. • Apply cream or lotion daily on whole of the body. • Put on clean clothing daily. • All bed linen and clothing should be washed in hot water and dried in sun and ironed on both sides. If not possible, place the plastic bag away from the family for 5 days. • All members of the house including regular guests should be treated simultaneously. • If secondary infection occurs, antibiotics may be indicated. Prevention:
• Hygiene promotion and education about the disease is most effective means of prevention. • General cleanliness including body washing and washing of clothes and bed linens. • Bedding material such as mattresses, bed linens, blankets and clothing should be kept in sun (from 10:00 a.m. to 1:00 p.m.), which will kill the parasites. Neonatal Tetanus
Infectious agent:
Bacterium - Clostridium tetani
Mode of transmission:
Contamination of wound with dust containing spores derived from
animal excreta, if childbirth takes place in an unhygienic
environment, tetanus neonatorum may result from infection of the
umbilical stump or the mother may develop the disease by
surgical procedure.
Incubation period:
From 3 days to 21 days, average 10 days.
Alert Threshold:
One case requires investigation for safe birth practices.

Outbreak threshold

Case Definition:
Suspected case:
Any neonatal death between 3 and 28 days of age, for which the
cause of death is unknown; or
Any neonate reported as having suffered from neonatal tetanus
between 3 and 28 days of age and not investigated.
Confirmed case:
• A confirmed case is any neonate with a normal ability to suck
and cry during the first 2 days of life and who, between the ages of 3 and 28 days cannot suck normally and becomes stiff or has convulsions (i.e. jerking of the muscles) or both. • Confirmation is entirely clinical and does not depend upon bacteriological confirmation. Management:
• Debridement of any associated wound • Tetanus immune globulin (TIg) is given to neutralize the toxin. • Inj: Penicillin 600mg-6 hourly IV for 7 days (metronidazole if allergic to penicillin) to kill the toxin producing C. tetani. • Muscle spasms may be treated with muscle relaxants such as chlorpromazine (50-150 mg every 4-8 hours in adults) and diazepam (2-20 mg/IV every 2-8 hours) to control spasms and convulsions. • Bed rest with a non-stimulating environment is also recommended (dim light, reduced noise and stable temperature). • Respiratory support with oxygen, endo-tracheal tube and mechanical ventilation may be necessary. • General measures: Maintain hydration, nutrition and treat secondary infections. Prevention:
Tetanus is completely preventable by active tetanus immunization,
which begins in infancy as a series of DPT shots (D= diphtheria,
P= pertussis and T= tetanus). Boosters are given to teenagers
and older adults specially who have been injured.
The immediate danger of tetanus can be greatly reduced by the
injection of 1200 mg of penicillin followed by 7 days course of oral
Thorough cleaning of all injuries and wounds and the removal of
dead or severely injured tissue (debridement) may reduce the risk
of developing tetanus.
When the risk of tetanus is judged to be present, an injection of
250 units of Human Tetanus Antitoxin should be given and an
intra-muscular injection of toxoid that should be repeated 1 month
and 6 months later. For those already protected; only a booster
dose of toxoid is required.
*ln areas or countries where more than 85% of newborns with
tetanus die, this definition will be practical for surveillance
purposes even though children who survive will be excluded.
Where the survival rate is higher, removing death as a criterion
may modify the definition.

1. Scaling up interventions to eliminate neonatal tetanus: Factors
associated with the coverage of tetanus toxoid and clean deliveries among women in Vientiane, Lao PDR. Masuno K, Xaysomphoo D, Phengsavanh A, Douangmala S, Kuroiwa C. Vaccine. 2009 May 15. PMID: 19450637 2. Epidemiology of Pertussis and Haemophilus influenzae type b Disease in Canada With Exclusive Use of a Diphtheria-Tetanus-Acellular Pertussis-Inactivated Poliovirus-Haemophilus influenzae type b Pediatric Combination Vaccine and an Adolescent-Adult Tetanus-Diphtheria-Acellular Pertussis Vaccine: Implications for Disease Prevention in the United States. Greenberg DP, Doemland M, Bettinger JA, Scheifele DW, Halperin SA, Waters V, Kandola K; for the IMPACT Investigators. Pediatr Infect Dis J. 2009 May 11. PMID: 19436236 3. Coverage of recommended vaccines in children at 7-8 years of age in Flanders, Belgium. Theeten H, Vandermeulen C, Roelants M, Hoppenbrouwers K, Depoorter AM, Van Damme P. Acta Paediatr. 2009 May 7. PMID: 19432835 4. Traditional birth attendants in rural Nepal: Knowledge, attitudes and practices about maternal and newborn health. Thatte N, Mullany LC, Khatry SK, Katz J, Tielsch JM, Darmstadt GL. Glob Public Health. 2009 May 8:1-17. PMID: 19431006 5. Pediatric and neonatal tetanus: a hospital based study at eastern Nepal. Poudel P, Singh R, Raja S, Budhathoki S. Nepal Med Coll J. 2008 Sep;10(3):170-5. PMID: 19253861 6. Neonatal tetanus. Becker-Christensen FG. Ugeskr Laeger. 2008 Nov 3;170(45):3685. Danish. No abstract available. PMID: 19006839 7. UNICEF aims to eliminate tetanus in mothers and babies by 2012. Zarocostas J.BMJ. 2008 Oct 8;337:a1987. doi: 10.1136/bmj.a1987. No abstract available. PMID: 18842652 Infectious agent:
Bacterium: Mycobacterium tuberculosis.
Mode of transmission:
Exposure to tubercle bacilli in airborne droplet nuclei produced by
people with pulmonary or laryngeal tuberculosis during expiratory
efforts, such as coughing and sneezing
Bovine tuberculosis results from exposure to tuberculous cattle,
usually by ingestion of un-pasteurized milk or dairy products, and
sometimes by airborne spread to farmers and animal handlers
Incubation period:
Incubation period is about 4-10 weeks, but latent infections may
persist all life.
Alert Threshold:
An increase in number of cases in crowded settings must lead to
an alert and requires an immediate investigation.
Case definition:
Suspected case of TB:
• Any person who presents with symptoms or signs suggestive
of pulmonary TB, in particular cough for more than two weeks. • May also have haemoptysis, chest pain, breathlessness, fever/night sweats, tiredness, and loss of appetite and significant weight loss. • All TB suspects should have three sputum samples examined by light microscopy, early morning samples are more likely to contain the TB organism than a sample later in the day Confirmed case of TB:
Pulmonary TB smear-positive (PTB+):

Diagnostic criteria should include: • At least two sputum smear specimens positive for acid fast bacilli (AFB) or • One sputum smear specimen positive for AFB and radiographic abnormalities consistent with active pulmonary TB or • One sputum smear specimen positive for AFB and a culture positive for M Tuberculosis Pulmonary TB smear-negative (PTB-):
A case of pulmonary tuberculosis that does not meet the above
definition for smear-positive TB. Diagnostic criteria should include:
• At least three sputum smear specimens negative for AFB and
• No response to a course of broad spectrum antibiotics and
• Decision by a clinician to treat with a full course of anti-
tuberculosis chemotherapy. • Radiographic abnormalities consistent with active pulmonary Specimen Collection:
Sputum (Expectorated)
• Collect 3 early morning specimens on different days having
the volume of 5 to 10 ml containing recently discharged material from the bronchial tree with minimal saliva content.
Sputum (Induced)
• If the patient has difficulty in producing sputum, then induction
should be considered by inhalation of a warm aerosol of sterile 5-10% sodium chloride in water produced by a nebulizer. • The specimen should be clearly marked "INDUCED" on the request slip since nebulized sputum is watery in consistency and could be mistaken for saliva.
Gastric Lavage
• This procedure can be employed where sputum production is
unsuccessful. This technique requires professional attention and should only be attempted in the hospital. • Gastric lavage is performed early in the morning before eating and at least 8 hours after the patient has eaten or taken oral drugs. • 5-10 ml specimen is required and neutralized with 100 mg of sodium carbonate. Urine
• An early morning midstream specimen should be collected.
• Multiple specimens over several days may be required to
obtain a positive specimen. • Due to contamination and deterioration, 24-hour urine specimens are NOT acceptable. Keep specimen refrigerated until transport.
• Collect specimens in an Isolator tubes. Store tubes at room
temperature and transport on the same day. Fluids
• Collect body fluids like spinal, pleural, pericardial, synovial,
ascitic, blood, pus, and bone marrow by aseptic technique. Tissue
• Any tissue to be cultured must be collected aseptically in a
sterile container without fixatives or preservatives. • Add sterile saline to keep the specimen moist. Do not place tissue specimen for culture in formalin. Keep refrigerated until transport. • Be sure specimen is sealed inside double bag, and form is inserted into outer pocket, separated from the specimen itself. • Transport to lab at 4-8oC (using ice packs to prevent overgrowth of respiratory flora) along with requisition form in the biohazard bag. Management:
The priority is the diagnosis and treatment of smear positive
infectious cases of TB. To ensure appropriate treatment and cure
of TB patients, strict implementation of the DOTS strategy is
important. The DOTS strategy has the following components:
• Case detection through sputum smear microscopy
• Standardized short-course chemotherapy to, at least, all
smear positive cases under direct observation of treatment, at least, during the initial phase of treatment. • Regular supply of anti-TB drugs • Monitoring system for programme supervision and evaluation There are primarily three types of regimens: category 1 regimen for new smear positive (infectious) pulmonary cases, category 2 regimen for re-treatment cases, and category 3 regimens for smear negative pulmonary or extra-pulmonary cases. The chemotherapeutic regimens are based on standardized combinations of 5 essential drugs: Rifampicin (R), Isoniazid (H), Pyrazinamide (P), Ethambutol (E) and Streptomycin (S). Each of the standardized chemotherapeutic regimens consists of 2 phases: Initial (intensive) phase: 2-3 months, with 3-5 drugs given daily under direct observation. Continuation phase: 4-6 months, with 2-3 drugs given daily, or in some cases (e.g. during repatriation of refugees) 2 drugs for 6 months given daily unsupervised, but in fixed dose combination form. All doses of rifampicin containing regimens should be observed by staff. Actual swallowing of medication should be checked. Prevention:
Detection and treatment of smear positive TB cases is the most
effective preventive measure. It helps in cutting the transmission
line of infection.
Health education to improve awareness and reduce stigma
Maintaining good ventilation and reducing overcrowding in health
clinics, and ensuring hospitalized patients are kept in a separate
ward for the first two weeks of treatment.
Isoniazid prophylaxis is not recommended in refugee situations,
except for children being breast-fed by smear positive mothers. If
the child is well, BCG vaccination should be postponed and
Isoniazid should be given to the child for 6 months. In the event of
a sudden disruption to the programme, Isoniazid may be stopped,
and BCG should be given before the child leaves the refugee
camp (preferably after a one week interval)
BCG has been shown to be effective in preventing severe forms of
TB such as meningitis in children.
BCG is strongly recommended for all newborn children and any
children up to the age of 5 years who have not already received it.
The vaccination of newborns should be incorporated into the
immunization programme for all children. Vaccination is not


1. Tuberculosis education for nurse practitioner students: where we are and where we need to go. Benkert R, Resnick B, Brackley M, Simpson T, Fair B, Esch T, Field K. J Nurs Educ. 2009 May;48(5):255-65. PMID: 19476030 2. Journeys to tuberculosis treatment: a qualitative study of patients, families and communities in Jogjakarta, Indonesia. Rintiswati N, Mahendradhata Y, Suharna S, Susilawati S, Purwanta P, Subronto Y, Varkevisser CM, van der Werf MJ. BMC Public Health. 2009 May 27;9(1):158. PMID: 19473526 3. Defective Solubilization of Immune Complexes and Activation of the Complement System in Patients with Pulmonary Tuberculosis. Senbagavalli P, Geetha ST, Venkatesan P, Ramanathan VD. J Clin Immunol. 2009 May 27.Epub ahead of print PMID: 19472039 4. Tuberculosis meningitis. Frikha N, Skhiri A, Mebazaa MS, Ben Ammar MS. Tunis Med. 2008 Jul;86(7):722-3. French. No abstract available. PMID: 19472745 5. Tuberculosis meningitis. Frikha N, Skhiri A, Mebazaa MS, Ben Ammar MS.Tunis Med. 2008 Jul;86(7):722-3. French. No abstract available. PMID: 19472745 Typhoid Fever
Infectious agent:
Bacterium - Salmonella typhi

Mode of transmission:
Fecal-oral route, particularly contaminated water and food
Incubation period: Usually between 8-14 days but may be from 3
days up to one month

Alert Threshold:
Two or more linked cases are an alert and require an immediate

Case Definition:
Suspected case:
Any person with acute illness and demonstrates:
Insidious onset of sustained fever, headache, malaise, anorexia,
relative bradycardia, constipation or diarrhoea and abdominal
tenderness progressing to prostration. Pulse is often slower than
expected due to the elevation of the temperature.
Confirmed case:
A suspected case that is laboratory confirmed by:
Isolation of Salmonella typhi from blood, stool or urine specimens
or a suspected case that has positive Widal Test, i.e. a fourfold
increase in agglutination titer against S. typhi O and H antigens, in
the 3rd week of illness.
In the 1st week of fever, blood culture is the most important
diagnostic method in suspected cases. During the 2nd and 3rd
weeks, the faeces will contain the organism more frequently.

Specimen Collection:
• Blood culture is one of the most important factors in the
isolation of S. typhi from typhoid patients. • Collect 10-15 ml of blood from school children and adults in order to achieve optimal isolation rates; 2-4 ml is required from toddlers and preschool children. • For blood culture inoculate media at the time of drawing blood. • Once specimens are inoculated, blood culture bottles should not be kept cold. They should be incubated at 37°C or in tropical countries, left at room temperature, before being processed in the laboratory. • Collect 1-3 ml of blood inoculated in a tube without anticoagulant for serological purposes. • 2nd sample should be collected at the convalescent stage, at least 5 days later. • Separate serum after clotting and store in aliquots of 200 ml at • Testing can take place immediately or storage can continue for a week without affecting the antibody titre. • For longer storage the serum may be frozen at -20°C.

• Collect stool sample in a sterile wide-mouthed plastic
container from acute patients, which is useful for the diagnosis of typhoid carriers. • Specimens should preferably be processed within two hours after collection. If there is any delay, then stored at 4°C or in a cool box with freezer packs and should be transported to the lab in a cool box. • If stool sample cannot be obtained, rectal swabs inoculated into Carry Blair transport medium can be used but it is less successful.
Patient is treated in bed and preferably in isolation. Special
attention must be paid towards the maintenance of nutrition and
fluid intake, care of the mouth and prevention of pressure sores.
Several effective antibiotics include: Co-trimoxazole (2 tab. or
I.V./12 hourly), Trimethoprim (300 mg 12 hourly), Amoxicillin (750
mg 6 hourly), Ciprofloxocin (500 mg 12 hourly), Chloramphenicol
(500 mg 6 hourly) for 14 days. ORS plays an important role in
correction of dehydration.

Two basic actions can protect from typhoid fever; avoid risky
foods and drinks and get vaccinated against typhoid fever. Eat
only thoroughly cooked and still hot foods. Avoid raw vegetables
and fruits that cannot be peeled. Avoid salads, food and
beverages from street vendors. Flies must not be allowed to
access food.
Immunization: Mass immunization may be an adjunct for the control of typhoid fever during a sustained, high incidence epidemic. This is especially true when access to well functioning medical services is not possible or in case of a multi-drug resistant strain. • Parenteral vaccine containing polysaccharide Vi antigen is the vaccine of choice amongst displaced populations. An oral, live vaccine using S. typhi strain Ty21a is also available. • Neither the polysaccharide vaccine nor the Ty21a vaccine is licensed for children under 2 years old. The Ty21a vaccine should not be used in patients receiving antibiotics.

1. A typhoid fever outbreak in a slum of South Dumdum municipality,
West Bengal, India, 2007: evidence for foodborne and waterborne transmission. Bhunia R, Hutin Y, Ramakrishnan R, Pal N, Sen T, Murhekar M. BMC Public Health. 2009 Apr 27;9:115. PMID: 19397806 2. Risk factors for typhoid in Darjeeling, West Bengal, India: evidence for practical action. Sharma PK, Ramakrishnan R, Hutin Y, Manickam P, Gupte MD. Trop Med Int Health. 2009 Apr 17. PMID: 19392739 3. Predictive value of clinical and laboratory findings in the diagnosis of the enteric fever. Kuvandik C, Karaoglan I, Namiduru M, Baydar I. New Microbiol. 2009 Jan;32(1):25-30. PMID: 19382666 4. Gallbladder carriage of Salmonella paratyphi A may be an important factor in the increasing incidence of this infection in South Asia. Khatri NS, Maskey P, Poudel S, Jaiswal VK, Karkey A, Koirala S, Shakya N, Agrawal K, Arjyal A, Basnyat B, Day J, Farrar J, Dolecek C, Baker S. Ann Intern Med. 2009 Apr 21;150(8):567-8. 5. Epidemiology of typhoid and paratyphoid fever hospitalizations in Spain (1997-2005) Gil R, Alvarez JL, Gómez C, Alvaro A, Gil A. Hum Vaccin. 2009 Jun 19;5(6). PMID: 19276655


POSSIBLE REMOVAL OF SEVERAL CONTAMINANTS FROM THE WASTEWATERS BY A NATURAL BIOFILTRATION PROCESS Binelli* A., Pogliaghi* A., Zicchinella* M., Marazzi° F., Parolini* M., Soave* C., Mezzanotte° V. *Department of Life Sciences, University of Milan, via Celoria 26, Milan (Italy) ° Department of Science of Environment and Territory, University of Milan-Bicocca, P.zza della Scienza 1, Milan (Italy)

C: users elindsley desktop draft fee petition_settlement.wpd

Case: 1:14-cv-06913 Document #: 48 Filed: 04/15/16 Page 1 of 6 PageID #:237 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS HEIDBREDER BUILDING GROUP, LLC, on behalf of plaintiff and the class members defined herein, Magistrate Judge Cole ASSOCIATION OF THE WALL AND and JOHN DOES 1-10, PETITION FOR ATTORNEY'S FEES