Disease Early Warning System

World Health Organization Disease Surveillance World Health Organization 27 April 2017 Surveillance is the ongoing systematic collection, collation, analysis and interpretation of data; And, dissemination of information to those, who need to know, in order that action may be taken. Future planning can also be made on the basis of surveillance and on the incidence and prevalence of diseases according to area. Preparedness plans can also be made on the basis of previous data for endemic diseases that are seasonal, like cholera or respiratory infections.

World Health Organization Objective World Health Organization 27 April 2017 To ensure timely detection, response and control of outbreaks by early detection at local level by time and place clustering of cases among IDPs and resident population To monitor trends of communicable diseases in order to take appropriate public health actions To estimate workload of different health units involved in the system to rationalize resource allocation Active surveillance means to verify and investigate and validate the diseases in the community and to detect more cases in the community. Passive means we don't verify and investigate and send the data without verification. Both types of surveillance have uses – passive surveillance may give you the information you need for future planning, for example, but active surveillance is what the DEWS is most used for – detecting cases of diseases we are concerned about and dealing with them before they get worse.

World Health Organization Types of Surveillance 27 April, 2017 Active: Active surveillance means to verify and investigate and validate the diseases in the community and to detect more cases in the community (more accurate, timely, short periods, more resource intensive) Passive: Passive means we don't verify and investigate and send the data without verification. – passive surveillance may give you the information you need for future planning In many countries, health workers are required to report on the number of individuals that come to their facility and are diagnosed with reportable diseases. These reportable diseases are usually diseases that have outbreak potential, such as cholera, polio, and measles, or diseases that are targets of national control programs, such as malaria and tetanus. Data on individual patients, which are recorded in patient registers, are used to calculate the number of cases of reportable diseases diagnosed by health facility staff over a certain period of time. These data are periodically reported to district authorities who compile and send them to higher administrative levels. This process of detecting and reporting information on diseases that bring patients to the health facility is known as passive surveillance. Passive surveillance yields only limited data because many sick people do not visit a health facility and because those cases that do show up may not be correctly classified, recorded, or reported. If managers fail to fully understand and account for these limitations, they may incorrectly interpret trends and patterns of infectious diseases. One way to overcome the limitations of passive surveillance and get a better picture of disease burden in the community is for health workers to visit health facilities and communities to seek out cases. This is known as active surveillance. Since passive surveillance has limitations due to its lack of access to some groups within the population, active surveillance is often used to enhance the completeness of a passive surveillance system. Active surveillance is also more expensive than a passive system and requires considerable additional effort to organize. This means that active surveillance is usually conducted on a limited segment of the population and for only a brief period. Active surveillance is, therefore, used to gain targeted insight into a situation and not collect routine data over a long period of time. Routine surveillance by health facilities, whether passive or active, is often hampered by the difficulty of making accurate diagnoses. health workers may lack the proper equipment or training for diagnosis in the health facility, and laboratory services are often not available to confirm clinical diagnoses. In certain instances, health workers conduct case-based investigations to learn more about a specific illness pattern, for example, when there is a suspected case of a disease targeted for eradication, such as polio, or during suspected outbreaks of epidemic- prone diseases such as yellow fever. In case-based investigations, health workers record information such as the patient’s name, age, vaccination status, location, date of disease onset, suspected diagnosis, and laboratory results (when available).

Conceptual framework of public health surveillance and action

World Health Organization DEWS Information Flow 27 April 2017 Reporting site Reporting site Reporting site Reporting site DoH Surveillance team EDO Health WHO Provincial Health Department/ MoH

Outbreak Detection and Response Without Preparedness World Health Organization 27 April 2017 Outbreak Detection and Response Without Preparedness First Case Late Detection Delayed Response Opportunity for control CASES DAY

Outbreak Detection and Response With Preparedness and rapid response World Health Organization 27 April 2017 Outbreak Detection and Response With Preparedness and rapid response Early Detection Rapid Response Potential Cases Prevented First Case CASES DAY

World Health Organization Diarrhoeal diseases Disease Early Warning System, Pakistan, 2009 27 April, 2017 Acute Watery Diarrhoea/Suspected Cholera: In an area where the disease is not known to be present Any Person aged over 5 years with severe dehydration with or without vomitting or death from acute watery diarrhoea Bloody Diarrhoea: More than 3 loose stools per day (24 hours) with visible blood Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences. Acute Diarrhoea: Any other types of Diarrhoea, (not acute watery nor Bloody) Three or more abnormally loose or fluid stools in past 24 hours with or without dehydration

Alert Thresholds of Diarrheal diseases AWD/Suspected Cholera: ONE case from an area is considered outbreak and immediate actions should be taken to contain the outbreak. Acute Diarrhea: 1.5 times the mean number of cases in the previous three weeks or 1 death in a patient five or more years old. Bloody Diarrhea: 3-5 cases reported from one location. (Clustering of cases)

World Health Organization 27 April, 2017 Acute Upper Respiratory tract Infections Any acute onset of cough, with mild fever , runny nose, sore throat, pharyngitis, laryngitis, otitis, tonsillitis, with normal breathing and without any danger signs. Alert threshold: A case count of 1.5 times the mean of cases for the previous three weeks Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

Lower Respiratory Tract Infections (Suspected Pneumonia) Children Under 5 yrs: Any child under 5 years old presenting with cough, difficult breathing and any one of the following signs: Fast breathing (by age of the child), Lower chest wall indrawing, Nasal flaring Unable to drink or breastfeed. Bluish colour of skin. Difficult to awaken, Fits/convulsions Stridor in a calm child Patients 5 Years and Over: Any person 5 years and above presenting with: Acute onset of cough, fever, difficulty in breathing and chest pain which increases with breathing.

Lower Respiratory Tract Infection Cont. Fast Breathing: Count the breathing rate in a calm child for one minute. The threshold of fast breathing depends on the age of child. A child has fast breathing if the child is: Less than 2 months old: breathing rate 60 or more breaths per minute 2 months to 12 months old: breathing rate 50 or more breaths per minute 12 months to 5 year old: breathing rate 40 or more breaths per minutes Alert Threshold: 1.5 times the mean of the previous three weeks.

World Health Organization 27 April, 2017 Suspected Measles Fever and maculopapular rash and cough, coryza (i.e. runny nose) or conjunctivitis (i.e. red eyes) Alert threshold: One case is an alert and requires investigation. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Suspected Meningitis Sudden onset of fever (> 38.5°C) and one of the following: Neck stiffness OR Altered consciousness OR Other meningeal sign or petechial/purpuric rash. In children <1 year meningitis is suspected when fever is accompanied by a bulging fontanelle. Alert threshhold: One case is an alert and requires investigation. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Acute Flaccid Paralysis Any case of sudden onset of flaccid paralysis (AFP) in a child <15 years of age or any case of paralytic illness (regardless of age) in which a clinician suspects polio. Alert threshold: One case is an alert and needs notification and investigation. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Acute Viral Hepatitis (Acute Jaundice Syndrome) Any person with acute onset of jaundice (yellow eyes or skin, dark urine, nausea, vomitting, itching, loss of appetite, fatigue, with or without fever) and absence of any known precipitating factor. Alert Threshold: A cluster of 3-5 cases in one location is an alert and requires investigation Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Acute Haemorrhagic Fevers Any person with severe illness, acute onset of fever >38.5C of >3 days and <10 days duration and any two of the following: Thrombocytopenia (<100000/mm3) Petechial or purpuric rash, Epistaxis, Haematemesis, Haemoptysis, Bloody stools, Vomiting blood and Unexplained bleeding from any other site (gums, nose, vagina, skin, eyes). Alert threshold: One case is an alert and requires investigation. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

Dengue and Dengue Haemorrhagic Fever (DHF) World Health Organization 27 April 2017 Dengue and Dengue Haemorrhagic Fever (DHF) Suspected Case: Any person with Acute febrile illness of two or seven days duration with intense Headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic manifestations and leucopoenia. Confirmed Case: Any suspected case confirmed by laboratory isolation of the virual antibodies. IgM-ELISA test. PCR.

World Health Organization Neonatal Tetanus 27 April, 2017 Any neonatal death between 3 and 28 days of age in which the cause of death is unknown and Tetanus cannot be excluded OR any neonate reported as having suffered from neonatal tetanus between 3 and 28 days of age and not investigated. Confirmed Case: Any neonate with a normal ability to suck and cry during the first two days of life, and who between 3 and 28 days of age cannot suck normally, and becomes stiff or has convulsions or both. Alert threshold: One case is an alert and requires investigation for safe birth practices. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Adult Tetanus Trismus of the facial muscles (masseter and neck) OR Painful muscular contractions Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Diphtheria An illness characterized by laryngitis or pharyngitis or tonsillitis, and an adherent membrane of the tonsils, pharynx and/or nose which is difficult to remove/detach and often bleeds if tried to remove. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Whooping Cough A person with a cough lasting at least two weeks with at least one of the following symptoms: Inspiratory whooping OR Post-tussive vomiting without other apparent cause Paroxysms (Un controllable)(i.e. fits) of coughing Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Mumps Acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting two or more days and without other apparent cause. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Suspected Malaria Person with fever or history of fever >38°C within the last 48 hours and/or other symptoms: such as nausea, vomiting and diarrhoea, headache, back & joint pains, chills, myalgia) Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Confirmed Malaria Person with fever or history of fever confirmed to have malarial parasites or antibodies in his blood by laboratory tests (Thin & thick smears, or on rapid diagnostic test. Alert: 1.5 times increase in the number of cases then the mean of previous three weeks. Thick and Thin Film Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Suspected Leishmania Person with clinical signs of prolonged (>2 weeks) irregular fever, splenomegaly and weight loss, and chronic coetaneous ulcer. Confirmed case: Person with above mentioned signs and serological or parasitological lab confirmation. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April 2017 Scabies Case Definition: Skin infestation characterized by rash or lesions and intense itching, especially at night. Lesions most common on finger webs, inner aspect of the wrist and elbow, and external genitalias. Alert Threshold: Case count of greater than 1.5 times the mean number of cases over the previous three weeks requires investigation. Scabies……….. Well this is some thing which must be differentiated from rash or allergy. Remember Skin infestation characterized by rash or lesions and intense itching, especially at night. Lesions most common on finger webs, inner aspect of the wrist and elbow, and external genitalias. Alert Threshold: Case count of greater than 1.5 times the mean number of cases over the previous three weeks requires investigation.

World Health Organization 27 April, 2017 Unexplained Fever Fever (more than 38.5oC for more than 48 hours in persons in which all obvious causes of fever have been excluded. Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Severe Malnutrition In children 6 to 59 months (65 cm to 110 cm in height): Weight for height (W/H) index < –3z scores (on table of NCHS/WHO) normalized reference values of weight-for-height by sex) Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Injuries Any person who has sustained, either directly or indirectly, a fatal or non-fatal injury caused by: War (any weapons or explosion of a landmine or unexploded Ordnance UXO), Road traffic accidents, domestic violence, burn,… Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April, 2017 Others Centre pix: Eight-year-old Seema lived in an isolated village and was not able to receive medical attention for several days. Her parents brought her to Muzaffarabad where she was airlifted to Islamabad's main referral hospital, the Pakistan Institute for Medical Sciences.

World Health Organization 27 April 2017 Filling the DEWS Form

World Health Organization 27 April 2017 DEWS morbidity and Mortality Form. This form to be filled by the Focal person at the reporting unit and should be submitted to the DHO office/ EDO or DEWS Coordinator in the district on daily basis initially. It has 4 sections, The first section is about general information of the reporting health facility; The second section is related to the consultation for the heath event under surveillance; The third section is regarding mortality from the health events under surveillance; The fourth section is about a brief detail of the deaths from the reportable diseases

Filling the DEWS / Surveillance Form World Health Organization 27 April 2017 Compile the data from the Daily OPD Register by age and sex for each Health event under surveillance Transfer the data on the Surveillance form Write the Morbidity (# of cases) and Mortality (# of deaths) data clearly in the relevant section Write Zero if there is no case or death for a health event in any age or sex group Submit the form to the relevant/focal authority (DHO/EDO Health or Surveillance Coordinator) on daily basis Facilitators: After this brief introduction on filling the form distribute surveillance form among the participants and go through each section of the form on by one

World Health Organization General Information 27 April 2017 Weekly Morbidity (disease) and Mortality (death) Surveillance Reporting Form (Please send to EDO-H/WHO office every Saturday before 12.00) Province:________________________ District: __________________ Sub district/Tehsil:__________________ Town/Village/Camp:______________ Population:________________ Population <5yrs ___________________ Date:____/____/____ Epidemiological Week _____ from Saturday: ____/____/2009 to Friday ____/____/2009 Supporting Agency/NGOs__________ Health Facility________Phone # ________________________________ Name of contact Officer_________________________________ Phone # ________________________________ Write name of Province, District and Tehsil in the section Under town / village/ camp write the name of place the health facility is functioning. In case of displaced population the place may be an IDP Camp Under population note the total catchments population of the health facility. Incase if the Facility is functioning in an IDP camp the population will be the total population at the Camp. In addition note the population under 5 years age. ( If the exact Under 5 year population is not known then calculate estimated <5 population as 16% of the total catchment area population) Mention the date when the report was submitted Epidemiological week starts from Saturday and ends on Friday. For weekly reporting the data form the starting day (Saturday) and Closing day (Friday) should be included in the week of report Type of facility can be a DHQ/THQ Hospital, RHC, BHU, CD or a temporary field clinic/hospital or a mobile Medical Camp Write the name of the NGO which is supporting the Health Facility Write the name designation and contact number (mobile, telephone #) of the reporting official

Events Under Surveillance World Health Organization 27 April 2017 Events Under Surveillance No of Consultations 0-<5yrs = >5 - < 15yrs 15-44yrs 45 + yrs M F 01 Acute Diarrhoea 02 AWD/ Suspected Cholera 03 Bloody Diarrhoea 04 Acute Flaccid Paralysis (AFP) 05 Suspected Malaria 06 Acute Upper Respiratory Infection 07 Acute Lower Respiratory Infection 08 Suspected Measles 09 Suspected Meningitis 10 Acute Jaundice Syndrome 11 Neonatal Tetanus 12 Suspected Hemorrhagic Fever 13 Unexplained Fever >38.50 C 14 Scabies 15 Bronchial Asthma 16 Hypertension 17 Diabetes 18 Injuries 19 Severe Malnutrition (wfh* < -3Z) Red Zone 20 Moderate Malnutrition (wfh* -2 to -3Z) Orange zone 21 No. of Antenatal Consultations 22 No. of normal deliveries 23 ** No. of Pregnant women referred 24 Others 25 26 27 Total Consultations There are 16 health events under surveillance. While diagnosing the health problem follow the standard case definition and write clearly in the OPD register Count the number of cases for each of the health event under surveillance by age and sex from the OPD Register and transfer the data on the Morbidity section of the DEWS form and fill the relevant cell. Health events which are out of the 16 reportable (under surveillance) Diseases should be counted under Others and transfer on the Surveillance form. For each health event note the number of cases in each age group and by sex. Write zero if there is no case in any health event

MORTALITY INFORMATION World Health Organization 27 April 2017 All Maternal deaths related to pregnancy and child birth and Neonatal Deaths must be reported From the row no. 3 Write the name of the health event and the number of deaths for each health event by sex and age Write zero if there is no death in some age or sex group. If there are no deaths write zeros or put a – in all the columns.

Brief details of reported deaths World Health Organization 27 April 2017 For each death reported in your catchments population provide a brief detail filling the provided form Clearly write the name, age, sex and cause of death Note/write down the complete address of the deceased (such as house #, street, Block #, Ward/Lan,Mohallah, Village/city, Union council etc)

World Health Organization Exercise World Health Organization 27 April 2017 Now we will do a brief exercise on filling the surveillance form Each participant will compile the data from the Daily OPD register Count the number of cases by age and sex category for each health event Count the number of deaths by age and sex category for each health event Transfer the data on the Morbidity and Mortality sections of the surveillance form Facilitators: Provide the sample of the Daily OPD Register (The dummy sheet) filled with data for this exercise purpose and ask the participants to compile it and transfer the data on the surveillance form Facilitators also compile the data and then ask the participants to check their forms and compare with yours if there is any discrepancy and discuss

World Health Organization 27 April 2017 Give a sheet of the filled daily OPD register (having data for one week) to each participant and ask them to compile the data Give 15 minutes time to compile the data and transfer it on the surveillance form After the exercise finished ask the participants to check for any difference in filling the surveillance form Discuss if there was any difficulty of confusion in compiling the data from OPD register and filling the surveillance form Rectify if there was any confusion

World Health Organization 27 April 2017 Prevention and Management of Diarrhea (Acute, Bloody, and Suspected Cholera)

World Health Organization Case Definitions World Health Organization 27 April 2017 Cholera 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. Acute Diarrhea Three or more abnormally loose or fluid stools in past 24 hours with or without dehydration. Bloody Diarrhea Acute diarrhea with visible blood in stools This is a reminder of the case definitions, which you have seen before Any of these are prone to epidemics, particularly among displaced persons or after disasters, when clean water is not available and hygiene standards are difficult to maintain Much of the prevention and management for these three different diseases is the same, though there are some differences. You should not wait for confirmation before starting to treat cases, particularly in suspected cholera.

World Health Organization When to Worry World Health Organization 27 April 2017 For Cholera: 1 case For Acute Diarrhea and Bloody Diarrhea: A sudden increase and clustering of cases If you see a single case of cholera, there are probably more, so you should investigate if possible and check all the people who have been in contact with the case. Diarrhea is more common, and therefore a few cases is not necessarily something to worry about. However, if the number of cases suddenly rises, you may have a problem and should take steps to find the cause and stop it – you may not be able to stop it yourself, and may need to ask for help from the department of health, who can make an investigation.

World Health Organization Modes of Transmission World Health Organization 27 April 2017 Oral/fecal transmission unclean water contaminated food poor hygiene practices lack of latrines In a situation such as flooding, it can be expected that water will become contaminated both at the source and in the home, if the home itself is flooded, making diarrhea or cholera more likely. Damage to infrastructure may make good hygiene practices more difficult.

Prevention – for Patients World Health Organization 27 April 2017 Water must be decontaminated – boiling or chlorinating Water should be boiled for a minimum of 15 minutes after reaching boiling point Chlorine tablets can also be used to purify water and should be given to families of the patients The key for stopping outbreaks of diarrhea is usually making sure that everyone has safe drinking water. By giving patients directions on how to make water safe, you may prevent further cases Boiling is the preferred method – chlorine makes the water taste unpleasant, and can be unacceptable for some people, making them less likely to use the safe drinking water.

World Health Organization Food and Hygiene World Health Organization 27 April 2017 Wash hands with soap after toilet use, or after contact with fecal matter Wash hands before preparing or eating food, or before feeding children. Cooked food and eating utensils should be kept separate from uncooked foods and potentially contaminated utensils. Cook food until it is hot throughout and eat while still hot or reheat thoroughly before eating. Avoid raw food except fruits and vegetables that can be peeled in hygienic manner. Wash cooking and serving utensils with soap thoroughly after use. Since we know that transmission is through fecal/oral route, all control should be of these two elements. Hand washing is key, as is making sure that food is not contaminated. Giving this advice to patients will help stop outbreaks and does not cost anything Street food in particular can be very dangerous, and the advice to eat only hot cooked foods applies to this too. Avoid street drinks unless they are bottled or canned. Avoid ice.

World Health Organization Sanitation World Health Organization 27 April 2017 Good sanitation is necessary to avoid contamination of clean water sources. Human waste disposal at appropriate distance from water source and supply – minimum 10 metres Faecal material and vomit must be properly disinfected and disposed of. Health education programmes should be conducted on hygiene and disinfection measures with simple messages on safe water, safe food and hand-washing. Funerals should be held quickly and near the place of death. Those who prepare the body for burial must be meticulous about washing their hands with soap and clean water IDP camps should have sufficient latrines. However, for people who are not in camps, but with damaged homes, advice on proper hygiene practices may be useful. They can be advised to dig a latrine if their home is destroyed, but it should be a minimum of 10 metres away from any water source. Health education messages can be given by health care providers, but also by mosques, the media, or others. Those preparing bodies for burial must be very careful and wash thoroughly. If possible, provide an appropriate disinfection solution. Burials should be as soon as possible after death.

Management of cholera or acute diarrhea in the camp or facility World Health Organization 27 April 2017 First line treatment: The key to therapy is the provision of adequate rehydration Patients should be assessed for the degree of dehydration This table shows how to assess for level of dehydration simply by looking at the patient and doing a skin pinch. In some infants and children the eyes normally appear somewhat sunken. It is helpful to ask the mother whether the child’s eyes are normal or more sunken than usual. Dryness of the mouth and tongue can also be palpated with a clean finger. The mouth may always be dry in a child who habitually breathes through the mouth. The mouth may be wet in a dehydrated patient owing to recent vomiting or drinking. The skin pinch is less useful in infants or children with marasmus (wasting) or kwashiorkor (severe malnutrition with edema) or in obese children. Treatment will differ by degree of dehydration

Treatment by Dehydration Level World Health Organization 27 April 2017 Plan A Dehydration is mild and can be treated at home Give the patient plenty of food to prevent malnutrition Continue to breastfeed babies frequently If the child is not breastfed, give the usual milk If the child is 6 months or older, or already taking solid food: Also give cereal or other starchy food mixed, if possible, with pulses, vegetables, and meat or fish; add one or two teaspoonsful of vegetable oil to each serving Give fresh fruit juice or mashed banana to provide potassium Give freshly prepared foods; cook and mash or grind food well Encourage the patient to eat: offer food at least six times per day Give the same food after diarrhea stops and give an extra meal each day for 2 weeks. Take the patient to the health worker if he/she does not get better in 3 days or develops any of the following: Many watery stools Repeated vomiting Marked thirst Eating or drinking poorly Fever Blood in the stool

World Health Organization Plan B World Health Organization 27 April 2017 If a patient fits into Plan B, they have moderate dehydration and need immediate care to prevent it from becoming more severe. Actions to take in the first four hours: If the child wants more ORS than shown in the chart, give more Encourage mothers to continue breastfeeding For infants less than 6 months who are not breastfed, also give 100-200 ml of clean water during the first four hours Observe the child carefully and help the mother give ORS, showing her how much and frequency Check from time to time to see if there are problems If the child vomits, wait 10 minutes and continue giving, but more slowly If the child’s eyelids become puffy, stop the ORS and give plan water or breastmilk. Give ORS according to Plan A when the puffiness is gone After 4 hours, reassess the child using the assessment chart, then select Plan A, B, or C to continue If there are no signs of dehydration, shift to Plan A. When dehydration has been corrected the child usually passes urine and may also be tired and fall asleep If signs indicating some dehydration are still present, repeat Plan B, but start to offer food, milk, and juice as described in Plan A If signs indicating severe dehydration have appeared, shift to Plan C If the mother must leave before completing treatment Plan B: Show her how much ORS to give to finish the 4 hour treatment at home Give her enough ORS packets to complete rehydration, and for 2 more days as shown in Plan A, and show her how to prepare ORS solution Explain to her the three rules in Plan A for treating children at home: Give ORS or other fluids until diarrhea stops Feed the child Bring the child back to the health worker, if necessary

World Health Organization Plan C World Health Organization 27 April 2017 Start IV fluids immediately. If the patient can drink, give ORS by mouth while the drip is set up Give 100 ml Ringer’s lactate solution per kg of body weight (or if not available, give normal saline), divided as follows: Age First give 30ml/kg in: Then give 70ml/kg in: Infants (under 12months) 1 hour* 5 hours Older 30 minutes* ½ hours * Repeat once if radial pulse is still very weak or undetectable. Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. Also give ORS (about 5 ml/kg per hour) as soon as the patient can drink: usually after 2-4 hours (infants) or 1-2 hours (older patients). After 6 hours (infants) or 3 hours (older patients), evaluate the patient using the assessment chart. Then choose the appropriate Plan (A, B or C) to continue treatment. Do not use glucose, use Ringers lactate If condition is not improving after the first 6 hours in infants or 3 hours in adults, Start rehydration by tube with ORS solution: give 20ml/kg per hour for 6 hours (total of 120 ml/kg). Reassess the patient every 1-2 hours: - if there is repeated vomiting or increased abdominal distension, give the fluid more slowly; - if hydration is not improved after 3 hours, send the patient for IV therapy. After 6 hours, reassess the patient and choose the appropriate treatment plan.

Antibiotics for Cholera World Health Organization Antibiotics for Cholera 27 April 2017 Antibiotic therapy is not essential to the management of Cholera. Effective rehydration therapy is life saving. Antibiotics should only be given in severe cases to reduce the duration of symptoms and reduce carriage of the pathogen Oral antimicrobials only must be given, and after the patient has been rehydrated (usually in 4–6 hours) and vomiting has stopped.

World Health Organization Remember 27 April 2017 No anti-diarrheal, anti-emetic, anti-spasmodic, or corticosteroid drugs should be used to treat Cholera. Blood Transfusion and plasma volume expanders are not recommended.

Establishment of Diarrhea Treatment Centre World Health Organization 27 April 2017 If you have a large number of cases spread of the disease will be prevented by isolating patients and treating them in a treatment centre A diarrhea treatment centre consists of 4 sections: 1. Admission and observation 2. Neutral part – for staff. If the cholera centre is a tent facility being setup near an existing facility or hospital, this section can be omitted 3. Hospitalization unit - reserved for severe patients on IV 4. Recovery unit – with ORS space Each section should have latrines for exclusive use of that section, washing areas, large quantity of safe water, and safe disposal of waste

Design of Diarrhea Treatment Centre World Health Organization 27 April 2017 Hospitalization Unit Neutral Part Admission & Observation Unit Recovery Unit Entrance Exit One way flow of people Disinfection at entrance and exit point (usually a disinfectant spray) Access limited to patient + one family member + staff Hand washing stations with safe water and soap in sufficient quantities in each section Wash hands with water and soap at the handwashing stations: before and after taking care of patients, after using latrines, before cooking or eating, after leaving the admission ward Ensure exclusive latrines for the unit If possible, use Special cholera beds Separate morgue If possible, Food provided by the unit (preferably not by families) Health care workers should not handle food or water Large quantity needed – minimum 10 litres per person per day, if possible, 50 litres per person per day Wash clothes and linen with appropriate chlorine solution

World Health Organization Disinfection World Health Organization 27 April 2017 Disinfection is very important in the treatment centre and will prevent the disease from spreading further. The concentrations differ depending on use

Acute Watery Diarrhoea, Daily Case Report IDP camp: Reporting Unit / Agency: Date: Name of Reporting Person: Phone No: Contact #: (WHO / DHO) S No Name / Father’s name Age Sex Complete address T-B-S Date/ Time of onset New case / Follow up Presenting Symptoms Dehydration* Treatment Outcome ** N / F Frequency of stool Consistency Color Blood N / A / B / C I/V Fluids ORS A / O / R / D 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 * N = No dehydration, A = Mild Dehydration B = Moderate Dehydration, C = Severe Dehydration ** A = Admission, O = Outpatient, R = Refer, D = Death

Malaria Situation in Jalozai IDP Camp

Trend of Unexplained fever

World Health Organization 27 April 2017 Thank you Dr. Sardar Hayat Khan Public Health Officer Cell no: 0333 9022060 Email: khansar@pak.emro.who.int drshk1@hotmail.com