key: cord-020544-kc52thr8 authors: Bradt, David A.; Drummond, Christina M. title: Technical Annexes date: 2019-12-03 journal: Pocket Field Guide for Disaster Health Professionals DOI: 10.1007/978-3-030-04801-3_7 sha: doc_id: 20544 cord_uid: kc52thr8 7.1 Humanitarian Programs 141; 7.2 Security Sector 153; 7.3 Health Sector 158: Core Disciplines in Disaster Health 161. Primary Health Care Programs 162. Disease Prevention 162. Clinical Facilities 164. Reproductive Health 165. Water and Sanitation 166. Food and Nutrition 171. Chemical Weapons 181. Epi Methods 184; 7.4 Tropical Medicine 187: Tropical Infectious Diseases—Vector-borne and Zoonotic 196. Tropical Infectious Diseases—Non-vector-borne 215; 7.5 Epidemic Preparedness and Response 239; 7.6 Communicable Disease Control 242: Diarrhea 244. Influenza 257. Malaria 263. Measles 267. Meningitis 269. Viral Hemorrhagic Fever 272; 7.7 Diagnostic Laboratory 275: Indications, Laboratory Tests, and Expected Availability 276. Specimen Handling 278; 7.8 Acronyms 282; This section provides guidance on technical issues in the health sector. The annexes contain compilations of frequently used reference information. • Humanitarian programs-contains conceptual frameworks on global clusters, relief programs, humanitarian financing, and early recovery. • Security sector-contains key definitions from the Rome Statute of the International Criminal Court • Health sector-contains a broad range of core health technical information including environmental classification of water and excreta-related diseases, disease prevention measures, water treatment end points, anthropometric classifications, micronutrient deficiency states, management of chemical weapon exposures, and epi methods. • Tropical medicine-contains clinical summaries of tropical infectious diseases with details on disease vector and host, clinical presentation, diagnostic lab tests, clinical epidemiology, and therapy. • Epidemic preparedness and response-contains core principles of epidemic preparedness and response. • Communicable disease control-contains an overview of selected communicable diseases of epidemic potential including diarrhea, influenza, malaria, measles, meningitis, and viral hemorrhagic fever. • Diagnostic laboratory-contains guidance on lab specimen handling and testing. • Acronyms-contains acronyms commonly used in disaster management and humanitarian assistance. a. in-kind donations (eg food, seeds, tools, fishing nets, etc) b. types of community projects in food-for-assets programs (1) natural resources development (a) water harvesting (b) soil conservation (2) restoration of agri(aqua)culture potential (a) irrigation systems (b) seed systems (3) infrastructure rehabilitation (a) schools (b) market places (c) community granaries (d) warehouses (e) roads (f) bridges (4) diversification of livelihoods (a) training and experience sharing 2. Increase individual purchasing power a. cash distribution b. cash for work (cash for assets) c. vouchers d. micro-credit e. job fairs f . artisanal production g. livelihoods/income generation 3. Support market resumption a. market rehabilitation b. infrastructure rehabilitation c. micro-finance institutions Goals-protect what's left (1 month), restore the system (6 months), improve the system ( 1. Promote transformational development Support far-reaching, fundamental changes in relatively stable developing countries, with emphasis on improvements in governance and institutions, human capacity, and economic structure, so that countries can sustain further economic and social progress without depending on foreign aid. Focus on those countries with significant need for assistance and with adequate (or better) commitment to ruling justly, promoting economic freedom, and investing in people. Reduce fragility and establish the foundation for development progress by supporting stabilization, reform, and capacity development in fragile states when and where U.S. assistance can make a significant difference. 3. Support strategic states Help achieve major U.S. foreign policy goals in specific countries of high priority from a strategic standpoint. 1. International cooperation to protect lives and health 2. Timely and sustained high-level political leadership to the disease 3. Transparency in reporting of cases of disease in humans and in animals caused by strains that have pandemic potential to increase understanding, enhance preparedness, and ensure rapid and timely response to potential outbreaks 4. Immediate sharing of epidemiological data and clinical samples with the World Health Organization (WHO) and the international community to characterize the nature and evolution of any outbreaks as quickly as possible 5. Prevention and containment of an incipient epidemic through capacity building and in-country collaboration with international partners 6. Rapid response to the first signs of accelerated disease transmission 7. Work in a manner supportive of key multilateral organizations (WHO, FAO, OIE) 8. Timely coordination of bilateral and multilateral resource allocations; dedication of domestic resources (human and financial); improvements in public awareness; and development of economic and trade contingency plans 9. Increased coordination and harmonization of preparedness, prevention, response and containment activities among nations 10. Actions based on the best available science 1. Genocide (Article 6)-acts committed with intent to destroy, in whole or in part, a national, ethnic, racial, or religious group a. killing members of the group b. causing serious bodily or mental harm to members of the group c. inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part d. imposing measures intended to prevent births within the group e. forcibly transferring children of the group to another group 2. Crimes against humanity (Article 7)-acts committed as part of a widespread or systematic attack against any civilian population, with knowledge of the attack a. murder b. extermination c. enslavement d. deportation e. imprisonment in violation of international law f. torture g. rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or other comparable form of sexual violence h. persecution on political, racial, national, ethnic, cultural, religious, gender, or other grounds universally recognized as impermissible under international law i. enforced disappearance j. apartheid k. other inhumane acts intentionally causing great suffering or serious injury to body or to mental or physical health 3. War crimes (Article 8) a. grave breaches of the Geneva Conventions of 12 Aug 1949 (1) willful killing (2) torture or inhumane treatment including biological experiments (3) willfully causing great suffering (4) extensive destruction and appropriation of property (5) compelling a POW to serve in the armed forces of a hostile power (6) willfully depriving a POW of the right to a fair trial (7) unlawful deportation (8) taking of hostages b. serious violations of laws and customs applicable in international armed conflict (1) intentionally directing attacks against the civilian population or against civilians not taking direct part in hostilities (2) intentionally directing attacks against civilian objects (3) intentionally directing attacks against personnel, installations, material, units, or vehicles involved in humanitarian assistance or peacekeeping mission (4) intentionally launching an attack in the knowledge that it will cause incidental civilian loss of life or severe damage to the natural environment (5) attacking undefended towns, villages, dwellings, or buildings which are not military targets (6) killing or wounding a combatant who has surrendered (7) improper use of a flag of truce, flag or insignia or uniform of the enemy or of the UN, or emblems of the Geneva conventions resulting in death or serious personal injury (8) transfer by the Occupying Power of parts of its own civilian population into the territory it occupies, or the deportation or transfer of all or parts of the population of the occupied territory within or outside the territory (9) intentionally directing attacks against buildings dedicated to religion, education, art, science, charitable purposes, historic monuments, hospitals, and places where sick are collected, provided they are not military objectives (10) subjecting persons to physical mutilation or to medical or scientific experiments which are not justified by the medical treatment nor carried out in his/her interest (11) killing or wounding treacherously individuals belonging to the hostile nation or army (12) declaring that no quarter will be given (13) destroying or seizing the enemy's property unless such be imperatively demanded by the necessities of war (14) declaring abolished, suspended, or inadmissible in a court of law the rights and actions of the nationals of the hostile party (15) compelling the nationals of the hostile party to take part in the operations of war directed against their own country (16) pillaging a town or place, even when taken by assault (17) A range of generic prevention measures should be considered for its impact on diseases in a biological "all-hazards" environment. Overall, excreta disposal, water quantity, personal hygiene, and food hygiene commonly contribute more to environmental health than do other listed measures. Epidemic threats will oblige heightened consideration of disease-specific strategies for prevention and control. C. Water Treatment (bold text of particular relevance in clinical facilities) 1 ppm = 1 mg/kg (solids) = 1 mg/L (liquids) = 1 ug/mL (liquids) = basic unit of measure for chloroscopes :10,000 ppm = 1% • SAM = WHZ < −3, MUAC <11.5 cm, or bilateral pitting edema (WHO). WHM not in definition. • SAM prevalence worldwide ≈ 20,000,000. • SAM mortality ≈ 9x mortality of normally nourished child and its CFR can be 10-50%. • GAM = MAM + SAM • GAM = moderate wasting cases, severe wasting cases, or bilateral pitting edema cases (where due to malnutrition) • Underweight is not used for screening or surveys in nutritional emergencies. It reflects past (chronic) and present (acute) undernutrition and is unable to distinguish between them. It encompasses children who are wasted and/or stunted. However, weight gain over time can be a sensitive indicator of growth faltering which is easily tracked on Road to Health charts. • Stunting generally occurs before age 2. It is irreversible. • Stunting prevalence worldwide ≈ 165,000,000. • Stunting is not a good predictor of mortality, but the CFR from IDs in cases of severe stunting ≈ 3x the CFR from IDs in cases without stunting. Reference standards can be absolute MUAC, centile, % of median reference, or z scores: • MUAC Easy to understand. An excellent predictor of mortality. Permits comparisons between age groups insofar as the low growth velocity of MUAC in the U5 age group makes data roughly comparable. May be used alone in "quick-and-dirty" convenience samples to estimate local prevalence of wasting. However, not used alone in authoritative anthropometric surveys, and is commonly part of a two stage screening process to determine eligibility for feeding programs. • Overall WHZ gives higher prevalence of malnutrition than WHM for the same population. This is most marked where there is low baseline prevalence of disease, and especially for adolescents (who get subsequently over-referred). WHZ is more statistically valid, but WHM is better predictor of mortality and is used for admission to TFCs. Weight-for-age is influenced by weight-for-height and height-for-age. It can be difficult to interpret. b. adults and adolescents (O10) anthropometrics: BMI = weight (kg) / height (m) 2 1. Death rates-calculated incidence of death expressed per 10,000 p/d or per 1000 p/mo; data collected by retrospective surveys (eg 3 month period) to gauge severity of public health emergency particularly where sudden events lead to spike in mortality a. CDR-crude death rate b. ASDR-age-specific death rate (eg U5DR or death rate of children 0-5 yr) during a studied time interval (written as 2. Mortality rates-calculated probability of dying before a specified age expressed per 1000 live births; data collected by national health authorities in periodic (annual) demographic surveys to reflect ongoing health status a. CMR-calculated probability of mortality in given population for specific time b. IMR-calculated probability of a live borne child dying before 1 yr c. U5MR-calculated probability of a live borne child dying before 5 yr NB MR ≠ DR. Eg CMR ≠ CDR, U5MR ≠ U5DR. Different rates measure different things and are not directly comparable. However, MRs may be converted into DRs by the following: CDR or U5DR (deaths/10,000/d) = − ln(1−p/1000) × 5.47 where p = CMR or U5MR (deaths/1000 live births). However, this has little field utility. NB MMR-maternal mortality ratio has different units in numerators (maternal deaths) and denominators (live births), thus is a ratio, not a rate The application of study findings to an entire population from which the sample was drawn. If the survey was well-conducted, the results may be considered representative of the entire population. This is scientifically justified. However a confidence interval should accompany any parameter estimate of that population. Extrapolation The extension of study findings to a population or period which was not represented in the sample. It works by association-if 2 populations appear to be experiencing similar conditions, the morbidity/mortality experience of one may be imputed to the other. This is not scientifically justified, but is often done where data are insufficient or impossible to collect. 6 S/Sx Think differential diagnosis (below). 2. Severe muscle pain may be a symptom of sepsis even without fever. 3. Elderly patients with sepsis may be afebrile. In elderly patients, fever is rarely caused by a viral infection. 4 . Septic patients who are hypothermic have a worse prognosis than those with high fever. Treat as a medical emergency. 5. Fever in a postoperative patient is usually related to the surgical procedure (eg pneumonia, UTI, wound, or deep infection). 6 . Fever with jaundice is rarely due to viral hepatitis. Think liver abscess, cholangitis, etc. 7. The rash of early meningococcal infection may resemble a viral rash. 8. Generalized rashes involving the palms and soles may be due to drugs, viral infections, rickettsial infections, or syphilis. 9. All febrile travelers in or returned from a malaria infected area must have malaria excluded. 10. Disseminated TB must be suspected in all elderly patients with fever and multisystem disease who have been in an area with endemic TB. 11. Septic arthritis may be present even in a joint which is mobile. 12. Back pain with fever may be caused by vertebral osteomyelitis or an epidural abscess. 13. A patient may have more than one infection requiring treatment (eg malaria and typhoid), especially if they are elderly, immunosuppressed, or have travelled. 14. Always remember common infections, not just opportunistic infections, in AIDS patients with a fever. Understand morbidity multipliers-measles, malnutrition, and TB/HIV. Understand occult co-morbidities. For any undifferentiated illness, even in infants, think of HIV, TB, syphilis, and sarcoid. For any child, think of malaria, hookworm, and anemia. Malarial anemia usually in pedes <3 year-old; hookworm anemia usually in pedes >3 year-old. For any ICP, think of TB, VL, histoplasmosis, and strongyloides. Must treat early. Watch for clinical mimics-malaria presenting as pneumonia or diarrhea in pedes; VL presenting as malaria in adults; lepto presenting as mild DF (esp in DF endemic areas where the Pt has mild onset of illness, worsening course, and no rash but jaundice). Tx Do basic things well, use equipment you understand, teach others, delegate. This Annex profiles selected communicable diseases of epidemic potential whose incidence, management complexity, or mortality obliges particular attention. • If (+) agglutination to O1 antisera, then the strain is further tested for agglutination to antiserum of Ogawa and Inaba serotypes. • If (+) agglutination to O139 antisera, then the strain is not further subdivided (except as producer or non-producer of CT as noted below). • If (−) agglutination to O1 and O139 antisera, then the strain is known as non-O1, non-O139 V. cholerae. A strain is further identified as a producer or non-producer of cholera toxin (CT). CT production is a major determinant of disease development. Strains lacking CT do not produce epidemics even if from the O1 or O139 serogroup. • Serogroup O1 exists as 2 main biotypes-classical and El Tor-though hybrids also exist. Each biotype occurs as two serotypes-Ogawa and Inaba. Classic biotype caused the 5th and 6th pandemics but little epidemic disease since the 1970s though it still causes cases in India. El Tor biotype caused the 7th (current) pandemic and almost all recent outbreaks. El Tor was first isolated in 1905 in El Tor, Egypt after importation by Indonesian pilgrims travelling to Mecca. It survives longer in the environment and produces CT similar to the classical biotype. Presumably because of CT pathogenicity, the % of cholera patients with severe disease has doubled over the past 10 yrs. These patients tend to require IV fluid therapy. • Serogroup O139 may have evolved from strains of O1 El Tor as they share many properties though not agglutination. In spring of 2002 in Dhaka, O139 cases exceeded O1 El Tor cases for the first time, and it was postulated that O139 may become the cause of an 8th pandemic. However, since then, O1 has again become dominant. Infective dose depends on individual susceptibility. Relevant host factors include immunity produced by prior infection with serogroup O1 as well as stomach acidity. ID 50 may be 100,000 orgs, so personal hygiene plays a lesser role than in shigellosis where the ID 50 is much lower. Shigella has 4 species. • S. dysenteriae type 1 (SD1 or Shiga bacillus) causes the severest disease of all Shigella sp because of its neurotoxin (Shiga toxin), longer duration of illness, higher ABX resistance, higher CFR thru invasive complications, and great epidemic potential. • S. flexneri is the most common, and is generally endemic, in developing countries • S. sonnei is the most common in industrial countries • S. boydii and S. sonnei give mild disease. Some kinds of E. coli produce a Shiga toxin. Shiga toxin genes reside in a bacteriophage genome integrated into the bacterial chromosome. Some ABX, eg fluoroquinolones, induce expression of phage genes. The bacteria that make these toxins are variously called "Shiga toxin-producing E. coli" (STEC), "enterohemorrhagic E. coli" (EHEC), or "verocytotoxic E. coli" (VTEC). All terms refer to the same group of bacteria. • E. coli O157:H7 (often called "E. coli O157" or "O157") is the most commonly identified STEC in North America, and it causes most E. coli outbreaks. Approximately 5-10% of EHEC infections result in HUS. • Non-O157 STEC serogroups also cause disease. In the USA, serogroups O26, O111, and O103 are the most commonly identified E. coli pathogens overall. weather (esp weeks 15-20 in Apr-May) creating increased biological activity; post-monsoon (esp weeks 30-40 in Aug-Sep) with contamination of water sources. Pre-monsoon epidemics are generally worse than postmonsoon ones. Dysentery has low level year-round incidence, but epidemics occur roughly each decade. Epidemic strains display new, additive antibiotic resistance which probably triggers the epidemic. Once resistant strains have become endemic, antibiotic susceptibility rarely reappears. SD1 acquires resistance quickly. Sf acquires it more slowly, and that resistance may wane with decreasing ABX pressure. At ICDDR, annual proportional incidence approximates the following: Clean water and waste management especially for cholera. Personal hygiene (hand washing with soap and clean towels) especially for shigella. Water safe drinking water (boiled, chlorinated) NB Sphere standards are not enough-you need increased quantities of chlorinated water at household level. San clean latrines for safe disposal of excreta hand washing with soap Food safe food (cooked, stored) breast feeding Fomites safe disposal of dead bodies with disinfection of clothing NB After outbreak of a fecal-oral pathogen, food hygiene and funereal practices may influence human-to-human transmission more than water quality. Health education to affected population Wash hands with soap: after using toilets/latrines. after disposing of children's feces. before preparing food. before eating. before feeding children. Dukoral has been the main vaccine considered for use in high-risk populations. • mORC-VAX and Shanchol-similar to Dukoral except they do not contain the rBS, hence do not require a buffer, and are 1/3 the cost to produce. mORC-VAX, produced in Vietnam, is derived from a vaccine administered to millions of people since 1997, but is not WHO pre-qualified, and is not expected to have international distribution. • Shanchol, produced in India, has international distribution (eg used in the Haiti cholera vaccination campaign of 2012), and is now the agent of choice for WHO. It confers immunity 10d p 2nd dose, effectiveness > 85% at 6 mo, and protection >50% at 5 yr. Also confers short-term protection vs ETEC. Dose: 1.5 cc vaccine followed by water ingestion but no fasting needed; 2 doses, 2 wks apart; cold chain required except for day of use. • Orochol-bivalent formulation as in Dukoral without rBS of CT. Dose: single dose. No longer manufactured. WHO recommendations: "Vaccination should not disrupt the provision of other high-priority health interventions to control or prevent cholera outbreaks. Vaccines provide a short-term effect that can be implemented to bring about an immediate response while the longer term interventions of improving water and sanitation, which involve large investments, are put into place." [1] ICDDR recommendations: "Because of limitations in terms of transport, formulation, and cost of the current Dukoral vaccine, the COTS program does NOT require the utilization of the vaccine during an outbreak; it is NOT necessary to vaccinate to overcome an outbreak. However, if Dukoral is readily available and staff are properly trained in its use according to the guidelines that come with the vaccine, the COTS program PERMITS Dukoral's use (ideally before an outbreak) in the following high-risk populations: refugee populations in which cholera is present, health care workers managing cholera cases, and communities in which the incidence rate is greater than 1 in 1000 annually." [2] Epidemiological Surveillance (specific to cholera) Epidemiological assumptions (WHO, COTS): Estimated attack rates: 10-20% extremely vulnerable hosts and poor environmental health (WHO) 5% (refugee camps with malnutrition) (COTS) 2% (rural communities of <5000 p) (COTS) 1% (severe epidemic-good estimate of ultimate disease burden) (WHO) 0.6% (endemic areas with bad sanitation) (COTS) 0.2% (endemic areas in open settings-suitable for initial calculations of early resource requirements) NB Overall, 90% of cases are mild and difficult to distinguish from other types of D. NB Asymptomatic carriers are very common (10x # of cases). Referral rates for IVs 20% of cases (much higher-70% at ICDDR as it shortens recovery time) Case fatality ratios 1% (with good care) The following catchment populations will yield 100 acute Pts of whom 20 will be severely dehydrated: refugee camp of 2000 people (AR of 5% = 100 Pts) open settings in endemic area with 50,000 people (AR 0.2% = 100 Pts) A population of 100,000 infected individuals in an epidemic area will yield the following (WHO): Population infected 100,000 Clinical cases 1,000 (1% of infected population) Cases needing early resources 200 (20% of cases) Cases needing IV therapy 200 (20% of cases) Anticipated deaths 10 (1% CFR) NB In non-endemic areas, AR adults > AR pedes because adults have higher exposure risks. In endemic areas, AR pedes > AR adults because adults have been exposed since childhood Delivery of Health Services Shigella are fragile and difficult to recover if transport time > 1 d. 5-10 isolates initially to confirm outbreak 30-50 isolates initially to create ABX use policy (bacterial resistance renders cotrimoxazole, amp/amox, nalidixic acid, and tetracycline unusable) 20-30 isolates monthly from IPD and OPD before ABX therapy to assess evolving ABX resistance 10-20 isolates periodically to reference laboratory to confirm ABX resistance patterns and undertake molecular studies 20 isolates at end of the outbreak to confirm that new diarrheas are not epidemic pathogens NB Systematic sampling is most representative-eg every 10th Pt or all Pts q 2 weeks adjusted as needed to collect the necessary specs. Sensitivity > > important than specificity in RDT screening during an epidemic. Pts from one geographic area are more likely to constitute a cluster involving a new pathogen. An area may be considered cholera-free after 2 incubation periods (total of 10 d) have passed without cholera disease. However, hospital monitoring should continue for a year due to tendency of enteric pathogens to re-emerge long after they are declared gone. Cholera may be viable but nonculturable from the environment; environmental monitoring has many false negatives. consider improvements to existing diagnostic labs • hotline set up for reporting of rumor This often translates into a hastily conceived vaccination campaign that distracts from core principles of cholera management. For every symptomatic Pt, there may be 90 asymptomatic carriers. In an established epidemic, the affected community is already extensively infected. Cholera vaccination, under these circumstances, has little public health benefit for the resource investment. If undertaken, the following will apply: • Vaccination campaign requires numerous staff. Community mobilizers are key. Clinical staff should not be poached from their clinical duties. Supervisors must be free to move at will. • Logistics is key-if the 1st day goes badly, the campaign goes badly. • Mark the domiciles which are done. • Hold after-action meetings each day. • Last day, use mobilizers with mobile broadcasting to attract those who missed out. • Second phase vaccination should include CHWs with multi-purpose messages on water and sanitation. Avoid: press exaggeration ABX prophylaxis reliance on IVF and insufficient ORS lab investigation of cases once epidemic etiology is ascertained prolonged hospitalization hospital discharge criteria requiring multiple negative stool cultures enthusiasm for OCV during epidemic exaggerated water purification objectives concentration of technical competencies in MOH at expense of districts failure to share information with stakeholders Influenza viruses comprise 3 genera-influenza types A, B, and C-each with 1 species. • Influenza type A is divided into subtypes based upon serological response to hemagglutinin (HA) and neuraminidase (NA) glycoproteins. There are 16 different HA subtypes and 9 different NA subtypes. H1N1, H2N2, and H3N2 are responsible for the major human pandemics in the last century. H2N2 virus circulated between 1957 and 1968 but currently does not. Only influenza A subtypes infect birds, and all subtypes can do so. Bird flu viruses do not usually infect humans. But, in 1997, an outbreak of H5N1 avian influenza in poultry in Hong Kong marked the first known direct human transmission of avian influenza virus from birds to humans. Since then, H5, H7, and H9 avian influenza subtypes have been shown to infect humans. • Influenza type B is morphologically similar to A and also creates seasonal and epidemic disease. • Influenza type C is rare but can cause local epidemics. Seasonal human influenza vaccine currently has 3 strains-H1N1/H3N2/B. Influenza disease in humans has a short incubation period (1-3 d). Early symptoms are non-specific. It is highly infectious, especially early in the course of the disease, with a large # of asymptomatic carriers. Transmission potential (R 0 ) is a function of infectivity, period of contagiousness, daily contact rate, and host immunity. In general, the faster the transmission, the less feasible is interrupting transmission thru usual disease control tools of case finding, isolation, contact tracing, and ring vaccination. • specific groups of exposed or at risk in the community-most likely to work when there is limited disease transmission in the area, most cases can be traced to a specific contact or setting, and intervention is considered likely to slow the spread of disease eg quarantine of groups of people at known common source exposure (airplane, school, workplace, hospital, public gathering; ensure delivery of medical care, food, and social services to persons in quarantine with special attention to vulnerable groups) (useless once there is community-based spread) eg containment measures at specific sites or buildings of disease exposure (focused measures to > social distance) cancel public events (concerts, sports, movies) close buildings (recreational facilities, youth clubs) restrict access to certain sites or buildings • community-wide measures (affecting exposed and non-exposed)most likely to work where there is moderate to extensive disease transmission in the area, many cases cannot be traced, cases are increasing, and there is delay between Sx onset and case isolation. infection control measures ARI etiquette-cover nose/mouth during cough or sneeze, use tissues, wash hands avoidance of public gatherings by persons at high risk of complications NB use of masks by well persons is not recommended "snow" (stay-at-home) days and self-shielding (reverse quarantine) for initial 10 d period of community outbreak-may reduce transmission without explicit activity restrictions closure of schools, offices, large group gatherings, public transport (pedes more likely to transmit disease than adults) NB community quarantine (cordon sanitaire)-restriction of travel in and out of an area is unlikely to prevent introduction or spread of disease Anopheles vector biology egg becomes adult mosquito in 9 d adult mosquito becomes infective in 12 d after bite on infected host susceptible human host becomes infective in 9 d after bite from infected mosquito :. earliest human clinical disease in 30 d after eggs are laid Follow the 4-D rule: dusk and dawn stay indoors as much as possible with window screens in good repair dress in light colored long sleeve shirts and long pants when outside Identify cause of the outbreak Undertake vaccination campaign Strengthen routine immunization and surveillance Meningitis is a disease with significant mortality. Meningococcus (Neisseria meningitides) is renown for its rapid onset, rapid progression (death sometimes within hours), and high mortality (50% untreated). There are 13 serogroups of Neisseria meningitides but only 6 (A, B, C, W, X, Y) are known to cause epidemics. The bacteria spread from person to person via respiratory and nasal secretions. Polysaccharide vaccines are available with 2 serotypes (A and C), 3 serotypes (A, C, and W) or 4 serotypes (A, C, W, and Y). Duration of immunity is approximately 3 years. Meningococcal protein conjugate vaccines confer longer immunity but at higher cost than polysaccharide vaccines. Monovalent conjugate vaccine against group C dates from 1999, and tetravalent (A, C, W, and Y) conjugate vaccine dates from 2005. Group B vaccine made from 4 bacterial proteins has been licensed since 2014 but is not readily available. Meningococcal vaccines have a very low incidence of side effects. Regular disease surveillance is necessary to detect outbreaks. The epidemic threshold is 10 suspected cases/ 100,000 population in any given week. Two suspected cases of meningitis in the same settlement should trigger an outbreak investigation. Nasopharyngeal carriage rates do not predict epidemics. 80-85% of meningococcal disease presents with meningitis. 80% of cases occur in patients <30 y/o. Peak incidence in meningitis belt is ages 5-10 yrs. Diagnosis is straightforward when patient presents with signs of meningitis-fever, headache, vomiting, changes in mental status. However, most patients have non-specific illness 1-3 days before onset of meningitis. CFR of untreated meningococcal meningitis can be 50%. CFR of properly treated meningococcal meningitis is <1%. 15-20% of meningococcal disease presents with septicemia unaccompanied by meningitis or other focal features. It is a dramatic illness which affects previously healthy children and young adults. It presents with acute fever leading to purpura fulminans (hemorrhagic or purpuric rash), shock, and Waterhouse-Friderichsen syndrome (acute adrenal failure). Etiologic diagnosis can be easily missed. CFR of meningococcal septicemia is 50% and may be 25% even with proper treatment. Diagnosis may be confirmed by agglutination tests, polymerase chain reaction, culture and sensitivity testing of spinal fluid and blood. In many situations, these tests are not available. Throat swabs may be helpful on occasions. Do not delay treatment for tests or test results. Minutes count. It is more important to have a live patient without a confirmed diagnosis than a dead one with a diagnosis. Differential diagnosis in a tropical patient with fever and altered mental status, but without purpura or shock, includes cerebral malaria. Co-infection may occur. Standardized case management of bacterial meningitis in developed countries involves 7-10 days of parenteral antibiotic therapy. Drug of choice in adults and older children is ceftriaxone which also rapidly eliminates the carrier state. Alternate drugs include ampicillin and benzylpenicillin which do not eliminate the carrier state. In developing countries, 4 days of parenteral antibiotic therapy are empirically shown to be effective. In large epidemics in resource-poor settings, a single IM dose of chloramphenicol in oil is the drug of choice. For patients who do not improve in 48 hours, a repeat dose may be given. Viral meningitis is rarely serious and requires only supportive care, Recovery is usually complete. Patient isolation and disinfection of the room, clothing, or bedding are not necessary. Respiratory precautions are advised particularly early in the course of treatment. Chemoprophylaxis of contacts is available in some settings but rarely in the disaster setting. Vigilance and education of close contacts is mandatory. Epidemic preparedness and early detection of outbreaks are key. Vaccines against N. meningitides serogroups A, C, Y and W135 are very effective in controlling epidemics. In epidemic settings, children 2-10 are the priority target with serogroups A and C typically the priority antigens. Rapid mass vaccination campaigns can contain outbreaks in 2-3 weeks. For immunocompetent patients over 2 years, vaccine efficacy rate is 90% one week after injection. However, duration of immunity may be as little as 2 years in younger children. In some countries, vaccine may also be used with close contacts of sporadic disease cases to prevent secondary cases. Chemoprophylaxis of contacts is not recommended in epidemics, but community education and ready access to health care are essential. Preventive Medicine [1] Source control/reduction/elimination Undertake quarantine and culling of sick reservoir animals and known disease carrier species. Avoid unnecessary contact with or consumption of dead reservoir animals or known disease carrier species. Avoid unnecessary contact with suspected reservoir animals and known disease carrier species (eg primates). Avoid direct or close contact with symptomatic patients. Establish appropriate communicable disease controls for burial of the dead. Administrative controls (improve people's work practices) Environmental and engineering controls (isolate people from the hazard) Avoid needle stick exposure to blood specimens thru automated machine handling. PPE (protect people with PPE) Use standard precautions-gloves, masks, and protective clothing-if handling infected animals or patients. Wash hands after visiting sick patients. Active surveillance and contact tracing (enhanced surveillance) through community-based mobile teams Active case finding (screening and triage) and contact tracing Dedicated isolation facility Food provision to isolated patients so they are not dependent on family Case definition Treatment protocols emphasizing supportive care and treatment of complications Essential drugs Referral guidelines Secondary prevention barrier nursing strictly enforced family and community education Ministerial task force to address policy Local health authority task force to address procedures National level task forces to comprise If a lab is not available, then you need a sampling strategy that addresses specimen acquisition, preparation, and transportation in compliance with international regulations on the transport of infectious substances. Guidance Note on Using the Cluster Approach to Strengthen Humanitarian Response International Conference on Primary Health Care Selective primary health care-an interim strategy for disease control in developing countries Water and excreta-related diseases: unitary environmental classification Infections related to water and excreta: the health dimension of the decade World Health Organization. Cholera vaccines: WHO position paper Available from: International Centre for Diarrhoeal Disease Research History and epidemiology of global smallpox eradication Available from: US Department of Health and Human Services Communicable disease control in emergencies-a field manual. Geneva: World Health Organization Ebola: technical guidance documents for medical staff World Health Organization. Manual for the care and management of patients in ebola care units/community care centers-interim emergency guidance. WHO/ EVD/Manual/ECU/15.1. Geneva: World Health Organization What tests does it perform? Is there transport to and from the laboratory? Who prepares transport media? Who provides specimen collection material and supplies? How can these supplies be obtained? Who provides cool packs, transport boxes, car, driver …? • Refrigerate other vials for cytology, chemistry (4 °C) Leak-proof specimen container wrapped with enough absorbent material to absorb the entire content of the 1st container 2. Leak-proof secondary container usually plastic or metal 3. Outer shipping container whose smallest dimension is 10 mm Diagnostic specimens use IATA packing instruction 650 without biohazard label. Infectious materials use IATA packing instruction 602 with biohazard label. What to send with the sample? Lab request form with: • Sender's name and contact info • Patient name, age, sex • Sample date, time • Suspected clinical diagnosis with main signs and symptoms • Sample macroscopic description • Context-outbreak confirmation, ongoing verification, outbreak end, etc • Epidemiological or demographic data Where to send the sample? • Reference lab • Contact person What and when to expect results? Source: World Health Organization World Health Organization Department of Communicable Disease Surveillance and Response. Highlights of specimen collection in emergency situations. Undated 4 . Designate a lead official in the LCC. 5. Anticipate roles for partner agencies (eg inter-agency and team coordination, disease surveillance, field epidemiological investigation, laboratory identification, case management guideline development, outbreak logistics, public information, and social mobilization). 6. Identify sources of funds. 7. Intensify disease surveillance. 8 . Identify reference lab(s) for communicable diseases of epidemic potential. 9. Ensure mechanism for specimen transport. A. Initial Response to Suspected Outbreak 1. Form an emergency team to investigate and manage the outbreak a. identify key roles on the outbreak investigation team(s) (1) epidemiology and surveillance (2) case management (3) water and sanitation (4) laboratory services (5) communication b. staff those roles (1) epidemiologist-to monitor proper data collection and surveillance procedures (2) physician-to confirm clinical S/Sx and train health workers in case management (3) water and sanitation expert-to develop a plan for reducing sources of contamination (4) microbiologist-to take environmental/biological samples for laboratory confirmation, train health workers in proper sampling techniques, and confirm use of appropriate methods in the diagnostic laboratory (5)