• Integrated Disease Surveillance Project (IDSP) is a decentralized, state based surveillance programme in the country. It is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. It is also expected to provide essential data to monitor progress of on-going disease control programmes and help allocate health resources more efficiently.
1 Syndromes under Surveillance:• Fever • Less than seven days duration without any localizing signs • With Rash • With altered sensorium or convulsions • Bleeding from skin or mucus membrane • Fever more than seven days with or without localizing signs• Cough more than three weeks duration• Acute Flaccid Paralysis• Diarrhoea• Jaundice• Unusual Events causing death or hospitalization
Types of surveillance under IDSP:• Syndromic:• Presumptive:• Confirmed:
Symptoms, signs and syndrome• Symptom is complaint perceived by the patient or identified by the examiner (e.g. fever, loose motions, headache, vomiting, cough etc.)• Signs are findings on examination of patients e.g. skin rash, yellow discoloration (jaundice).•• Syndrome is group of symptoms and/or signs attributable to particular disease condition (e.g. fever with skin rash indicative of measles).
Reporting units for disease surveillance• Public health sector• Private health sector• RuralSub-centers, PHCs, CHCs, District HospitalsSentinel Private practitioners (SPPs) and Sentinel hospitals.UrbanUrban Hospitals, ESI / Railway / Medical college hospitalsSentinel Private nursing homes, sentinel hospitals, Medical colleges, Private and NGO laboratories
Weekly Information Flow under IDSP C.S.U.Sub-Centres Programme Officers S.S.U. P.H.C.s C.H.C.s Pvt. Practioners D.S.U. Dist.Hosp. Nursing Homes Private Hospitals Med.Col. Private Labs. P.H.Lab Other Hospitals: Corporate ESI, Municipal Hospitals Rly., Army etc.
Syndrome ActionOnly Fever Blood Smear for all patients Inform PHC MO immediately to arrange for collection of stool samples Two samples of stools taken at interval of 24 hours and transported to the MO PHC in reverse cold chainAcute Flaccid Paralysis Take sample of stools in a filter paper or in a sterile bottle and send it by reverse cold chain to the nearest District Laboratory (within two hours) orLoose watery stools with dehydration in an use Cary-Blair medium for transport of the sample adultFever with rashFever with altered sensoriumFever with bleeding Referred to the MO PHC for specific labFever more than 7 days actionCough for more than three weeksUnusual severe syndromes
COLLECTION, STORAGE & TRANSPORT OF SPECIMENSINTEGRATED DISEASE SURVEILLANCE PROJECT- TRAINING FOR STATE AND DISTRICT SURVEILLANCE OFFICERS
Methods of Collection:a) Venepuncture b) Finger prick For serum & For peripheral blood Blood culture smear
PERFORMING VENE PUNCTURELabel the collection container beforecommencement of venepuncture.Gloves should be worn.Use sterilized/sterile disposable syringesand needles.Clean the site well with spirit.Tighten tourniquet.
- Perform venepuncture,and collect 5 ml of blood.- After blood collection, remove tourniquet and withdraw the needle .- Remove the needle from the syringe.- Carefully transfer blood from the syringe without squirting, into a sterile screw capped plastic leak proof specimen container.- Any blood spill is wiped with 70% ethanol.- All the swabs are placed in plastic bags for disposal.- If the outside of the vial is visiblycontaminated with blood, it should becleaned with 10% freshly preparedsodium hypochlorite solution.
EXTRACTION OF SERUM 5ml of venous blood is collected remove the needle before transferring to sterile dry test tube. Let the specimen clot for 30 mins. at ambient temperature. Do not shake. Then place in a cool box for clot retraction at 4-8o C, for a minimum of 1-2 hours. If facilities for separation of serum are not available, then it should be refrigerated at 4o C. (NOT FROZEN). Otherwise centrifuge @ 1000 G for 10 mins. Separate the serum from the clot. Sera should be transported at 4-8o C and can last at this temperature for upto 10 days.
SERUM………Required for the diagnosis of the following diseases:1) Typhoid- Paired sera2) Leptospirosis- Paired sera3) Measles- Paired sera4) Dengue- Paired sera5) Japanese encephalitis- Paired sera6) Hepatitis – Single sample7) Plague- Paired seraIdeally blood should be collected within 5-7 days of the start of illness. The second sample should be collected with a gap of 10 days.(for paired sera)
BLOOD FOR CULTUREHow much?Venous blood0.5 – 2 ml for infants2-5 ml for children5-10 ml for adultsWhen?As early as possible and before starting antibioticsTransport:-Collect into blood culture bottles (with Glucosebroth Or Bile salt broth).--Should be transported at ambient temperature.
Blood culture contd…. SKIN PREPARATION (Very important) After palpating the vein, clean the site for venepuncture with 70% alchol for at least 30 secs Next clean with iodine (tincture iodine ) in concentric circles away from the puncture site covering an area of 1-2” in diameter
Collect required amount ofblood with a sterile needle andsyringe.Transfer with the needle intothe blood culture bottle.Shake the bottle properly toprevent clotting.Can be kept at roomtemperature.Always label the bottle andwith the patient detailsmention time & date ofcollection
Blood can also be collected in ananticoagulant solution e.g. EDTA.A second person wearing gloves should helpin shaking the vial for mixing the blood wellwith the anticoagulants.Usually collected for detection of malarialantigen.
FINGER PRICK – Examination of bloodsmear for malaria # Peripheral blood smears are prepared for the diagnosis of malaria. # Collect blood either during or 2-3 hours after the peak of temperature. # Sample should be taken before administration of antimalarial drugs. # Both thick and thin films should be made. # Thick film is used to detect the parasite and thin film to determine the species of the parasite.
Thick Films: Take 3-4 drops of blood and spread over a 1 cm square area or in a 1cm diameter circle. Allow to dry,Thin Films:These are prepared bytaking a drop of blood onone edge of the slideand spreading it evenlyover the surface withanother slide.
Examination of blood samples for leptospirosis, Dengue and chikun gunya• Serum from blood sample is prepared.• Antibody detection – IgM ELISA method. – Microplates precoated with inactivated antigen. – Patient’s serum sample is added. – Incubation at 37º C for a definite period. – Addition of conjugates followed by aspiration and washing many times. – Results read by colorimetric method using spectrometer.
RESPIRATORY TRACT SPECIMEN COLLECTIONSpecimens are collected from the upper or lowerrespiratory tract, depending on the site of infection.Upper respiratory tract pathogens(viral and bacterial):a) Throat swab.b) Nasopharyngeal swab.Lower respiratory tract pathogens:a) Sputum specimens.
MATERIALS REQUIRED :Transport media – bacterial and viral.Throat swabs (Dacron and cotton swabs).Tongue depressor Nasal speculum20-50 ml syringeSterile screw-cap test tubes and wide-mouthed cleansterile containers (minimum volume 25 ml.)
METHOD OF COLLECTING A THROAT SWAB :* Hold the tongue down with the tongue depressor.* Use a strong light source to locate areas of inflammationand exudate.(posterior pharynx and the tonsillar region ofthe throat behind the uvula) .* Rub the area back and forth with a sterile cotton swab.* Sample the posterior pharyngeal wall at the end to avoidgagging by the patient.•Withdraw the swab without touchingcheeks, teeth or gums and insert intoa sterile screw-cap test tubecontaining appropriate transportmedium required.
METHOD OF COLLECTING PER-NASAL AND POST- NASAL SWABS :- Seat the patient comfortably, tilt the head back and insert the nasal speculum.-Insert a flexible cotton swab through the speculum parallel to the floor of nose.- Alternately, bend the wire and insert it into the throat and move the swab upwards into the nasopharyngeal space.- Rotate the swab on the nasopharyngeal membrane a few times, remove it carefully and insert it into a screw-cap tube containing transport medium.- Break off the top part of the stick without touching the tube and tighten the screw cap firmly.- Label the specimen tube.
METHOD OF COLLECTING NASOPHARNGEAL WASH/ASPIRATE :- Have the patient sit with the head tilted slightly backward.- Flush a plastic catheter or tubing with 2-3 ml of VTM/sterile normal saline.- Instill 1-1.5 ml of VTM (viral transport medium)/sterile normal saline into one nostril.- Insert the tubing into the nostril parallel to the palate and aspirate nasopharyngeal secretions.- Repeat this procedure with the othe nostril.- Collect 1-2 ml in a sterile VTM and transport in cold chain at 2-8o C
COLLECTION OF SPUTUM SAMPLEMaterials required :Select a good wide-mouthed sputum container,which is disposable, made of clear thin plastic,unbreakable and leak proof material.Method of collection :Collect an early morning sample after rinsing the mouthwith water.Instruct the patient to inhale deeply 2-3 times, cough updeeply from the chest and spit in the sputum container bybringing it closer to the mouth.This should be done in the open or away from otherpeople.Make sure the sputum sample is of good quality. A goodsputum sample is thick purulent and sufficient in amount.
HANDLING AND TRANSPORT- If the specimen is collected in the field and cannot be immediately processed, it should be transported to the laboratory within 3-4 days of collection.- The specimen should be properly labelled and kept away from the sun and heat. These can be placed in a special box, which can withstand leakage of contents, shocks and other conditions incident to ordinary handling practices.-These boxes should be kept & transported in cool conditions.- If delay is unavoidable, the specimens should be refrigerated.
COLLECTION OF FAECES ACUTE (WATERY) DIARRHOEACausative Agents : Bacteria(eg.Cholera,Salmonella,Shigella, E.coli) Viruses (eg Rota virus) and Parasites.Which sample should be collected? Stool sample is preferred incase ofinfants rectal swabs can be collected.
When should it be collected?Collect soon after onset of diarrhoeaFor viruses : < 48hrs of onset,For bacteria : < 4days after onset of illness.PREFERABLY BEFORE STARTING ANTIBIOTICSIf required two or three samples can be collected onconsecutive/alternate days.
In which container? Clean dry leak proof container Container with spatula CONTAINERS SHOULD NOT BE WASHED WITH DISINFECTANT SOLUTION
INSTRUCTIONS FOR COLLECTING FAECES# Label the specimen container clearly with patientsname and date of collection. ( If a specimen container isnot available, a clean jar with a screw-top lid may beused.)# Pass faeces directly into the container. Do notcontaminate the faeces with urine/Or place a separateclean container with a wide opening (for example, an ice-cream container), or plastic wrap or newspaper in thetoilet bowl.Transfer enough faeces with spatula to atleast half fill the specimen container.# Screw the lid on the specimencontainer firmly. Place it in a sealedplastic bag.
COLLECTION OF RECTAL SWABThis method of sampling is less satisfactory than collectingfaeces. It is not appropriate for parasitology.•Moisten a cotton swab with sterile saline.•Insert it inside the anal sphincter and goupto 2-4 cm inside the rectum .•Gently rotate upto 90 degrees, so that faeces covers theswab.•Withdraw the swab•Place it in transport medium, break off the top portion ofswab stick and discard•Label the specimen and place it in a plastic bag with theappropriate request slip attached
HANDLING AND TRANSPORT• If delay of more than two hours is anticipated, inoculate the specimen in a transport medium• Cary Blair medium : for bacterialpathogens(Salmonella , Shigella,Esch coli and Vibrio). Shouldreach laboratory in 2-3 days time.Can keep at room temperature. Rectal swab in Cary Blair mediumV.R. Fluid :For Cholera shouldreach laboratory in 2-3 days time.Can keep at room temperature.For viruses keep in fridge (4ºC-8ºC)DO NOT FREEZE. Rice water stool in V.R. Fluid
When do we collect?The specimen must be taken by a physician experienced inthe procedure.CSF is used in the diagnosis of viral, bacterial, parasitic, andfungal meningitis.Also Dengue and Japanese Encephalitis.Collect as early in the disease as possible, before antibiotics
MATERIALS REQUIRED:Lumbar puncture tray which includes :Sterile materials : gloves, cotton,towels or drapes.Local anaesthetic, sterilized needle,syringe.Skin disinfectants : 10% providoneiodine or 70% alcoholTwo lumbar puncture needles, smallbore with stylet (sterilized)Six externally threaded sterile screw-cap tubes and tube rack. Gloves Drapes
METHOD OF COLLECTION :Only experienced clinicians should be involved in performingA lumbar puncture.CSF is collected directly into the separate screw-cap steriletubes. Separate tubes should be used for bacterial and viralprocessing.Step 1. Make the patient lie on the bed in left lateralposition. Ask the patient to flex the neck (so that the chintouches the chest) hip and the knee joint.
Step2: Using the iliac crest as the referencepoint, palpate the joint space between the 4thand the 5th lumbar vertebrae and identify the surface anatomy.Step3; Disinfect the site meticulously with10% povidone iodine or 70% isopropyl alcoholby swabbing the skin concentrically from L4the centre of the site outwards. Let the L5disinfectant evaporate.- Do not repalpate the site again.Step 4: Infiltrate the local area with thelocal anaesthetic and wait for 4-5 mins forthe effect to appear before performinglumbar puncture.
Step5: Insert the sterile lumbarpuncture needle between the 4th and5th lumbar vertebrae to a depth of 4-5cm, withdraw the stylet. Fluid flowsfreely through the needle.Step 6: Between 1 and 2 ml of CSF iscollected in each of the 3 tubes,a) one for culture,b) one for biochemical analysis andc) one for cytology.
HANDLING AND TRANSPORTATION : In general send the specimens to the laboratory andprocess as soon as possible. Transport CSF specimens for bacteriology at ambienttemperature, generally without transport media. Neverrefrigerate the CSF, as many of the bacterial pathogensdo not survive well at low temperatures. CSF specimens for virology do not need transportmedium. They should be transported at 4-8o C.
POST MORTEM SPECIMEN COLLECTIONWhen, why & how?# Need to be collected duringoutbreak situation when causativeagent is not known. # Strict precautions, includingrespiratory protection fromaerosolized particles, must be takenwhen carrying out post-mortemspecimen collection during outbreaks.# Collect the specimens as soon aspossible, preferably within 24 hoursince viral titres decline while bacteriamultiply rapidly after death..
Materials Required :- Barrier precautions : double gloves,sterile gown, eye goggles, mask.- Blood and other fluids, should becollected as mentioned before.- Aseptic surgical and biopsyinstruments for collecting tissuespecimens.- For histology :saline formalin.- For culture:Sterile saline/appropriateviral and bacterial transport media.- Sterile containers, sterile screw captubes or vials, glass slides and slidebox.- Disinfectant such as householdbleach diluted 1:10 in water.
Method of collection :- Use a separate sterile instrument for each tissuespecimen from affected sites (several fragments with 1-2grams of each is sufficient).- Smaller, but adequate, specimens may be taken with abiopsy needle.- Place different tissues in separate sterile containerscontaining the relevant medium- Label all containers and tighten the screw caps firmly.* Blood may be taken from the heart cavities.* If cerebral malaria is suspected, make several smearsfrom the cerebral cortex on glass slides to detectPlasmodium falciparum. Label the slides and transport in aslide box.
Handling and Transportation :- Fixed specimens can be stored and transported atambient temperature.- Tissue specimens for isolation of bacterial pathogenscan be transported at ambient temperature intransport media for upto 24 hours.- Transport tissue specimens for isolation of viralpathogens in viral transport medium or sterile saline at3-8o C for 24-48 hours. For longer periods, freeze andstore at –70o C.- If rabies is suspected and brain samples arecollected, freeze unfixed specimens immediately aftercollection. Formalin-fixed samples are also useful andmay be transported at ambient temperature.
Some general principlesEffective diagnostic microbiology depends upon thecorrect collection and timing of clinical specimens andtheir proper transport to the laboratory under optimalconditions.- Specimen should be in adequate quantity.- Must be collected before the administration ofantimicrobial agents.- Contamination of specimen with externally present organisms of normal flora of body must be prevented.- Specimen must be collected at appropriate stage ofthe diseases.- Specimen should not get contaminated during storage.- Specimen handling should not be risky to individual.
GENERAL RULES FOR COLLECTION ANDTRANSPORTATION OF SPECIMENS FORCULTUTRE:• Apply strict aseptic techniques.• Wash hands before and after the collection.• Collect or place the specimen in a sterilecontainer.• Ensure that the outside of the specimencontainer is clean.• Tightly close the container.• Appropriately label and date the container andcomplete the requisition form.• Arrange for immediate transportation to thelaboratory.
UNIVERSAL PRECAUTIONS• BARRIER PROTECTION• HAND WASHING• SAFE TECHNIQUE• SAFE HANDLING OF SHARP• SAFE HANDLING OF SPECIMEN• SAFE HANDLING OF SPILLS• USE OF DISPOSIBLE• IMMUNISATION WITH HEP-B VACCINE
BARRIER PROTECTION Gloves-• Use well fitting, disposable / autoclaved Change if visibly contaminated / breached Remove before handling telephones, performing office work, leaving workplace
BARRIER PROTECTION• Facial protection – When splashing or spraying of blood / blood fluids expected• Gowns/Special uniforms – in high risk areas• Occlusive bandage – breach of skin All skin defects must be covered with water proof dressing.
HAND WASHINGAn ideal safety precautionWashing with soap and waterHands must be washed-• Immediately after contamination• Before eating, drinking, leaving the workshop• After removing gloves• At completion of days work
Sharps policy• Reduce use• Selection of devices• Care in use• Disposal
Handling of sharps• Dispose your own sharps yourself.• Never pass used sharps to another person.• During exposure-prone procedures, minimize the risk of injury by ensuring that the operator has the best possible visibility. E.g. by positioning the patient, adjusting good light source and controlling bleeding.
Handling of sharps• Protect fingers from injury by using forceps instead of fingers for guiding suturing.• Never recap, bend or break disposable needles.• Place used needles and syringes in a rigid puncture resistant container• Destroy using needle destroyer.
MANAGEMENT OF BLOOD SPILLS• Spill on floor/ work surface should be covered with paper towel / blotting paper / newspaper / absorbent cotton.• 1% Bleach solution should be poured on an the spill and covered with paper for 30 minutes• All the paper / cotton should be removed with gloved hands
Occupational Exposure• Contact of blood with skin• mucous membrane• non intact skin• Percutaneous injury
On Exposure• Wash needle stick injuries and cuts with soap and water• Flush splashes to nose, mouth or skin with water• Irrigate eyes with clean water, saline or sterile irrigates
POST EXPOSURE PROPHYLAXIS• Assess risk of infection versus toxic side effects of drugs• PEP decision to be based on:• (1) Degree of exposure to HIV• (2) HIV status of the source of exposure
Standard Precautions• All patients to be treated as potential carriers of blood borne pathogens• Use of appropriate personal protective equipments• Careful handling of sharps and avoiding sharp injury• Proper disposal of sharps and infectious waste.