VPD Surveillance

1. Sensitization Meeting on
AFP, Fever Rash & DPT
Surveillance
WORLD HEALTH ORGANISATION

2. GlobalWPV1&cVDPVCases1,Previous6Months2
Data in WHO HQ as of 10 May
2022
Endemic country (WPV1)
1Excludes viruses detected from environmental surveillance; 2Onset of paralysis 11 Nov. 2021 to 10 May 2022
WPV1 cases (latest onset)
Pakistan 2 14-Apr-22
Afghanistan 2 14-Jan-22
Malawi 1 19-Nov-21
cVDPV1 cases (latest onset)
Madagascar 3 07-Jan-22
cVDPV2 cases (latest onset)
Mozambique 2 26-Mar-22
DR Congo 49 24-Mar-22
Nigeria 41 13-Mar-22
Somalia 2 18-Feb-22
Yemen 39 07-Jan-22
Ukraine 1 24-Dec-21
Niger 4 14-Dec-21
cVDPV3 case (latest onset)
Israel 1 12-Feb-22
Public Health
Emergency of
International Concern
declared under the
International Health
Regulations in May 2014 And
is continuing

3. Summary
India maintains polio free status since 2011
High risk of Poliovirus importation in the country
- Wild Polio virus transmission ongoing in Afghanistan and Pakistan
- Intense cVDPV2 transmission
- Vaccine hesitancy and Poor RI & SIA coverage in few vulnerable
areas
Sensitivity of AFP surveillance has declined in 2020-21 due to COVID-
19 pandemic
- Orient staff to report all cases of AFP
- Intensify active case searches
Conducting safe and quality IPPI is important

4. The Endgame Goal: complete the
eradication of all wild & vaccine-
related polioviruses.

5. Acute Flaccid Paralysis
Surveillance

6. 6
• India maintains polio free status since 2011
• High risk of Poliovirus importation in the country
- Wild Polio virus transmission ongoing in Afghanistan and Pakistan
- Intense cVPDV2 transmission
• Surveillance for AFP declined in 2020
- Continue to maintain global standards
• IEAG recommends one NID and two SNIDs
• Conducting safe and quality SNID is important
Polio Status

7. What is AFP?
Definition :
AFP(Acute Flaccid Paralysis) : “ Sudden onset of weakness
and floppiness in any part of the body in a child < 15
years of age or paralysis in a person of any age in which
polio is suspected”
Acute-Rapid progression or brief duration
Flaccid-floppy or soft yielding to passive stretching
Paralysis-Loss of motor strength, paresis or plegia
All cases of acute flaccid paralysis (as per existing case
definition) should be reported irrespective of diagnosis within 6
months of onset

8. Report AFP if…
Current flaccid paralysis at the time of examination
History of flaccid paralysis in the current
illness
Borderline, ambiguous or doubtful.
Therefore…..All cases of acute flaccid paralysis should
be reported at the earliest, irrespective of diagnosis

9. Common presentation of AFP
• Gulliain Barre’ Syndrome
• Transverse Myelitis
• Traumatic Neuritis ( foot drop due to damage to sciatic nerve
following injection into gluteal region )
• Poliomyelitis
• Encephalitis presenting with hypotonia ( not a drowsy or comatose patient )
• Infantile hemiplegia ( presenting with hypotonia)
• Hemiplegia / hemiparesis presenting with hypotonia
• Isolated cranial nerve palsy ( facial palsy or palatal palsy)
• Residual flaccid paresis after correction of post diarrhoeal hypokalaemia –
common with NPEV infection
• Post ictal paresis – Todd’s paralysis- If Paresis persists after 24 hrs of onset
• Peripheral Neuropathies
• Post-Diphtheritic neuropathy
• Transient paralysis
• Etc.

10. Surveillance Indicators
• To assess the quality and sensitivity of
surveillance at any point of time.
• Two principal Indicators :
• Non Polio AFP Rate- for India 2 per
100000 Under15 population/year
• Adequate Sample Rate->80% of
reported AFP

11. Adequate Sample Rate
Adequate sample :
 2 samples,
 each at least 8 gm,
 collected within 14 days of onset of paralysis,
 with minimum 24 hours interval,
 reaching an accredited lab in good condition (No leakage,
no desiccation, with proper documentation, maintaining
proper cold chain)
At least 80% of AFP cases must be with
adequate
sample - Indicator of reliable surveillance

12. Information of the case
 When: Immediate/ How : by the fastest means telephonically or personal
messenger / To : SMO/DIO, nodal officer and nodal person
What to Inform (Collect it always before the patient leaves)
 Name
 Age/Date of Birth
 Sex
 Father’s Name
 Grand Father’s Name
 Permanent Address including Landmark
 Local Address including Landmark
 Contact No.
 Date of Onset of Paralysis
Missed cases are usually from
OPD,Emergency,orthopedics,neurology,PMR

13. Measles and Rubella Elimination
Strategy & Update

14. 14
Immuniz
ation
Surveilla
nce
Support
&
Linkages
Laborato
ry
Network
95% coverage with
two doses of MRCV
Sensitive Case-based
MR Surveillance
Accredited MR
Laboratory Network
 Rapid response to
measles and rubella
outbreaks
 Ensure linkages with
SDGs and other
integrated programs
Strategic Objectives to Achieve Measles and Rubella Elimination

15. Measles Rubella Elimination
Regional Score card on Verification of Elimination
WHO Region
(No. Member States)
Regional
Verification
Commissions
Established
Elimination Achieved
Measles Re-
established
No. of MS (areas) % of MS
Americas (n=35) Yes
Measles: 33
Rubella: 35
94%
100%
Venezuela
Brazil
Europe (n=53) Yes
Measles: 33
Rubella: 49
62%
92%
Albania, Czech
Republic, Greece,
United Kingdom
Western Pacific (n=27) Yes
Measles: 7 (2)
Rubella: 4 (1)
26%
15%
Mongolia
Eastern Mediterranean
(21)
Yes
Measles: 3
Rubella: 3
14%
14%
South-East Asia
(n=11)
Yes
Measles: 5
Rubella :2
45%
18%
Africa (n=47) Yes - -
TOTAL (n=194)
Measles: 81 (42%)
Rubella: 93 (48%)
SEA Region-Eliminated-Rubella-SL,ML
Measles-SL,ML,DK,BH,TM

16. 16
Top 10 countries report 66% of all 2020 measles cases

17. In 2020, measles and rubella cases declined substantially for
multiple reasons
– Reduced exposure to measles and
importations due to COVID-19, closed
borders, reduced travel, social
distancing
– 2018-2019 outbreak led to burn-out of
susceptible groups
– Sub-optimal surveillance - fewer cases
detected, more under-reporting
• Laboratories redeployed to COVID-19
• Laboratory supplies limited
• People avoiding medical facilities
What we do
know: measles
immunity gaps are
widening
due to delayed
SIAs and drops in
routine
immunization,
exacerbating a
decade of
inadequate
coverage

18. Measles disease
• An acute disease
– Caused by measles virus
– Highly infectious: everyone exposed gets
the disease if not immune
– Mortality highest in children < 2 yrs and
in adults
• Classic manifestations:
– Fever
– Maculopapular rash
– The 3 Cs:
• Cough,
• Coryza (runny nose),
• Conjunctivitis (red eyes)

19. Transmission
• Droplet infection
• Portal of entry- respiratory tract or
conjunctivae
• Face to face contact not necessary
• Virus is viable in suspended air even 1-
2 hours after patient leaves the room
• Secondary spread can occur from
airplanes, hospitals, clinics
19

20. Clinical course of measles
-21 -20 -19 -18 -17 -16 -15 -14 -13 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6 +7 +8
-21 -4 0 +4
Incubation period
( 7–21 days max before rash)
Rash
( about 4–8 days)
Prodrome
period
Communicable period
Rash minus 21
days is earliest
possible
exposure date
Rash minus 4 days is
probable start
of infectiousness
Onset
of rash
Rash plus 4 days
is probable end
of infectiousness

21. Clinical features contd..
• Characteristic erythematous (red) maculopapular
(blotchy) rash appears ,starting behind the ears
and spreading to rest of body.
21

23. Maculo-papular rash

24. Koplik’s spot pathognomonic of measles

25. Measles - differential diagnosis
Fever + Rash
Dengue
Rubella
Scarlet fever
Toxoplasmosis
Chickungunya
Mononucleosis
Meningococcemia
Kawasaki
Other viral exanthemas
Measles
scrub typhus

26. Suspected Measles Case Definition (Old)
Any person with fever and
maculopapular rash with
any one of 3 ‘C’ - Cough or
Coryza or Conjunctivitis
Any person in whom
clinician or health worker
suspects measles infection
or
Fever
Cough
Maculopapular Rash
Coryza (Runny Nose) Conjunctivitis (Red
eyes)
For field epidemiological investigation,
suspected measles would be a case within last
3 months (90 days)

27. Suspected Measles Case Definition (Revised)
Any person with
fever and
maculopapular rash
Any person in whom
clinician or health worker
suspects measles or
rubella infection
or
Fever
Cough
Maculopapular Rash
Coryza (Runny Nose) Conjunctivitis (Red
eyes)
For field epidemiological investigation,
suspected measles would be a case
within last 3 months (90 days)

28. Impact of Transitioning to Fever Rash Surveillance : Three States
88(8%)
969
(92%)
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
FR FR + 3C
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
FR FR + 3C
1196
(27%)
3298
(73%)
Before Transition After Transition
23
(26%)
57
(65%)
Measles Rubella
Negative
459
(47%)
40
(4%)
458
(47%)
Measles Rubella
Negative
188
(16%)73
(6%)
935
(78%)
Measles Rubella
Negative
735
(22
%)
249
(8%)
2285
(70%)
Measles Rubella
Negative
* Others category excluded from the analysis
28
• 27 % FR cases detected which would have been
missed with earlier case definition
• 78% of these additional FR cases detected were
found to be negative cases (non- measles non-
rubella cases), which adds to the surveillance
sensitivity by increasing NMNR rate

29. Measles complications
Corneal scarring
causing blindness
Vitamin A deficiency
Encephalitis
Older children, adults
≈ 0.1% of cases
Chronic disability
Pneumonia &
diarrhea
Diarrhea common in developing
countries
Pneumonia ~ 5-10% of cases, usually
bacterial
desquamation

30. Measles Complications
S.No Complication Incidence
1 Ear Infection 1 in 10 with measles (Most common complication)
2 Diarrhea 1 in 10 with measles
3 Pneumonia
1 in 20 with measles (Most common cause of death
from measles in young)
4 Encephalitis 1 in 1000 with measles
5
Subacute sclerosing pan
encephalitis
1 in 100,000 with measles
Measles can be serious in all age groups
Children < 5 years and adults > 20 years old more likely to suffer from measles
complications

31. Basic Principles of management
• Anticipate complications
• Encourage breast feeding
• Provide nutritional support to all children
• Administer vitamin A – 2 doses
• Give paracetamol if temp > 39°C
• Give ORS-Zinc for diarrhea
• Treat eyes promptly to prevent blindness
• Use antibiotics if indicated
• Admit severely ill children
• Monitor growth regularly
31

32. Vitamin A schedule for management of measles
32
Age
Immediately on
diagnosis
Next day
< 6 months 50,000 IU 50,000 IU
6 – 11 months 1,00,000 IU 1,00,000 IU
> 12 months 2,00,000 IU 2,00,000 IU
2 dose schedule is more effective than single dose schedule

33. Rubella
• An acute, mild, self limiting viral illness affecting both
susceptible children and adults (~ 90% rubella cases
are < 15 years of age)
• Rubella infection occurring just before conception
and during early pregnancy may result in miscarriage,
fetal death or congenital defects known as CRS
(congenital rubella syndrome)
• Public health importance of rubella due to
teratogenic potential of the virus

34. Rubella Disease
• 20-50% of Rubella infections are mild/ without rash
/ asymptomatic
• Mild Prodrome
 Rare in children
 Adolescents and adults -Low grade fever,
malaise, cervical group of lymph node
enlargement, upper respiratory symptoms (lasts
1- 5 days)
• Mild Rash
 Maculopapular non-coalescent
 Begins on face and head
 Usually persists 3 days
 Mild Joint pain
In adolescents/adults

35. Rubella - Complications
• Lymphadenopathy
• Arthritis
 Children: rare
 Adult female up to 70%
• Thrombocytopenic purpura
 1/3000 cases
• Encephalitis
 1/6,000 cases
However, increased frequency
has been noted in some of the
Pacific Islands, Hong Kong and
Tunisia
 CRS is the most important complication (90%
chance if infected during 1st trimester of pregnancy)

36. Congenital Rubella Syndrome
• Infection early in pregnancy most
dangerous (<12 weeks gestation)
– Weeks 1- 10 – 90% CRS*
– Weeks 11-12– 33%
– Weeks 13-14– 11%
– Weeks 15-16– 24%
– Weeks > 17– 0%
• May lead to fetal death or
premature delivery
• Organ specificity generally related
to stage of gestational infection
*Miller E. Lancet 1982;2:781-4.

37. Investigation of each reported
case using MR-CIF
Notification
MR Case-based Surveillance: Case Investigation
Suspected Measles Case Reporting sites – Medical College, GH, Pvt Paediatrician,
PHC, informers, Community Health Worker
RU -Weekly Report along with AFP
38

38. Notification of Suspected Measles Case
• What: Cases of suspected measles
• When: whenever they get a case over phone &
also mention in weekly reporting format
• To whom: MO/DIO/DSO/SMO/Nodal Officer/
any other authorised person
• Data matching: BMO to match & collate the case
information from multiple sources including IDSP
• Data sharing: DIO and DSO to share their
information on suspected measles cases every
week – mismatch to be rectified Nil report to be sent even if no
case is seen in the last week

39. Key Information to be Collected on Suspected Measles Cases
by Reporting Sites
• Person: Name, Age
• Place: Address with mobile number
• Time: Date of rash onset = “Date
of Onset”
• Status of the case at the time of
reporting
– Vaccination status
– Alive or dead
• Samples collected

40. Case Investigation
• Every suspected measles case that is
reported should be investigated using MR-
CIF (case investigation form) (within 48
hours of case notification)
• MR-CIF can be filled up in the field by any
of the below mentioned medical officers,
including
(BMO/MO/clinician/Pediatrician/DIO/DSO/
SMO/any other authorized person)
• Each suspected case investigated will be
given an unique identifier (Example: MR
IND ST DIS YR XXX)

41. Investigation of each reported
case using MR-CIF
Notification
MR Case-based Surveillance: Specimen Collection
Suspected Measles Case Reporting sites – Medical College, GH, Pvt Paediatrician,
PHC, informers, Community Health Worker
RU -Weekly Report along with AFP
Specimen Collection
42

42. Specimen Collection
• Try to collect blood sample (for serology) and any one among
throat swab/urine sample/nasopharyngeal swab (for
virology)
• Blood sample to be collected from each suspected measles
case that is investigated on MR-CIF, if case is in the window
of ≤ 28 days of rash onset. Centrifuge & separate serum
• If the case is in the window of ≤ 7 days of rash onset then in
addition to blood sample , collect any one of (throat
swab/urine sample/nasopharyngeal swab) for genetic
characterization
• A MR-LRF (lab request form) will be filled in for every case
investigated and samples sent to the designated MR
laboratory under cold chain

43. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Date of onset
of Rash
(0 day)
Virology
(Throat swab/urine/
nasopharyngeal swab )
+
Serology
( Serum Sample)
Only Serology
( Serum Sample)
MR Specimen Collection
>28 days
No sample
collection
(But CIF will be
filled for all cases
with onset of rash
in last 3 months)

44. Summary : MR Specimen Collection
S.no Period from rash onset
Serum
sample collection (for
Serology)
Any one of the Sample to
be collected for Virology (Throat
swab/Urine/nasopharyngeal
swab)
1 Till 7 days Yes Yes
2 Between 8 – 28 days Yes No
3 More than 28 days No No
Adequate specimens for serology are those collected within 28 days after rash onset
that consist of ≥ 0.5 mL serum & shipped to laboratory under cold chain

45. Good Quality vs Haemolysed serum
13
Good Quality serum
Acceptable
Serum with
Haemolysis
Not Acceptable

46. Investigation of each reported
case using MR-CIF
Notification
MR Case-based Surveillance: Sample Shipment to Lab
Suspected Measles Case Reporting sites – Medical College, GH, Pvt Paediatrician,
PHC, informers, Community Health Worker
RU -Weekly Report along with AFP
Specimen Collection Designated MR Laboratory
Cold Chain
47

47. RAJASTHAN
ODISHA
GUJARAT
MAHARASHTRA
MADHYA PRADESH
BIHAR
KARNATAKA
UTTAR PRADESH
JAMMU & KASHMIR
ASSAM
TAMIL NADU
TELANGANA
CHHATTISGARH
ANDHRA
PRADESH
PUNJAB
JHARKHAND WEST
BENGAL
ARUNACHAL PR.
HARYANA
KERALA
UTTARAKHAND
HIMACHAL
PRADESH
MANIPUR
MIZORAM
MEGHALAYA
NAGALAND
TRIPURA
SIKKIM
GOA
A&N ISLANDS
D&N HAVELI
PONDICHERRY
LAKSHADWEEP
CHANDIGARH
DELHI
DAMAN & DIU
Measles – Rubella Laboratory Network
17 - National laboratories
2 - National reference laboratories
R
AJA
STHA
N
OD
ISHA
GU
JARA
T
MA
HARASH
TRA
MA
DHYAPRADES
H
B
IHAR
K
ARNAT
AKA
U
TTA
R PRA
DESH
J
AMMU &KASHMIR
A
SSAM
T
AMILNADU
T
EL
ANGANA
C
HHATT
ISGA
RH
AND
HRA
P
RADES
H
P
UNJ
AB
J
HAR
KHAND W
EST
B
ENGAL
A
RUNACH
AL P
R.
H
ARYAN
A
K
ERAL
A
U
TTA
RAKHA
ND
H
IMACHAL
PRADE
SH
MA
NIPUR
MI
ZORAM
ME
GHALA
YA
N
AGALA
ND
T
RIP
URA
S
IKKI
M
GOA
A
&N I
SLAN
DS
D
&N HAV
ELI
P
ONDICHE
RRY
L
AKS
HADWE
EP
C
HANDIGA
RH
D
ELHI
D
AMAN &DIU
District.shp
Alappuzha, Kerala
BJMC,Ahmedabad
ERC,Mumbai
GMCB, BHOPAL
IOS,Kolkata
IPM,Hyderabad
KIPM,Chennai
MCG,Guwahati
Manipal, Karantaka
NCDC, Delhi
NIV,Bangalore
PGIMER, Chandigarh
PMC, Patna
RIMS Ranchi
RMRC Bhubaneshwar
RMRC Jabalpur
RMRC Port Blair
SGPGI,Lucknow
SMS, Jaipur
State.shp
State.shp
600 0 600 1200 Miles
NIV, Kerala
BJMC, Ahmedabad
ERC, Mumbai
GMC, Bhopal
IOS, Kolkata
IPM, Hyderabad
KIPM, Chennai
MCG, Guwahati
KMC, Manipal
NCDC, Delhi
NIV, Bangalore
PGI, Chandigarh
PMC, Patna
RIMS, Ranchi
RMRC, Bhubaneshwar
RMRC, Jabalpur
RMRC, Port Blair
SGPGI, Lucknow
SMS, Jaipur
Further Lab Expansion Planned

48. Case Investigation within 48 hours of Notification
< 70%
70% to 80%
>=80%
No MR case
87
%
89
%
N =
15366
N =
13811
2020
2019
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
88% 90% 88% 86% 88% 89% 89% 86% 90% 89% 89% 89%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
83% 86% 82% 85% 85% 85% 88% 87% 88% 88% 89% 89%
* data as on 05 Mar 2021

49. Adequate Serum Specimen w/n 28 days of rash onset
< 70%
70% to 80%
>=80%
No MR case
89
%
87
%
N =
15943
N =
13499
2020
2019
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
90% 91% 86% 67% 78% 80% 81% 82% 83% 88% 89% 89%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
88% 86% 86% 89% 90% 86% 86% 89% 92% 93% 92% 92%
* data as on 05 Mar 2021

50. 51
NMNR
2019 2020
< 1 18 26
1-2 11 6
>2 7 4
NMNR
Discard Rate
2019 2020

51. Role of a Hospital / Health Institution
 A measles case in eruptive stage – report it
 A patient with diarrhoea with h/o measles in last 3
month – report it
 A patient with bronchopneumonia with h/o measles
in last 3 month – report it
 A patient with any clinical condition with h/o measles
in last 3 months – report it
 Investigation of the case using MR-CIF & Collection
of sample (Blood/Urine /Throat swab) – after initiation
of modified MR surveillance

52. Measles moves fast and
we need to move faster!
53

53. Surveillance for Diphtheria, Pertussis
and Neonatal Tetanus (DPT)

54. VPD surveillance
Basic tool for understanding epidemiology of disease
Surveillance
• Trigger public health control measures
• Identify outbreaks
• Assess the effectiveness of prevention program
• Identify pockets of susceptible populations to guide vaccination strategies
Diphtheria, Pertussis, Neonatal Tetanus
VPD
• DPT forms the backbone of current UIP schedule
• Detection of even a single case of Diphtheria means susceptible child/population
• Recent epidemics of Pertussis in high income countries highlighted the need for
better epidemiological data
• Monitor status of Neonatal Tetanus elimination

55. VPDs
• WHO estimates of burden of disease are based on
information available from variety of sources:
– Demographic data
– Immunization coverage levels
– Vital registration data
– Mortality data
– Mathematical modelling using numerous assumptions
• The degree of accuracy of these estimates depends on the
quality of surveillance data
• In 2017, India reported 5293 cases of Diphtheria, 23766
cases of Pertussis and 295 cases of Neonatal tetanus to
WHO and UNICEF through joint reporting form
– Quality and completeness of reports not known

56. Suspected VPD Cases
(Diphtheria/ Pertussis / Neonatal Tetanus)
Cases to be reported
to DIO/DSO / SMO
Case investigation
and CIF filling
Nodal Officer /
Medical Officer
Sample collection
and shipment to lab
Nodal Officer /
Medical Officer
Public health
response
Case
Management
Flow chart of lab supported VPD case surveillance

57. Diphtheria
Greek, diphtherie: meaning skin or hide

58. 0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
Number
of
Diphtheria
Cases
Year
SEAR
Global Burden of Diphtheria
• Overall Global burden is declining,
• Large outbreaks have occurred in 2017 and 2018 in a
growing number of countries including Bangladesh,
Indonesia, Kenya, Philippines, South Africa, Venezuela,
and Yemen, among others attracting global attention
• SEAR remains major contributor to Diphtheria
cases
• Under reporting, mostly clinical diagnosis,
problem may be bigger

59. Diphtheria: Aetiopathogenesis
• Bacterial disease caused by Corynebacterium
diphtheriae
– Gram positive, club shaped, slender bacilli
– Exotoxin producing bacteria
• Pathogenesis
– due to exotoxin and cell wall components
– exotoxin causes local and systematic cell
destruction
• High case fatality (> 10%) in endemic areas

60. Diphtheria: Transmission and communicability
• Person to person spread:
– droplet (airborne)
– direct contact with respiratory secretions
– rarely through discharges from skin lesions
• Incubation period: 2-5 days (range, 1-10 days)
• Period of infectivity:
– 2 weeks from onset
– antibiotic therapy promptly terminates shedding
– Transient carriers may shed organisms for 6 months
or more

61. Monthly Incidence of Diphtheria Cases, 2016 – 2020*
Bihar, Chhattisgarh, Delhi, Gujarat, Haryana, Himachal Pradesh, Jharkhand, Karnataka, Kerala, Madhya
Pradesh, Maharashtra, Punjab, Uttar Pradesh & Uttarakhand
0
150
300
450
600
750
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2016 2017 2018 2019* 2020*
*: as on 30 May 2020

62. Respiratory Diphtheria
• Acute communicable upper respiratory illness
caused by toxigenic strains of Corynebacterium
diphtheriae (Gm +Ve bacillus)
• The illness is characterized
– Membranous inflammation of upper respiratory tract,
usually pharynx but sometimes posterior nasal
passages, larynx, and trachea
– Widespread damage to other organs, primarily the
myocardium and peripheral nerves.
– Potent exotoxin produced by C. diphtheriae causes
extensive membrane production and organ damage.
• Cutaneous form of diphtheria commonly occurs
in warmer climates or tropical countries.

63. Respiratory Diphtheria
• Transmission mainly person to person for C.
diphtheriae through respiratory contact.
• Onset of respiratory diphtheria occurs after an
incubation period of 2–5 days
• Mild fever & an exudative pharyngitis which
organizes into a pseudo-membrane on pharynx,
larynx, tonsil causing obstruction of the airways.
Bull neck appearance.
• Complications of heart (myocarditis), nervous
system (neuritis), blood (thrombocytopenia)
may occur
• Diphtheria antitoxin (DAT) is highly effective
and is the gold standard for treatment.
• Case-fatality rates exceeding 10% have been
reported, in particular where DAT is unavailable

64. Case definition
A suspected case of diphtheria is defined as:
• An illness of upper respiratory tract
characterized by the following:
• Laryngitis or pharyngitis or tonsillitis
AND
• Adherent membranes of tonsils, pharynx and/or
nose

65. Case definition
• Pharyngitis and tonsillitis:
– fever with pain and redness of the throat and/or
tonsils
• Laryngitis:
– hoarseness of voice and cough
• Adherent membrane:

66. Adherent membrane
• Pseudomembrane: confluent sharply demarcated
membrane, tightly adherent and dark grey in
color
• Initially isolated spots of grey or white exudate in tonsillar
and pharyngeal area
• Spots coalesce within a day to form pseudomembrane that
becomes progressively thicker
• Extends beyond margins of tonsils into tonsillar
pillars, palate and uvula
• Streptococcal infection: white membrane limited to tonsillar
area
• Dislodging of membrane likely to cause bleeding

67. Other associated signs and symptoms
• Dysphagia: difficulty in swallowing
• Difficulty in breathing
• Headache
• Change of voice: hoarseness or thick speech
• Nasal regurgitation
• Serosanguineous nasal discharge

68. Complications
• Bull neck diphtheria:
– massive cervical adenopathy with
oedematous swelling of
submandibular region and
surrounding areas
• Systemic manifestations of toxin
– Myocarditis
– Polyneuritis
• Bulbar dysfunction
– Palatal, pharyngeal, facial, laryngeal,
oculomotor or ciliary paralysis

69. Demonstration of diphtheritic membrane
Diphtheria
Source: https://www.youtube.com/watch?v=DsyO-f269fI

70. Demonstration of laryngeal diphtheria
Source: https://www.youtube.com/watch?v=mbATsba5EuE

71. Case management and public
health interventions

72. General principles
• Morbidity and mortality still high in developing
countries
• Early treatment reduces complications and
mortality
• Prompt initiation of therapy on clinical suspicion
– Don’t wait for laboratory results for initiating specific
therapy
• Collect specimen preferably prior to initiation of
treatment
• Patient should be kept in strict isolation

73. Management and Interventions
• Case management:
– Three main components:
• Antibiotic therapy
• Administration of diphtheria antitoxin
• Supportive care
• Public health interventions:
– Two main components
• Immunisation in community
• Antimicrobial prophylaxis of contacts

74. Antibiotic therapy
• Drug of choice
– Penicillin 0.6-1.2 g 6-hourly for 14 days
– or erythromycin 0.5 g 6-hourly for 14 days
• Advantages
– Limit further bacterial growth
– Limits carrier state
• Limitation
– No impact on already established toxin induced
lesions

75. Administration of diphtheria antitoxin
• Reduces case fatality rates
• Hyper-immune antiserum produced in horse
• Administered
– Intramuscular or intravenous
– Early administration recommended as it neutralizes
free toxin
• Recommended dose
• Tonsillar diphtheria: 10 000 units
• Pharyngeal diphtheria: 40 000 to 60 000 units
• Extensive disease: 100 000 to 150 000 units

76. Supportive care
• Close monitoring including
– Regular ECG to monitor cardiac manifestations
– Attention to airway
• Early interventions like
– Pace maker for conduction disturbances
– Drugs for arrhythmias
– Tracheostomy or intubation to ensure continued
patency of airway
– Mechanical removal of tracheobronchial
membrane

77. Public health interventions
• Single dose of DPT to children less than 7 years
of age
• Persons aged more than 7 years can be given
DT/Td/Tdap depending on availability
• DT – full dose of Diphtheria and Tetanus Toxoid
• Td – low dose Diphtheria toxoid with full dose of
Tetanus Toxoid
• Tdap - contains low dose of Diphtheria toxoid and
acellular pertussis along with Tetanus Toxoid
• Post exposure microbial prophylaxis to all
contacts

78. Public health interventions
Age Immunization
Prophylaxis
Antibiotic Dose Route Duration
< 7 years
old
DPT
Penicillin G
benzathine
600 000
units
IM
Single
dose
or
Erythromycin (not
recommended for
age <1month)
40 mg/kg
in 4 divided
doses
Per oral 7-10 days
> 7 years
old
DT/Td/Tdap as
per availability
Penicillin G
benzathine
1.2 million
units
IM Single
dose
or
Erythromycin
1g/day in 4
divided
doses
Per oral 7-10 days

79. Public health significance
• Occurrence of diphtheria reflects inadequate coverage
under the routine immunization programme
– Helps identify pockets of susceptible individuals
• Aggressive efforts should be made to improve
immunization coverage
• Epidemiological surveillance ensuring early detection
of diphtheria outbreaks, with laboratory facilities for
diagnosis essential
– to guide control measures at local level
– to assess progress & impact of vaccination programme
– to generate data to formulate vaccination strategies
Diphtheria

80. Summary
• Caused by exotoxin producing bacteria
• Pseudomembrane over tonsil, pharynx, larynx is
pathognomonic
• Myocarditis & neuritis are common complications
• Bacterial culture is gold standard laboratory test
• Case management involves antibiotics, antitoxin
serum and supportive care
• Public health interventions involve appropriate
vaccination and prophylaxis for contacts
Diphtheria

81. Pertussis
Latin: violent cough

82. Aetiopathogenesis
• Bacterial disease caused by Bordetella pertussis
– Aerobic, gram negative, coccobacilli
– Three other species cause milder disease
• B. parapertussis, B. holmesii, B. bronchisepta

83. Transmission and communicability
• Highly infectious:
– spread by aerosolised droplets
• Incubation period:
– 9-10 days (range; 6-20 days)
• Secondary attack rate:
– 80-100% for susceptible household contacts
• Period of infectivity:
– 3 weeks from onset
– Antibiotics therapy reduces the period

84. Occurrence and reservoir
• Occurs worldwide
– continues to be a public health concern even in
countries with high vaccination coverage
– important cause of death in infants
– ~ 12-32% of chronic cough in adults
• Human specific disease
– no animal or insect source/ vector
– no prolonged carrier state
– adolescents and adults are an important reservoir
and source of transmission to unvaccinated infants

85. Monthly Incidence of Pertussis Cases, 2017 – 2019*
0
100
200
300
400
500
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2017 2018 2019*
*: as on 10 August2019
State Cases in
2017
Cases
in 2018
Cases
in 2019
Bihar 110 150 50
Gujarat NA NA 11
Haryana 68 81 39
HP NA 7 3
Jharkhand NA NA 6
Karnataka NA 2 32
Kerala 93 179 95
Maharashtra NA NA 7
MP 38 180 63
Punjab NA 55 18
UP 1378 1350 172
Uttarakhand NA NA 6
Total 1687 2004 502

86. Catarrhal
• Non specific symptoms- cough,
rhinorrhoea, sore throat and
conjunctivitis
Spasmodic
• Paroxysm of cough ending in
characteristic whoop, post tussive
vomiting, symptoms severe at night
Convalescent
• Coughing gradually subsides, relapse
if another respiratory infection is
acquired
0 day
4-8 weeks
2 weeks
Months
Clinical features and complications
Pertussis

87. Clinical features and complications
• Other common presenting features-
– Infants: apnoea, cyanotic episodes, poor feeding
– Adults: prolonged cough, phlegm, intracranial
haemorrhages
– Partially immunised: reduced duration of catarrhal
phase, whoop may not occur
• Complications-
– Secondary bacterial pneumonia
– Neurological complications: seizures, encephalopathy

88. Laboratory diagnosis
• Culture of nasopharyngeal secretions considered
best
– fastidious growth requirement s makes it difficult to
isolate
– chances of isolation maximum during catarrhal phase
and declines rapidly after two weeks
– small window of opportunity for culture proven
diagnosis
• PCR
– detects DNA sequence of the bacteria
– sensitivity decreases after 4 weeks of onset
• Serology
– useful for diagnosis in convalescent phase

89. Case definition-Pertusis
A suspected case of pertussis is defined as:
• A person with a cough lasting at least two
weeks with at least one of the following:
– Paroxysms (i.e. fits) of coughing
– Inspiratory whooping
– Post-tussive vomiting
– Without other apparent causes

90. Case definition
• Paroxysms of cough:
– Cough becomes more frequent and spasmodic
– Repetitive bursts of five to ten coughs, often within a
single expiration
– During paroxysm there may be a visible vein
distension, bulging eyes, tongue protrusion and
cyanosis
– Frequency of paroxysmal episodes varies from several
per hour to 5-10 per day
– Episodes are often worse at night and interfere with
sleep

91. Case definition
• Whoop:
– Sound produced due to rapid inspiration against closed
glottis at the end of cough paroxysm
• Post tussive vomiting:
– Vomiting immediately after coughing occasionally with
a mucous plug expelled at the end of an episode
• Without other apparent causes:
– Exclude other causes of chronic cough like tuberculosis,
asthamatic episodes, chronic bronchitis etc.

92. Other associated signs and symptoms
• In young infants: apnoea and cyanosis may be the
only presenting symptoms
• Paroxysms of cough lead to increased intra
thoracic pressure
– Subconjunctival haemorrhage
– Intracranial haemorrhage
– Rectal prolapse
– Hernias
– Pneumothorax
– Petechiae
– Rib fracture

93. Demonstration of whooping cough: child
Source: https://www.youtube.com/watch?v=KZV4IAHbC48

94. Demonstration of whoop: infant
Source: https://www.youtube.com/watch?v=S3oZrMGDMMw

95. Case management

96. General principles
• Treatment is most effective if offered early
– First two weeks before coughing paroxysms occur
– But during early stage pertussis is most difficult to
diagnose
• Treatment in later stages prevents transmission
– The period of communicability is reduced to 5 days
after treatment with antibiotics
• No proven treatment exist for pertussis induced
cough
– Steroids and beta agonists are not effective

97. General principles
• Coughing (symptomatic) household members of a
pertussis patient should be treated as pertussis cases
• Earlier treatment and prevention of transmission
may reduce the considerable burden of adult
pertussis
– loss of work
– prolonged symptoms
– multiple hospital visits
• Suspected pertussis cases should not be allowed to
go for work/school until completion of at least 5 days
of antimicrobial therapy

98. Case management
• Azithromycin is drug of choice for infants less
than 1 month
– Erythromycin is associated with idiopathic
hypertrophic pyloric stenosis
– Cotrimoxazole is associated with risk of
kernicterus
• Cotrimoxazole is contraindicated in pregnancy
and lactation

99. Public health intervention
• Single dose of DPT to children less than 7
years of age
• Persons aged more than 7 years can be given
Tdap if available
– Tdap - contains low dose of Diphtheria toxoid and
acellular pertussis along with Tetanus Toxoid
• Post exposure microbial prophylaxis to
contacts

100. Post exposure antimicrobial
prophylaxis (PEP)
• PEP to all pertussis contacts is not cost
effective measure
– No data available on effectiveness of widespread
use of PEP for pertussis outbreak control
• Serious complications and deaths are
primarily limited to infants
– Antibiotic prophylaxis should be given to all
infants and their contacts

101. Recommended treatment and post-exposure
prophylaxis, by age group
Age group Azithromycin Erythromycin Clarithromycin
Alternate agent: TMP-
SMX
<1 month
Recommended
drug; 10 mg/kg
per day in a single
dose x 5 days
40–50 mg/kg per
day in 4 divided
doses x 14 days
Not
recommended.
Contraindicated in
infants <2 months of
age
1–5
months
10 mg/kg per day
in a single dose x 5
days.
As above
15 mg/kg per day
in 2 divided doses
x 7 days.
For infants aged >2
months of age, TMP 8
mg/kg per day; SMX 40
mg/kg per day in 2
divided doses x 14
days.

102. Age group Azithromycin Erythromycin Clarithromyci
n
Alternate agent:
TMP-SMX
Children aged
more than 6
months
10 mg/kg as a single
dose on day 1
(maximum 500 mg);
then 5 mg/kg per
day as a single dose
on days 2–5
(maximum 250
mg/day)
40 mg/kg per
day in 4 divided
doses for 7-14
days
(maximum 1-2
g per day)
Maximum
1g/day
TMP 8 mg/kg
per day; SMX 40
mg/kg per day
in 2 divided
doses x 14 days
Adolescents
and adults
500 mg as a single
dose on day 1 then
250 mg as a single
dose on days 2–5
2g/day in 4
divided doses x
14 days
1g/day in 2
divided doses
x 7 days
TMP 320
mg/day, SMX
1600mg/day in
2 divided doses
x 14 days
Recommended treatment and post-exposure
prophylaxis, by age group

103. Neonatal Tetanus

104. Tetanus
Latin tetanus from Greek tetanos "muscular spasm," literally "a
stretching, tension," from teinein "to stretch"

105. Aetiopathogenesis
• Bacterial disease caused by Clostridium tetani
– spore forming, strictly anaerobic, gram positive
bacilli
• Spores survive normal disinfection and heating
• Spores contaminating the wounds germinate to
vegetative cells
– bacilli produce extremely potent neurotoxin
tetanospasmin
• blocks inhibitory neurotransmitter leading to muscular
stiffness and spasm

106. • Highly infectious but not communicable disease
• Maternal tetanus:
– unclean delivery/abortion and poor post natal
hygiene
• Neonatal tetanus:
– unclean instrument to cut the umbilical cord
– umbilical stump covered with contaminated material
or cloth
• Incubation period: 3-21 days (range; 0->60days)
Transmission and communicability

107. Case definition-NNT
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/spasms (i.e. jerking of the muscles)
or both

108. Case definition
• Spasm:
– Initially increased tone of facial muscles (lockjaw,
grimace)
– Inability to suck, stiffness in the neck, shoulder and
back muscles
– Subsequent involvement of other muscles produces
rigid abdomen and stiff proximal limb muscle
– These spasms occur repetitively and may be
spontaneous or provoked by even the slightest stimuli

109. Demonstration of neonatal tetanus
Source: https://www.youtube.com/watch?v=lrcPC3RtAJw

110. 2003 - 2013 2014 2015
19 states/UTs 30 states/UTs 36 states/UTs
India achieved
Maternal & Neonatal Tetanus Elimination..
15 May 2015:
“WHO congratulates
India on achieving the
milestone of MNTE”
NNT Elimination: <1 NNT
case per 1000 live births per
district per year

111. Sample collection and transportation

112. Prerequisites /
Conditions
Diphtheria Pertussis
Window period
from onset
Within 4 weeks Within 4 weeks Upto 12 weeks
Type of
specimen
Throat swab or pieces
of membrane
Nasopharyngeal swab* Serum
Number 2 2 1
Transport media Amies transport media
Regan-Lowe / Amies
transport media with
charcoal
Not applicable
Storage and
transportation
2-8 OC 2-8 OC 2-8 OC
Diagnostic Tests
Culture / PCR / Elek’s
Test
Culture / PCR IgG serology
*Within 4 weeks collect both NPS and Serum

113. Throat swab
(posterior pharyngeal swab)
Hold tongue away with
tongue depressor
Locate areas of inflammation
and exudate in posterior
pharynx, tonsillar region of
throat behind uvula
Avoid swabbing soft palate;
do not touch tongue
Rub area back and forth with
cotton or Dacron swab
WHO/CDS/EPR/ARO/2006.1

114. Nasopharyngeal swab sample collection
• Obtain a thin flexible nasopharyngeal swab made
up of Dacron or nylon
– Cotton and calcium alginate swabs are not to be used
• Check the expiry date
• Label the specimen collection tube

115. Nasopharyngeal swab sample collection
• Have patient sit with head against a wall or a
support
– Patients have a tendency to pull away during this
procedure
• Explain the procedure to the parents or patient
• Measure the distance between anterior nares to
the lower lobe of the ear of one side
• Mark the swab with half of the above measured
distance
• Ask the patient to blow the nose forcefully to
remove any mucous plug

116. Nasopharyngeal swab sample collection
• Position the head slightly upwards and insert the swab
along the floor of the nose up to the distance marked
– Avoid insertion of swab in upward direction
• Do not force swab if obstruction is encountered before
reaching the nasopharynx
– Remove swab and try the other side
• Try to leave the swab in place for 5-10 seconds to
increase sensitivity
• Immediately place the swab in transport media and
tighten the cap
– Best is to wrap the tape around cap to prevent any leakage
• Ship at 2-8OC

117. Format for investigation of a VPD case
• Format: Case
Investigation Form
(CIF) for other VPDs
• Different from the
CIF for AFP / MR
surveillance
EPID Number: DTH / PTS / NNT - IND _____ ________ ______ _______
(matches Lab Request Form)
1. Reporting / Investigation Information:
Date Case Reported: _____ /_____ / _______ Reported by: ______________________________ Title: ___________________________
Date Case Investigated:_____ /_____ / _______ Investigated by: ___________________________ Title: DIO / DSO / Medical Officer / Nodal Officer / SMO / Other
Date Case verified: _____ /_____ / _______ Verified by: _____________________________ Title: SMO / DIO / DSO
Reporting Health Facility: Type: RU / Informer / Other / ACS (facility) / Community Search Setup: Govt. Allopathic / Pvt Allopathic / ISM Pract. / Others
2. Case Identification: Patient's Name: _________________________________ other given names: ______________________
Sex: M/F/O Date of birth (DOB): _____ /_____ / _______ [_] precise DOB unknown (enter best estimate of age: y ears________ months_______ )
Father's Name:_________________________________________ Mother's Name:____________________________________
Father's Occupation:_____________________________________ Grandfather's Name:________________________________
Address: ______________________________________________ Religion: Hindu / Muslim / Other Caste: ___________________
Landmark: ____________________________________________ Village / Mohalla: ______________________________
HRA per microplan?: Y / N
Block /Urban area: ______________________________________ District: _________________________________
Setting: Urban / Rural
State: ________________________________________________ Tel. ____________________ Alternate tel. _________________
Child belongs to migratory family/Community : Yes/ No/ Unknown
3. Hospitalization: Yes / No Name of Hospital:________________________________
Date of Admission:_____ /_____ / _______ Date of Discharge/LAMA/Death:_____ /_____ / ______
4. Vaccination Status: Has the case ever received one or more vaccines (of any listed below) in his or her lifetime? Yes / No / Unknown
If vaccinated, Encircle vaccines received irrespective of age when they were received
At birth 6 weeks 10 weeks 14 weeks 9 months 16 months 5 years Others
OPV 0 OPV 1 OPV 2 OPV 3 M1 / MR1 / M2 / MR2 / DPT Booster Td
BCG DPT 1 DPT 2 DPT 3 MMR1 / MMRV1
MMR2 / MMRV2 Tdap
HepB 0 Pentavalent 1 Pentavalent 2 Pentavalent 3 JE 1 DPT Booster TT
HepB 1 Hep B 2 HepB 3 PCV 3 OPV Booster HPV
f-IPV 1 f-IPV 2 / IM-IPV JE 2
PCV 1 PCV 2
Rotavirus 1 Rotavirus 2 Rotavirus 3
Source of vaccination status: RI Card / Any Record or Register / Recall / Both recall and register / Other, Specify (if Others)_________________________________________
Date of last dose of diphtheria or pertussis-containing vaccine: For diphtheria (DPT,Pentavalent, Td or Tdap); For pertussis (DPT, Pentavalent, Tdap) ____/____/_____
Tetanus Toxoid (TT/Td): 0 / 1 / 2 / Booster / Unknown Date of last dose of TT/Td:____/____/_____
5. Clinical Symptoms: Duration of illness in days: ___________
Date of Onset:_____/_____/_______ Diphtheria: Pertussis:
Sore Throat: Yes / No
Fever: Yes / No
Diphtheria*:
Date of onset of sore throat Cough leading to vomiting:
Pertussis*: Bloody nasal discharge: Yes / No Yes / No
Date of onset of cough Hoarseness of voice: Yes / No Whoop: Yes / No
Neonatal Tetanus*: Bull neck: Yes / No Apnoea: Yes / No
Date of onset of inability to suck Nasal regurgitation: Yes / No Cyanosis: Yes / No
Difficulty in swallowing: Yes / No
Difficulty in breathing: Yes / No
CIF contains two pages, both pages must be filled for all suspected VPD cases
Neonatal Tetanus:
Inability to suck and cry: Yes / No
Vaccine Preventable Diseases
Onset of following symptom(s) at 3-28 days of age:
Paroxysms of cough: Yes / No
(Encircle syndrome)
Child sucked and cried normally at 0-2 days: Yes / No
If yes, specify: Slum with migration/ Nomad/ Brick Kiln/ Construction site/
Others (specify): __________________________________________________________
CASE INVESTIGATION FORM
In case of NNT - Vaccination of mother during pregnancy:
History of active TB / other
chronic URTI: Yes / No
*Neonatal tetanus: 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/spasms (i.e. jerking of the muscles) or both OR any neonate who died of unknown casuse during the first month of life
Any substance applied on cord: None / Medicine / Other
Duration of cough:
Spasms / Seizures: Yes / No
Greyish white adherent membrane
in throat: Yes / No
If yes, precipitated by stimuli: Yes / No
Stiffness: Yes / No
If home delivery, birth attended by:
Medical doctor / Nurse / ANM / Other (Specify: _______)
*Pertussis: A person with an acute cough lasting ≥ two weeks or of any duration in an infant with at least one of the following:• paroxysms (i.e. fits) of coughing • inspiratory whooping
• post-tussive vomiting or vomiting without apparent cause • Apnoea (only in <1 year of age) OR Clinician suspicion of pertussis
If other substance, specify: ___________________
Cough >2 weeks:Yes / No
Delivery: Institutional / Home / Other (Specify: _________)
*Diphtheria: An illness of upper respiratory tract characterized by the following:• laryngitis or nasopharyngitis or pharyngitis or tonsillitis AND • adherent membranes of tonsils,
pharynx and/or nose
Specialist Physician strongly
suspects pertussis: Yes / No

118. Format for investigation of a VPD case
EPID Number: DTH / PTS / NNT - IND _____ ________ ______ _______
(matches Lab Request Form)
1. Reporting / Investigation Information:
Date Case Reported: _____ /_____ / _______ Reported by: ______________________________ Title: ___________________________
Date Case Investigated:_____ /_____ / _______ Investigated by: ___________________________ Title: DIO / DSO / Medical Officer / Nodal Officer / SMO / Other
Date Case verified: _____ /_____ / _______ Verified by: _____________________________ Title: SMO / DIO / DSO
Reporting Health Facility: Type: RU / Informer / Other / ACS (facility) / Community Search Setup: Govt. Allopathic / Pvt Allopathic / ISM Pract. / Others
2. Case Identification: Patient's Name: _________________________________ other given names: ______________________
Sex: M/F/O Date of birth (DOB): _____ /_____ / _______ [_] precise DOB unknown (enter best estimate of age: years________ months_______ )
Father's Name:_________________________________________ Mother's Name:____________________________________
Father's Occupation:_____________________________________ Grandfather's Name:________________________________
Address: ______________________________________________ Religion: Hindu / Muslim / Other Caste: ___________________
Landmark: ____________________________________________ Village / Mohalla: ______________________________
HRA per microplan?: Y / N
Block /Urban area: ______________________________________ District: _________________________________
Setting: Urban / Rural
State: ________________________________________________ Tel. ____________________ Alternate tel. _________________
Child belongs to migratory family/Community : Yes/ No/ Unknown
3. Hospitalization: Yes / No Name of Hospital:________________________________
Date of Admission:_____ /_____ / _______ Date of Discharge/LAMA/Death:_____ /_____ / ______
4. Vaccination Status: Has the case ever received one or more vaccines (of any listed below) in his or her lifetime? Yes / No / Unknown
If vaccinated, Encircle vaccines received irrespective of age when they were received
At birth 6 weeks 10 weeks 14 weeks 9 months 16 months 5 years Others
OPV 0 OPV 1 OPV 2 OPV 3 M1 / MR1 / M2 / MR2 / DPT Booster Td
BCG DPT 1 DPT 2 DPT 3 MMR1 / MMRV1
MMR2 / MMRV2 Tdap
HepB 0 Pentavalent 1 Pentavalent 2 Pentavalent 3 JE 1 DPT Booster TT
HepB 1 Hep B 2 HepB 3 PCV 3 OPV Booster HPV
f-IPV 1 f-IPV 2 / IM-IPV JE 2
PCV 1 PCV 2
Rotavirus 1 Rotavirus 2 Rotavirus 3
Source of vaccination status: RI Card / Any Record or Register / Recall / Both recall and register / Other, Specify (if Others)_________________________________________
Date of last dose of diphtheria or pertussis-containing vaccine: For diphtheria (DPT,Pentavalent, Td or Tdap); For pertussis (DPT, Pentavalent, Tdap) ____/____/_____
Tetanus Toxoid (TT/Td): 0 / 1 / 2 / Booster / Unknown Date of last dose of TT/Td:____/____/_____
5. Clinical Symptoms: Duration of illness in days: ___________
Date of Onset:_____/_____/_______ Diphtheria: Pertussis:
Sore Throat: Yes / No
Fever: Yes / No
Diphtheria*:
Date of onset of sore throat Cough leading to vomiting:
Pertussis*: Bloody nasal discharge: Yes / No Yes / No
Date of onset of cough Hoarseness of voice: Yes / No Whoop: Yes / No
Neonatal Tetanus*: Bull neck: Yes / No Apnoea: Yes / No
Date of onset of inability to suck Nasal regurgitation: Yes / No Cyanosis: Yes / No
Difficulty in swallowing: Yes / No
Difficulty in breathing: Yes / No
CIF contains two pages, both pages must be filled for all suspected VPD cases
Neonatal Tetanus:
Inability to suck and cry: Yes / No
Vaccine Preventable Diseases
Onset of following symptom(s) at 3-28 days of age:
Paroxysms of cough: Yes / No
(Encircle syndrome)
Child sucked and cried normally at 0-2 days: Yes / No
If yes, specify: Slum with migration/ Nomad/ Brick Kiln/ Construction site/
Others (specify): __________________________________________________________
CASE INVESTIGATION FORM
In case of NNT - Vaccination of mother during pregnancy:
History of active TB / other
chronic URTI: Yes / No
*Neonatal tetanus: 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/spasms (i.e. jerking of the muscles) or both OR any neonate who died of unknown casuse during the first month of life
Any substance applied on cord: None / Medicine / Other
Duration of cough:
Spasms / Seizures: Yes / No
Greyish white adherent membrane
in throat: Yes / No
If yes, precipitated by stimuli: Yes / No
Stiffness: Yes / No
If home delivery, birth attended by:
Medical doctor / Nurse / ANM / Other (Specify: _______)
*Pertussis: A person with an acute cough lasting ≥ two weeks or of any duration in an infant with at least one of the following:• paroxysms (i.e. fits) of coughing • inspiratory whooping
• post-tussive vomiting or vomiting without apparent cause • Apnoea (only in <1 year of age) OR Clinician suspicion of pertussis
If other substance, specify: ___________________
Cough >2 weeks:Yes / No
Delivery: Institutional / Home / Other (Specify: _________)
*Diphtheria: An illness of upper respiratory tract characterized by the following:• laryngitis or nasopharyngitis or pharyngitis or tonsillitis AND • adherent membranes of tonsils,
pharynx and/or nose
Specialist Physician strongly
suspects pertussis: Yes / No
EPID No.: DTH / PTS / NNT - IND - ____ -__________ - ______ - ___________
6. Treatment History: Antibiotic given: Yes /No / Unknown if Yes: Antibiotic started before specimen collection: Yes / No / Unknown
(Ask if it is possible to see
medication to confirm antibiotic type
Diphtheria Antitoxin (DAT): Y / N / Unknown / Not Applicable (not a diphtheria case) Dose of DAT: ________________IU
Reason for not giving antitoxin: DAT not available / Other ___________________
7. Contact History:
History of contact with a laboratory confirmed case: Yes / No If yes, EPID No of laboratory confirmed case: _______________
Similar symptoms in other household contact(s): Yes / No If yes, No. of sick contacts: _____ details: ___________________________
Similar symptoms in other neighbourhood/ work/ school contact(s): Yes / No
If yes, No. of sick contacts: _____ details: ___________________________
8. Travel History: Travel of suspected case prior to onset (indicate dates and place of travel with arrows on date line)
Diphtheria:
Pertussis:
Incubation period (range) Most likely period of getting infection
District of residence: ____________________________
Requires cross notification? Yes / No (In case of Neonatal Tetanus, district of delivery)
If yes, date of cross notification: ____/_____/_____ Block/ Urban area of residence: ___________________
(In case of Neonatal Tetanus, block of delivery)
Name & address of Hospital/
doctor:
Phone no. / Email ID
Dates case visited:
Already RU/informer?
Did they report this case?
Date of sensitization visit/
Actions taken to improve
case reporting
10. Specimen Collection:
Number Date Collected Date Sent Name of Lab Date of Result Condition
Throat swab (Diphtheria) ___/___/___ ___/___/___ ___/___/___
Nasopharyngeal swab
(DTH/PTS) ___/___/___ ___/___/___ ___/___/___
Serum (Pertussis)
If no specimen is collected, reason for not collecting specimen: Death / Not willing / Lost to follow-up / Logistic issue / Late notification / Other
If other, specify: ____________________________________________________________________
11. Active Case Search, Contact Tracing and Response in Community: Fill this information from VPD-ACS format
Active case search in community done: Yes / No
If yes, Date of search: _____/_____/______ Number of individuals verified: ___________ Number of suspected cases found: ___________
Number of contacts identified: _________ Number of contacts received antibiotics:_______ Number of susceptibles vaccinated:_______
12. Final Classification: Laboratory confirmed / Epi-linked / Clinically compatible / Rejected / Confirmed NNT
13. 60 Day follow-up (telephonic) Date of follow-up: ___/___/___ Outcome: Alive / Lost / Death (Death date: ____/ ___/ _____)
14. Complications: At anytime during illness or follow up:
Complications of Diphtheria: Myocarditis / Paralysis (palatal,pharyngeal,facial,oculomotor, limb) / Peripheral neuropathy / Pneumonia / Otitis media / Respiratory insufficiency / Other
Complications of Pertussis: Pneumonia / Seizures / Encephalopathy / Otitis media / Pressure effects (pneumothorax,epistaxis,subdural hematomas,hernias,rectal prolapse) / Other
Complications of Neonatal Tetanus: Residual weakness / Delayed milestones /Other _______________
Use extra sheet of paper to write additional information, if any.
Positive / Negative / Other
Positive / Negative / Other
Positive / Negative / Equivocal
___/___/___
If antibiotic given, indicate which: Penicillin/Azithromycin/Erythromycin/Cotrimoxazole/Clarithromycin/Tetracycline/Doxycycline/
Amoxicillin/Ampicillin/Augmentin/Cefixime/Unknown type/Other:Specify______________________________________
CIF (Page 2)
9. History of contacts with healthcare providers after the date of onset ( including reporting health facility):
1 2 3 4
Yes/No Yes/No Yes/No Yes/No
Good / Poor
Good / Poor
___/___/___
___/___/___
Yes/No Yes/No Yes/No
Laboratory Result
Good / Poor
Yes/No
Page 1 Page 2
1. Reporting & Investigation details
2. Case details
3. Hospitalization details
4. Vaccination status
5. Clinical symptoms
1. Treatment history
2. Contact history
3. Travel history
4. History of contacts with healthcare providers
5. Specimen collection
6. Active case search
7. Final classification
8. 60-day follow up
9. Complications

119. Suspected case
Clinical examination
Meets case definition
Yes No
Sample
Yes No
Lab result
Pos Neg
Laboratory
confirmed
Epidemiological
linkages
Yes No
Epidemiological
confirmed
Clinical
confirmed
Rejected

120. Whom to Inform
Dr. S K Ray (SMO)
9836000773