VPD Surveillance.pptx

VPD Surveillance

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

2. Global WPV1 & cVDPV Cases 1 , Previous 6 Months 2 Data in WHO HQ as of 10 May 2022 Endemic country (WPV1) 1 Excludes viruses detected from environmental surveillance; 2 Onset of paralysis 11 Nov. 2021 to 10 May 2022 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 3

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 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 +1 +2 +3 +4 +5 +6 +7 +8 -21 -4 +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

22. Maculo-papular rash

23. Koplik’s spot pathognomonic of measles

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

25. 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)

26. 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)

27. Impact of Transitioning to Fever Rash Surveillance : Three States 1196 (27 %) 3298 (73%) Before Transition After Transition * 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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 1 st trimester of pregnancy)

35. Congenital Rubella Syndrome (CRS) Occurs if a susceptible pregnant mother is infected in early pregnancy Infection of the the fetus in utero causes these multiple anomalies leading to missed abortion, fetal deaths, premature delivery and serious life long disabilities Characterized by following clinical signs: Hearing Impairment Cataracts Heart defects (particularly PDA ) Microcephaly Developmental Delay Bone alterations Liver and spleen damage

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: D ate 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. 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 H a e m o l y sis 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. Measles – Rubella Laboratory Network 17 - National laboratories 2 - National reference laboratories 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 i t 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

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. 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 *: 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. d iphtheriae 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* *: 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. 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 Clarithromycin 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 O C 2-8 O C 2-8 O C 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 2-8 O C

117. Format for investigation of a VPD case Format: Case Investigation Form (CIF) for other VPDs Different from the CIF for AFP / MR surveillance

118. Format for investigation of a VPD case Page 1 Page 2 Reporting & Investigation details Case details Hospitalization details Vaccination status Clinical symptoms Treatment history Contact history Travel history History of contacts with healthcare providers Specimen collection Active case search Final classification 60-day follow up 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. Total 20 suspected Diphtheria cases reported in 2021 8 suspected Pertussis cases reported in 2021 No NNT case reported in 2021 DPT Surveillance in KOLKATA

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