Guidelines for Case-Based Reporting

澳門特別行政區傳染病強制申報機制

Macao SAR Notifiable Communicable Diseases Guidelines for Case-based Reporting

(FIRST DRAFT)

2008

澳門特別行局區政府衛生局 Health Bureau, Government of Macao Special Administrative Region ii

iii

Contents

Contents ...... iii Signs and abbreviations ...... 5 Acquired immunodeficiency syndrome (AIDS) ...... 6 Acute gastroenteropathy due to Norwalk agent (ICD-9 : 008.6, ICD-10 : A08.1 ) ...... 11 Acute haemorrhagic conjunctivitis (ICD-9 : 077, ICD-10 : B30.3 ) ...... 12 Acute poliomyelitis ICD-9 045 ICD-10 A80 ...... 13 Amoebiasis ICD-9 006 ICD-10 A06 ...... 14 Anogenital herpesviral (herpes simplex) infection ICD-9 054 ICD-10 A60 ...... 16 Anthrax ICD-9 022 ICD-10 A22 ...... 17 Chickenpox (Varicella) ICD-9 052 ICD-10 B01 ...... 19 Cholera ICD-9 001 ICD-10 A00 ...... 20 Congenital Rubella Syndrome (ICD-9 771.0 ICD-10 P35.0) ...... 21 Creutzfeldt-Jakob disease (Subacute spongiform encephalopathy, CJD) ICD-10 A81 ...... 23 Dengue fever ICD-9 061, 065.4 ICD-10 A90-A91 ...... 26 Diphtheria ICD-9 032 ICD-10 A36 ...... 28 Ebola viral disease (Ebola viral infection) ICD-9 078.8 ICD-10 A98.4 ...... 29 Enterohaemorrhagic Escherichia coli infection ICD-9 008.04 ICD-10 A04.3 ...... 31 Enteroviral infection (excluding poliomyelitis) ...... 32 Gonococcal infection (ICD-9 098 ICD-10 A54) ...... 35 Haemophilus meningitis ICD-9 320.0 ICD-10 G00.0 ...... 36 Hantavirus disease ( ICD-9 078.6, 480.8 ICD-10 A98.5, B33.4 ...... 37 Human immunodeficiency virus (HIV) infection ICD-9 795.8 ICD-10 Z21 ...... 39 Influenza ICD10: J10-J11 ...... 41 Influenza, caused by H5N1 ICD10: J10-J11 ...... 42 Japanese encephalitis (Epidemic encephalitis B) (ICD-9 : 062.0 ; ICD-10 : A83.0 ...... 43 Legionellosis (Legionnaires’ disease) ICD-9 482.8 ICD-10 A48.1 ...... 45 Leprosy (Hansen.s Disease) (ICD-9 030 ICD-10 A30) ...... 46 Leptospirosis ( ICD-9 : 100 ; ICD-10: A27) ...... 48 Malaria ( ICD-9 084 ICD-10 B50-B54 ) ...... 49 Measles ( ICD-9 055 ICD-10 B05 ) ...... 51 Meningococcal disease ( ICD-9 036 ICD-10 A39 ) ...... 53 Mumps ( ICD9 072 ICD10 B26 ) ...... 54 Other bacterial food-borne Intoxications ICD-9 005 ICD-10 A05 ...... 55 Table 2 Causative agents and clinical-epidemiological characteristics of common bacterial foodborne intoxications(1) ...... 57 iv

Other Viral Infection of the Central Nervous System (ICD-9 062-064 ICD-10 A83.1-A84) ...... 59 Other salmonella infections ( ICD-9 003 ICD-10 A02 ) ...... 60 Pertussis ( ICD-9 033 ICD-10 A37 ) ...... 61 Plague ( ICD-9 020 ICD-10 A20 ) ...... 62 Rabies (ICD-9 071 ICD-10 A82) ...... 64 Rotaviral enteritis ( ICD-9 : 008.61 ; ICD-10 : A08.0) ...... 66 Rubella (German measles) ( ICD-9 056 ICD-10 B06 ) ...... 67 Scarlet fever ( ICD-9 : 034.1 ; ICD-10 : A38 ) ...... 69 SARS ICD-10 B97.2 ...... 70 Shigellosis ( Bacillary dysentery ) ICD-9 004 ICD-10 A03 ...... 74 Syphilis ( ICD-9 090-096 ICD-10 A50-52 ...... 75 Tetanus ICD-9 037, 771.3 ICD-10 A33-A35 ...... 77 Tuberculosis ICD-9 010-018 ICD-10 A15-A19 ...... 78 Typhoid and paratyphoid fevers ICD-9 002 ICD-10 A01 ...... 81 Typhus (Scrub typhus) ICD-9 080-081.2 ICD-10 A75 ...... 82 Viral hepatitis A ICD-9 070.1 ICD-10 B15 ...... 83 Viral hepatitis B ICD-9 070.3 ICD-10 B16 ...... 84 Viral hepatitis C virus ( ICD-9 070.51 ICD-10 B17.1 ...... 85 Hepatitis D ( ICD-9 070.52 ICD-10 B17.0 ...... 86 Hepatitis E ( ICD-9 070.55 ICD-10 B15-17.2 ...... 87 Yellow fever ( ICD-9 060 ICD-10 A95 ...... 88 Reference ...... 89

Signs and abbreviations

AIDS Acquired Immuno Deficiency Syndrome

CD4 T4 Lymphocytes

CDC Center for Disease Control and Prevention

DDO Notifiable Communicable Diseases

DNA Deoxyribonucleic Acid

FTA-ABS Fluorescent treponemal antibodies absorbed

ICD-9 International Classification of Diseases, 9th revision

ICD-10 International Classification of Diseases, 10th revision

HIV Human Immunnodeficiency Virus

MHA-TP Microhemagglutination assay for Treponema pallidum

PCR Polymerase chain reaction

RPR Rapid plasmatic reagin

RT-PCR RreverseTtranscriptase Polymerase chain reaction

TPHA Treponema pallidum hemagglutination assay

VDRL Venereal disease research laboratory

Acquired immunodeficiency syndrome (AIDS)

( ICD-9 042, 279.5 ICD-10 B20-B24

Pathogen HIV (including HIV-1 and HIV-2)

Clinical See clinical case definition description

Clinical Adolescents and adults aged greater than or equal to 13 years case Any of the following definition  Candidiasis of bronchi, trachea, or lungs  Candidiasis, esophageal  Cervical cancer, invasive  Coccidioidomycosis, disseminated or extrapulmonary  Cryptococcosis, extrapulmonary

 Cryptosporidiosis, chronic intestinal  Cytomegalovirus retinitis  Cytomegalovirus disease (other than liver, spleen or nodes)  Encephalopathy, HIV-related  Herpes simplex, chronic ulcer, bronchitis, pneumonitis or esophagitis  Histoplasmosis, disseminated or extrapulmonary  Isosporiasis, chronic intestinal

 Kaposi's sarcoma  Lymphoma, Burkitt's  Lymphoma, immunoblastic  Lymphoma, primary of brain  Mycobacterium avium complex or kansasii, disseminated or extrapulmonary  Mycobacterium tuberculosis, extrapulmonary or pulmonary/cervical lymph node (only if CD4 < 200/uL) 7

 Mycobacterium, other species, disseminated or extra-pulmonary  Penicilliosis, disseminated  Pneumocystis carinii pneumonia  Pneumonia, recurrent  Progressive multifocal leukoencephalopathy  Salmonella septicemia, recurrent  Toxoplasmosis of brain

 Wasting syndrome due to HIV Children aged 0-12 years A. MILDLY SYMPTOMATIC: Children with two or more of the conditions listed below but none of the conditions lists in Categories B and C.  Lymphadenopathy (>=0.5 cm at more than two sites; bilateral = one site)  Hepatomegaly  Splenomegaly  Dermatitis

 Parotitis  Recurrent or persistent upper respiratory infection, sinusitis, or otitis media CATEGORY B: MODERATELY SYMPTOMATIC Children who have symptomatic conditions other than those listed for Category A or C that are attributed to HIV infection. Examples of conditions in clinical Category B include but are not limited to:  Anemia (<8 gm/dL), neutropenia (<1,000/mm3), or thrombocytopenia (<100,000/mm3) persisting >=30 days

 Bacterial meningitis, pneumonia, or sepsis (single episode)  Candidiasis, oropharyngeal (thrush), persisting (>2 months) in children >6 months of age  Cardiomyopathy  Cytomegalovirus infection, with onset before 1 month of age  Diarrhea, recurrent or chronic  Hepatitis 8

 Herpes simplex virus (HSV) stomatitis, recurrent (more than two episodes within 1 year)  HSV bronchitis, pneumonitis, or esophagitis with onset before 1 month of age  Herpes zoster (shingles) involving at least two distinct episodes or more than one dermatome  Leiomyosarcoma  Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia complex

 Nephropathy  Nocardiosis  Persistent fever (lasting >1 month)  Toxoplasmosis, onset before 1 month of age  Varicella, disseminated (complicated chickenpox)

CATEGORY C: SEVERELY SYMPTOMATIC Children who have any of the following conditions

 Serious bacterial infections, multiple or recurrent (i.e., any combination of at least two culture-confirmed infections within a 2-year period), of the following types: septicemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and indwelling catheter-related infections)  Candidiasis, esophageal or pulmonary (bronchi, trachea, lungs)  Coccidioidomycosis, disseminated (at site other than or in addition to lungs or cervical or hilar lymph nodes)  Cryptococcosis, extrapulmonary  Cryptosporidiosis or isosporiasis with diarrhea persisting >1 month  Cytomegalovirus disease with onset of symptoms at age >1 month (at a site other than liver, spleen, or lymph nodes)  Encephalopathy (at least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings): a) failure to attain or loss of 9

developmental milestones or loss of intellectual ability, verified by standard developmental scale or neuropsychological tests; impaired brain growth or acquired microcephaly demonstrated by head circumference measurements or brain atrophy demonstrated by computerized tomography or magnetic resonance imaging (serial imaging is required for children <2 years of age); c)acquired symmetric motor deficit manifested by two or more of the following: paresis, pathologic reflexes, ataxia, or gait disturbance  Herpes simplex virus infection causing a mucocutaneous ulcer that persists for >1 month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a child >1 month of age

 Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes)  Kaposi's sarcoma  Lymphoma, primary, in brain  Lymphoma, small, noncleaved cell (Burkitt's), or immunoblastic /or large cell lymphoma of B-cell or unknown immunologic phenotype  Mycobacterium tuberculosis, disseminated or extrapulmonary

 Mycobacterium, other species or unidentified species, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)  Mycobacterium avium complex or Mycobacterium kansasii, disseminated (at site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)  Pneumocystis carinii pneumonia  Progressive multifocal leukoencephalopathy  Salmonella (nontyphoid) septicemia, recurrent  Toxoplasmosis of the brain with onset at >1 month of age

 Wasting syndrome in the absence of a concurrent illness other than HIV infection that could explain the following findings: a) persistent weight loss >10% of baseline OR b) downward crossing of at least two of the following percentile lines on the weight-for-age chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child >=1 year of age OR c) <5th percentile on weight-for-height chart on two consecutive measurements, >=30 days apart PLUS a) chronic diarrhea (i.e., at least two loose stools per day for >30 days) OR b) documented fever (for >=30 days, intermittent or constant)

Laboratory Adolescents and adults aged greater than or equal to 13 years criteria for  less than 200 CD4 positive T-lymphocytes/uL, or diagnosis  a CD4 positive T-lymphocyte percentage of total lymphocytes of less than 14% ; Children aged 0-12 yesrs

Age of child

Immunologic <12 mos 1-5 yrs 6-12 yrs

category uL (%) uL (%) uL (%)

1)No evidence >=1,500 (>=25) >=1,000 (>=25) >=500 (>=25) of suppression 2)Evidence of 750-1,499 (15-24) 500-999 (15-24) 200-499 (15-24) moderate suppression 3)Severe <750 (<15) <500 (<15) <200 (<15) suppression

Case Adolescents and adults aged greater than or equal to 13 years classification Confirmed: HIV confirmed evidence and clinical case definition or laboratory criteria for diagnosis Children aged 0-12 years Confirmed : HIV confirmed evidence and severe immunologic suppression indicated by clinical case definition or laboratory criteria for diagnosis.

Notification Confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours.

Laboratories should notify the case that is compatible with laboratory diagnosis to CDC. Whom has been declared for HIV infection before, should be notified again when appearance in immune-suppressive. Laboratories should unconditionally refer the specimens to Public Health Laboratory, Health Bureau, for further examination and determination.

Acute gastroenteropathy due to Norwalk agent (ICD-9 : 008.6, ICD-10 : A08.1 )

Pathogen Norovirus

Clinical The incubation period is 24-48 hours. Characterized by nausea, description vomiting, diarrhoea, abdominal pain, myalgia, headache, malaise, and low grade fever. Symptoms may last for 24-48 hours.

Laboratory  Demostartion of virus by EM RIA or RT-PCR technique. criteria for  Demonstration of recent infection by IEM, RIA in paired serum diagnosis specimen which is 3-4 weeks apart.

Case  Suspected: any individual with diarrhoea, especially occurred in classification outbreaks.  Confirmed: suspected case confirmed by laboratory test.

Notification Confirmed case should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Acute haemorrhagic conjunctivitis (ICD-9 : 077, ICD-10 : B30.3 )

Pathogen Enterovirus 70, Coxsackieviruses A24v

Clinical Sudden onset of redness, swelling and pain oftern in both eyes; the description course of the inflammatory diseases is 4-6 days, during which subconjunctival hemorrhage appear on the bulbar conjunctive as petechiae that enlarge to form confluent subconjunctival hemorrhages. Large hemorrhages gradually resolve over 7-12 days. Incubation period 12 hours to 3 days.

Laboratory  Isolation of virus from conjunctival swabs and respiratory swab in criteria for cell culture diagnosis  Demonstration of virus antigen by PCR  Demonstration of virus antigen by immunofluorescence in conjunctival cell

 Demonstration of IgM or 4 folder rising IgG in serum or demonstration of IgA antibody in eye secretes

Case  Suspected: a clinically compatible case with no other cause. classification  Probable: suspected case that is epidemiologically linked to a confirmed case.  Confirmed: a clinically compatible case that is laboratory confirmed.

Acute poliomyelitis ICD-9 045 ICD-10 A80

Pathogen Polio virus, is one type of enterovirus.

Clinical description

Clinical case Any child under fifteen years of age with acute, flaccid paralysis definition (including Guillain Barré syndrome) or any person with paralytic illness at any age when poliomyelitis is suspected.

Laboratory  Wild polio virus detected from stool criteria for diagnosis

Case  Suspected: a case that meets the clinical case definition. classification  Probable: a case that meets the clinical case definition and without adequate specimens (two stool specimens 48 hours apart within 14 days of onset) collected for virus culture, residual weakness, died or lost to follow-up, when reviewed 60 days after onset by Expert Committee.  Confirmed: a clinically compatible case that is laboratory confirmed.

Notification Suspected and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Amoebiasis ICD-9 006 ICD-10 A06

Pathogen Entamoeba histolytica

Clinical Infection of the large intestine by Entamoeba histolytica may result description in an illness of variable severity ranging from mild, chronic diarrhea to fulminant dysentery. Infection also may be asymptomatic. Extraintestinal infection also can occur (e.g., hepatic abscess).

Laboratory Intestinal amebiasis criteria for  Demonstration of cysts or trophozoites of E. histolytica in stool or diagnosis  Demonstration of trophozoites in tissue biopsy or ulcer scrapings by culture or histopathology Extraintestinal amebiasis  Demonstration of E. histolytica trophozoites in extraintestinal tissue

Case Intestinal amebiasis classification  Probable: Clinically compatible illness with demonstration higher sero antibody to E. histolytica, or microscopic demonstration of trophozoites or cysts suspect of E. Histolytica in stool.  Confirmed: a clinically compatible illness that is laboratory confirmed Extraintestinal amebiasis

 Probable: Clinically compatible case.  Confirmed,: a parasitologically confirmed infection of extraintestinal tissue, or among symptomatic persons (with clinical or radiographic findings consistent with extraintestinal infection), demonstration of specific antibody against E. histolytica as measured by indirect hemagglutination or other reliable immunodiagnostic test (e.g., enzyme-linked immunosorbent assay). 15

Notification Probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify case that is compatible with laboratory criteria. Asymptomatic intestinal amebiasis patients (carriers) do not need to be declared. Positive serology test does not indicate extraintestinal amebiasis infection to asymptomatic patients.

Anogenital herpesviral (herpes simplex) infection ICD-9 054 ICD-10 A60

Pathogen Herpes Simplex Virus type 2

Clinical A condition characterized by visible, painful genital or anal lesions. description

Laboratory  Isolation of herpes simplex virus from cervix, urethra, or criteria for anogenital lesion, or diagnosis  Demonstration of virus by antigen detection technique in clinical specimens from cervix, urethra, or anogenital lesion, or  Demonstration of multinucleated giant cells on a Tzanck smear of scrapings from an anogenital lesion

Case  Probable: a clinically compatible case (in which primary and classification secondary syphilis have been excluded by appropriate serologic tests and darkfield microscopy, when available) with either a diagnosis of genital herpes based on clinical presentation (without laboratory confirmation) or a history of one or more previous episodes of similar genital lesions

 Confirmed: a clinically compatible case that is laboratory confirmed

Notification Probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory criteria. Abbreviation of name, sex and birth of patient should be reported but other identifiable details are not required.

Anthrax ICD-9 022 ICD-10 A22

Pathogen Bacillus anthracis

Clinical An illness with acute onset characterized by several clinical description forms. These are 1) Cutaneous: skin lesion evolving over 1 to 6 days from a papular through a vesicular stage, to a depressed black eschar invariably accompanied by oedema that may be mild to extensive; 2) Gastro-intestinal: abdominal distress characterized by nausea, vomiting, anorexia and followed by fever 3) Inhalation: brief prodrome resembling acute viral respiratory illness, followed by rapid onset of hypoxia, dyspnoea and high temperature, with X-ray evidence of mediastinal widening 4) Meningeal: acute onset of high fever possibly with convulsions, loss of consciousness, meningeal signs and symptoms; commonly noted in all systemic infections

Laboratory  Isolation of Bacillus anthracis from a clinical specimen (e.g., criteria for blood, lesions, discharges) diagnosis  Demonstration of B. anthracis in a clinical specimen by microscopic examination of stained smears (vesicular fluid, blood, cerebrospinal fluid, pleural fluid, stools)

 Positive serology (ELISA, Western blot, toxin detection, chromatographic assay, fluorescent antibody test (FAT), PCR)

Case  Suspected: a clinically compatible case that is epidemiologically classification linked to a confirmed or suspected animal cases or contaminated animal products  Probable: a suspected case that has a positive reaction to allergic skin test (in non-vaccinated individuals)  Confirmed: a suspected case that is laboratory confirmed 18

Chickenpox (Varicella) ICD-9 052 ICD-10 B01

Pathogen Varicella-zoster virus

Clinical The incubation period is between 2 to 3 weeks, usually 14-16 days. description It is an acute communicable disease with high infectivity. The disease is characterized by a low-grade fever without other significant causes. A skin rash develops on the child's scalp and body, which spreads to the face, arms and legs with formation of vesicles over a period of 5 days. The rashes occur mainly on the trunk. The vesicles are itchy and dry up and form a scab in about three days.

 Laboratory Isolation of Varicella-zoster virus from clinical specimen, or  criteria for Significant rise in specific-virus IgG by any standard serological diagnosis assay.

Case  Probable: a clinically compatible case classification  Confirmed: a laboratory confirmed case, or a clinically compatible case and is epidemiologically linked to a probable or confirmed case.

Notification Probable and confirmed cases should be notified to Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Cholera ICD-9 001 ICD-10 A00

Pathogen Vibrio cholerae O1 and O139 are the known pathogen. Serum group O1 can be classified into two biotypes, classical and El Tor, and each type of biotypes can be classified into Hirojima, Inaba and Ogawa these three serogroups.

Clinical Most persons infected with V. cholerae are present with mild description diarrhoea and vomiting of variable severity, but generally without abdominal pain or fever. In its severe form, cholera is characterized by sudden onset of profuse watery diarrhoea with rice-water like stool, severe dehydration, circulatory failure and muscle (especially the gastrocnemius) spasm.

Laboratory  Isolation of Vibrio cholerae O1 or O139 from stools or vomitus, or criteria for  Serological evidence of recent infection. diagnosis

Case  Suspected : classification 1) Person aged over 5 with dehydration or death from watery diarrhea during non-epidemic period. 2) Person with watery diarrhea during epidemic period. 3) Any patient with diarrhea and epidemiology linkage to confirmed cases.  Probable: not applicable.  Confirmed: a clinically compatible case that is laboratory confirmed.

Notification Suspected, probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 1 hour. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC, but the non-pathogenic Vibrio cholerae case does not need to be declared. If cases are notified to CDC by phone at first, the details should be reported within 1 hour by fax. 21

Congenital Rubella Syndrome (ICD-9 771.0 ICD-10 P35.0)

Pathogen Rubella virus

Clinical Congenital Rubella Syndrome is a sequela of Rubella virus description infection during pregnant period (especially the first three months), characterized by congenital malformations.

Clinical case Case that has any two complications listed in paragraph “1” plus definition one complication listed in from “2” : 1) Cataracts/congenital glaucoma, congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis), hearing impairment, pigmentary retinopathy. 2) Purpura, hepatosplenomegaly, jaundice happened within 24 hours, microcephaly, mental retardation, meningoencephalitis, radiolucent bone disease.

 Isolation of rubella virus from clinical specimen, or Laboratory criteria for  Detection of rubella-specific immunoglobulin M (IgM) antibody, diagnosis or  Infant rubella antibody level that persists at a higher level and for a longer period than expected from passive transfer of maternal antibody (i.e., rubella titer that does not drop at the expected rate of a twofold dilution per month).

 Case Suspected: a case with some compatible clinical findings but not classification meeting the criteria for a probable case.  Probable: a case that meets the clinical case definition.  Confirmed: a clinically compatible case that is laboratory confirmed. 22

Creutzfeldt-Jakob disease (Subacute spongiform encephalopathy, CJD) ICD-10 A81

Pathogen prion

Clinical See paragraph of case classification description

Clinical case See paragraph of case classification definition

Case 1. Sporadic CJD classification (a) Possible CJD:  Progressive dementia; and  EEG atypical or not known and

 Duration <2 years and  At least 2 out of the following 4 clinical features:  myoclonus, visual or cerebellar disturbance, pyramidal / extrapyramidal dysfunction, akinetic mutism (b) Probable CJD: (in the absence of an alternative diagnosis from routine investigation)  Progressive dementia; and  At least 2 of the following 4 clinical features:

 Myoclonus  Visual or cerebellar disturbance  Pyramidal / extrapyramidal dysfunction  Akinetic mutism and  A typical EEG, whatever the clinical duration of the disease, and/or  A positive 14-3-3 assay for CSF and a clinical duration to death 24

<2years

(c) Confirmed (definite) CJD:  Neuropathological confirmation; and/or  Confirmation of protease-resistant prion protein (PrP) (immunocytochemistry or Western blot) and/or  Presence of scrapie-associated fibrils 2. Iatrogenic CJD  Progressive cerebellar syndrome in a recipient of human cadaver-derived pituitary hormone; or  Sporadic CJD with a recognized exposure risk 3. Familial CJD  Confirmed or probable CJD plus confirmed or probable CJD in a first degree relative and/or  Neuropsychiatric disorder plus disease-specific PrP mutation  Note: For purposes of surveillance, includes Gerstmann-Sträussler-Scheinker (GSS) syndrome and fatal familial insomnia (FFI). 4. New variant CJD (nvCJD) New variant CJD cannot be diagnosed with certainty on clinical criteria alone at present. On the basis of the few neuropathologically confirmed cases, the diagnosis of nvCJD should be considered as a possibility in a patient with a progressive neuropsychiatric disorder and at least 5 of the following 6 clinical features:  Early psychiatric symptoms

 Early persistent paraesthaesia / dysaesthesia  Ataxia  Chorea / dystonia or myoclonus  Dementia  Akinetic mutism The suspicion of nvCJD for surveillance purposes is strengthened by the following: 25

 No history of potential iatrogenic exposure  Clinical duration >6 months  Age at onset <50 years  No PrP gene mutation  EEG does not show the typical periodic appearance  Routine investigations do not suggest an alternative diagnosis  Magnetic Image Resonance shows abnormal symmetrical and bilateral high signals from the pulvinar on axial T2- and/or proton-density-weighted images

Suspected: A patient with a progressive neuropsychiatric disorder and 5 out of the 6 clinical criteria mentioned earlier plus all of the criteria of suspicion listed immediately above should be considered as a suspect case of nvCJD for surveillance purposes.

Probable: not applicable Confirmed: Neuropathology is mandatory for the diagnosis of definite nvCJD: the use of cerebral biopsy in living patients is to be discouraged unless its purpose is to arrive at an alternative diagnosis of a treatable disorder. Autopsy (or post-mortem biopsy of the brain where autopsy is not possible) is strongly encouraged in any suspect case of CJD. See under "special aspects" for the neuropathological criteria in CJD and other human transmissible spongiform encephalopathies.

Dengue fever ICD-9 061, 065.4 ICD-10 A90-A91

Pathogen Dengue virus, including 4 serotypes (DEN-1, DEN-2, DEN-3, and DEN-4).

Clinical An acute febrile disease characterized by intense neck pain, myalgia, description arthralgia, rash, haemorrhagic manifestations, thrombocytopenia and leukopenia. The severe case may present as dengue shock syndrome (ICD-9 : 065.4 ; ICD-10 : A91). Although rare, it may be fatal.

Dengue hemorrhagic fever is characterized by different levels of blood concentration (hematocrit>20%), or increased vascular permeability (pleural or abdominal effusions). Dengue shock syndrome includes clinical and laboratory description of dengue hemorrhagic fever, it is also characterized by hypotension, narrow pulse pressure (less than 20 mmHg).

Clinical case Fever with 2 or more of the followings: headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic manifestations, leukopenia. definition

 Laboratory Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy criteria for samples.  diagnosis Demonstration of a fourfold or greater change in reciprocal IgG or IgM antibody titres to one or more dengue virus antigens in paired serum samples  Demonstration of dengue virus antigen in autopsy tissue by immunohistochemistry or immunofluorescence or in serum samples by EIA  Detection of viral genomic sequences in autopsy tissue, serum or CSF samples by polymerase chain reaction (PCR)

Case Dengue Fever classification  Suspected: a clinically compatible case without laboratory confirmation,  Probable: a clinically compatible case with one or more of the followings: 1) Supportive serology (reciprocal haemagglutination-inhibition antibody titer over 1280, comparable IgG EIA titre or positive IgM 27

antibody test in late acute or convalescent phase serum specimen).

2) Occurrence at same location and time as other confirmed cases of dengue fever.  Confirmed: a clinically compatible case that is laboratory confirmed.

Dengue Hemorrhagic Fever Clinical description of dengue fever plus blood concentration identified to the symptoms of dengue fever with abdominal or pleural effusion, or with hematocrit (up by 20%), or increased vascular permeability (pleural or abdominal effusions)

Dengue shock syndrome Dengue hemorrhagic fever plus hypotension and narrow pulse pressure (less than 20 mm/Hg).

Notification Suspected, probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC. If dengue hemorrhagic fever or/and dengue shock syndrome occurs in notified dengue case, re-notification is required.

Diphtheria ICD-9 032 ICD-10 A36

Pathogen Corinebacterium diphtheriae

Epidemiology Patient and carrier are the only reservoir. The incubation period ranges from 1 to 7 days, usually 2 to 5 days. Transmission is most often person-to-person spread from the respiratory tract. Rarely, transmission may occur from skin lesions or articles soiled with discharges from lesions of infected persons

Clinical An acute bacterial upper respiratory tract disease that primarily involves description the tonsil, pharynx, larynx, nose, other mucous membranes or skin. The characteristic lesion, caused by liberation of a specific cytotoxin, is an asymmetrical adherent grayish white membrane with surrounding inflammation

Laboratory  Isolation of Corynebacterium diphtheriae; or criteria for  Histopathologic diagnosis of diphtheria; or diagnosis  Antibody titer increased four times or more of two serum samples which are apart from two weeks

Case  Suspected: not applicable classification  Probable: a clinically compatible case.  Confirmed: a probable case that is laboratory confirmed or epidemiologically linked to a laboratory confirmed case.

Ebola viral disease (Ebola viral infection) ICD-9 078.8 ICD-10 A98.4

Pathogen Ebola virus

Epidemiology Ebola haemorrhagic fever is a rare but severe disease occurring primarily in areas of African rain forest. The disease is characterized by person-to-person transmission through close contact with patients, dead bodies or infected body fluids. Epidemics of the disease can be dramatically amplified in health care centers with poor hygiene standards; the attendant potential for explosive nosocomial infection constitutes the main threat to public health posed by the disease. (WHO)

Clinical Ebola haemorrhagic fever begins with acute fever, diarrhoea that can be description bloody (referred to as “diarrhée rouge” in francophone Africa), and vomiting. Headache, nausea, and abdominal pain are common. Conjunctival injection, dysphagia, and haemorrhagic symptoms such as epistaxis, gum bleeding, hematemesia, melena and purpura may further develop. Some patients may also show a maculopapular rash on the trunk. Dehydration and significant wasting occur as the disease progresses. At a later stage, there is frequent involvement of the central nervous system, manifested by somnolence, delirium, or coma. The case-fatality rate ranges from 50% to 90%. (WHO)

Laboratory  Supportive: positive serology (ELISA for IgG and/or IgM), or criteria for  Confirmatory: diagnosis 1) Positive virus isolation (only in a laboratory of biosafety level 4) or

2) Positive skin biopsy (immunohistochemistry) or 3) Positive PCR

Case  Suspected: a clinically compatible case. classification  Probable (in epidemic situation) : 1) Any person having had contact with a clinical case and presenting with acute fever, or 2) Any person presenting with acute fever and 3 of the following 30

symptoms: headache, vomiting / nausea, loss of appetite, diarrhoea, intense fatigue, abdominal pain, general or articular pain, difficulty in swallowing, difficulty in breathing, hiccoughs, or 3) Any unexplained death.  Confirmed: any suspected or probable case that is laboratory confirmed.  Contact (in epidemic situation): an asymptomatic person having had physical contact within the past 21 days with a confirmed or probable case or his/her body fluids (e.g., care for patient, participation in burial ceremony, handling of potentially infected laboratory specimens).

Enterohaemorrhagic Escherichia coli infection ICD-9 008.04 ICD-10 A04.3

Pathogen Escherichia coli (mainly serotype O157:H7)

Clinical An infection of variable severity characterized by diarrhea (often description bloody) and abdominal cramps. Illness may be complicated by hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP); asymptomatic infections also may occur and the organism may cause extraintestinal infections.

Laboratory  Isolation of Escherichia coli O157:H7 from a clinical specimen. criteria for  Isolation of Shiga toxin-producing Escherichia coli O157:NM diagnosis from a clinical specimen.

Case  Suspected: a case of postdiarrheal HUS or TTP. classification  Probable: a clinically compatible case that is epidemiologically linked to a confirmed case, or with isolation of E. coli O157 from a clinical specimen without confirmation of H antigen or Shiga toxin production.  Confirmed: a clinically compatible case that is laboratory confirmed.

Notification Clinician should deal with suspected cases for further examination to determine the diagnosis. Patients should be referred to an appropriate medical center for further examination by clinician unconditionally. Probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Enteroviral infection (excluding poliomyelitis)

(ICD9 85-87 ICD10 B08.4-B08.5)

Pathogen Enteroviruses which are members of the family Picornaviridae are a group of viruses including Coxsackievirus (type A1~A22 A24 typeB1~B6), Echovirus (type l 33, except for type 10 and type 28) and Enterovirus (EV type 68 71).

Clinical Enterovirus can cause various diseases clinically. Most of the description infections are asymptomatic while some may cause unspecific febrile illness and/or upper respiratory symptoms suggestive of common cold. In some cases, enterovirus infection may have special clinical manifestations such as hand-foot-mouth disease, herpangina, aseptic meningitis, viral encephalitis, polio-like syndrome, acute hemorrhagic conjunctivitis, acute neonatal myopericarditis and adult myopericarditis, pleurodynia, acute lymphonodular pharyngitis and febrile illness with rash. The incubation period is 1-10 days, average 3-5 days.

1. Herpangina Caused by Coxsackievirus A, characterized by sudden onset of fever, vomiting and ulceration or papulovesiclcular lesion around the oropharynx. The illness usually lasts for 4-6 days. A majority of cases manifest mild symptoms without complications. However, there are a few cases with aseptic meningitis complications. 2. Hand-foot-mouth disease Caused by Coxsachievirus A and EV 71, characterized by fever and vesicular eruption on hands, feet and buttocks. Ulcers may also be found both at the fore and hind portions of oral cavity. The rash is usually not itchy and does not leave a scar, but the oral lesion will cause discomfort when eating. The illness may last for 7-10 days. 3. Pleurodynia Caused by Coxsackievirus B, the symptoms usually manifest themselves as acute chest pain which may last somewhere from 33

several minutes to several hours, combined with fever, headache, temporary nausea, vomiting, diarrhea; the endemic period usually lasts approx. one week. 4. Acute neonatal myopericarditis and adult myopericarditis Caused by type B Coxsakie virus, the symptoms are marked by acute dyspnea, paleness, cyanosis, chills, vomiting - likely to be diagnosed as pneumonia, followed by obvious tachycardia and soon leading to heart failure, shock or even death, but children that survive tend to recover very rapidly. 5. Acute lymphonodular pharyngitis Caused by Coxsackievirus A10, characterized by fever, headache, sore throat, obvious whitish patches on uvula and posterior pharynx. It usually lasts for 4-14 days.

6. Acute meningitis and encephalitis Caused by type A Coxsakie virus -A10, the symptoms are marked by fever, headache, sore throat, and prominent whitish nodules on the uvula and posterior pharynx; the endemic period usually lasts somewhere from four to fourteen days. 7. Aseptic meningitis and encephalitis Can be caused either by Coxsakie virus, poliovirus, or echovirus and can not always be told by clinical symptoms. Some characteristics include fever, nausea, vomiting, headache etc. 8. Febrile illness with rash Usually linked to various types of Coxsakie virus and echovirus, where the skin rashes usually appear as maculopapules, occasionally with vesicles.

 Laboratory Isolation of enterovirus from stool or respiratory discharge or criteria for detection of virus genomic sequences by PCR; or diagnosis  At least a fourfold increase of virus-specific antibody titer in paired serum

 Case Probable: a clinical description compatible with herpangina, hand-foot –mouth disease. 34 classification  Confirmed: a clinically compatible case that is laboratory confirmed.

Gonococcal infection (ICD-9 098 ICD-10 A54)

Pathogen Neisseria gonorrhoeae

Clinical case Gonorrhea commonly manifested by urethritis, cervicitis, or definition salpingitis. Infection may be asymptomatic.

 Isolation of typical gram-negative, oxidase-positive diplococci Laboratory criteria for (presumptive Neisseria gonorrhoeae) from a clinical specimen, diagnosis or  Demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or nucleic acid, or  Observation of gram-negative intracellular diplococci in a urethral smear obtained from a male

Case  Probable: classification 1) demonstration of gram-negative intracellular diplococci in an endocervical smear obtained from a female or

2) a written morbidity report of gonorrhea submitted by a physician

 Confirmed: a case that is laboratory confirmed

Notification Suspected, probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC. Abbreviation of name, sex and birth of patient should be reported, but other identifiable details are not required.

Haemophilus meningitis ICD-9 320.0 ICD-10 G00.0

Pathogen Haemophilus influenzae type b (Hib)

Clinical Haemophilus influenza is classified into two types of infection: description 1) Invasive infection: sever illness, is usually accompanied with bacteremia. Infection can manifest as meningitis, pneumonia and epiglottitis, osteomyelitis, arthritis and cellulitis.

2) Infection in conjunction with nasopharyngeal: characterized by tympanitis, sinusitis, conjunctivitis or bronchial pneumonia. Sever manifestations commonly occur in the 0-5 age group children. Bacterial meningitis is characterized by acute onset of fever, headache, neck stiffness. The meningitis is caused by Hib has no specific difference with other bacterial meningitis. It cannot be distinguished by clinical manifestation.

 Laboratory Isolation of Hib from a normally-sterile clinical specimen of cerebrospinal criteria for fluid (CSF) or blood. However, positive culture of Hib from non-sterile diagnosis sites such as the throat, where bacteria can grow without causing disease, is not defined as Hib disease (antigen detection cannot be evidence of diagnosis).  Identification of Hib antigen from a normally-sterile clinical specimen.

Case  Suspected: a child with any clinical symptoms consistent with bacterial classification meningitis.

 Confirmed: a case that is laboratory confirmed.

Hantavirus disease ( ICD-9 078.6, 480.8 ICD-10 A98.5, B33.4

Pathogen Hantavirus

Clinical Hemorrhagic Fever with Renal Syndrome description Incubation period usually 1 to 2 weeks, but my up to 8 weeks. Initial symptoms begin suddenly and include intense headaches, back and abdominal pain, fever, chills, nausea, and blurred vision. Individuals may have flushing of the face, inflammation or redness of the eyes, or a rash. Later symptoms can include low blood pressure, acute shock, vascular leakage, and acute kidney failure, which can cause severe fluid overload. The severity of the disease varies depending upon the virus causing the infection. Hantaan and Dobrava virus infections usually cause severe symptoms, while Seoul and Puumala virus infections are usually more moderate. Complete recovery can take weeks or months.

Hantavirus pulmonary syndrome (HPS) A febrile illness characterized by bilateral interstitial pulmonary infiltrates and respiratory compromise usually requiring supplemental oxygen and clinically resembling acute respiratory disease syndrome (ARDS). The typical prodrome consists of fever, chills, myalgia, headache, and gastrointestinal symptoms. Typical clinical laboratory findings include hemoconcentration, left shift in the white blood cell count, neutrophilic leukocytosis, thrombocytopenia, and circulating immunoblasts.

Clinical case Hantavirus pulmonary syndrome (HPS) definition An illness characterized by one or more of the following clinical features:  A febrile illness (i.e., temperature greater than 101.0 F [greater than 38.3 C]) characterized by bilateral diffuse interstitial edema that may radiographically resemble ARDS, with respiratory compromise requiring supplemental oxygen, developing within 38

72 hours of hospitalization, and occurring in a previously healthy person  An unexplained respiratory illness resulting in death, with an autopsy examination demonstrating noncardiogenic pulmonary edema without an identifiable cause

Laboratory  Detection of hantavirus-specific immunoglobulin M or rising titers criteria for of hantavirus-specific immunoglobulin G, or diagnosis  Detection of hantavirus-specific ribonucleic acid sequence by polymerase chain reaction in clinical specimens, or  Detection of hantavirus antigen by immunohistochemistry

Case  Probable: a clinically compatible case that is epidemiologically classification linking to confirmed cases  Confirmed: a clinically compatible case that is laboratory confirmed

Human immunodeficiency virus (HIV) infection ICD-9 795.8 ICD-10 Z21

Pathogen HIV (including HIV-1 and HIV-2)

Laboratory In adults, adolescents, or children aged greater than or equal to 18 months, at least one of the following criteria: criteria for diagnosis  Positive result on a screening test for HIV antibody (e.g., repeatedly reactive enzyme immunoassay), followed by a positive result on a confirmatory (sensitive and more specific) test for HIV antibody (e.g., Western blot or immunofluorescence antibody test), or  Positive result or report of a detectable quantity on any of the following HIV virologic (nonantibody) tests:  HIV nucleic acid (DNA or RNA) detection (e.g., DNA polymerase chain reaction [PCR] or plasma HIV-1 RNA)  HIV p24 antigen test, including neutralization assay  HIV isolation (viral culture)

In a child aged less than 18 months, at least one of the following criteria:

 Positive results on two separate specimens (excluding cord blood) using one or more of the following HIV virologic (nonantibody) tests:  HIV nucleic acid (DNA or RNA) detection  HIV p24 antigen test, including neutralization assay, in a child greater than or equal to 1 month of age  HIV isolation (viral culture)

Case  Probable: case with one positive serology test. classification  Confirmed: case that is laboratory confirmed.

Notification Confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician. Laboratories should notify the case that is compatible with 40

laboratory diagnosis to CDC.

Laboratories should unconditionally refer the specimens to Public Health Laboratory, Health Bureau, for further examination and determination. 41

Influenza ICD10: J10-J11

Pathogen Influenza virus, classified into 3 types influenza (A, B, C)

Clinical The infection is manifested by fever, headache, tiredness, myalgia, running description nose, cough and sore throat. These symptoms may last for about 1 week. The young, the elderly and chronic disease patients more likely lead to complications.

Clinical case A person with sudden onset of fever of >38°C, with cough or sore throat in definition the absence of other diagnosis.

 Laboratory Virus isolation from swab or aspirate of the suspected patient, or  criteria for Direct detection of influenza viral antigen, or  diagnosis Serology: four-fold rise in antibody titre between early and convalescent phases.

Case  Suspected: a clinically compatible case. classification  Confirmed: a clinically compatible case that is laboratory confirmed.

Influenza, caused by H5N1 ICD10: J10-J11

Pathogen Influenza virus H5N1

Clinical The infection is manifested by fever, headache, tiredness, muscle ache, description runny nose, cough and sore throat. These symptoms may last for about 1 week. The young, the elderly and chronic disease patients more likely lead to complications.

Clinical case A person with sudden onset of fever of ≧38°C, with cough or sore throat definition in the absence of other diagnosis.

Case  Suspected: a case has acute respiratory symptoms, including fever (≧ classification 38°C) and with cough/sore throat, and is also epidemiologically linked to a H5N1 confirmed case during infectivity period, or has visited farm with reported HPAI outbreak, or laboratory worker who has managed human or animal specimens of suspected HAPI infection.  Probable: a suspected case with limited laboratory evidence of infection of H5N1 (eg. H5 single clonal antibody IFA+) and is in the absence of other diagnosis.

 Confirmed: a case has positive culture for influenza virus H5N1, or positive PCR for influenza virus H5N1, or a 4-fold rise in H5-specific antibody titer.

Japanese encephalitis (Epidemic encephalitis B) (ICD-9 : 062.0 ; ICD-10 : A83.0

Pathogen Japanese Encephalitis Virus, or Japanese "B" Encephalitis Virus, belongs to flavivirus, which is often known as Epidemic encephalitis B in mainland China.

Clinical The incubation period is 3-5 days. Japanese encephalitis is a viral description infection which may result in a febrile illness of variable severity associated with neurological symptoms ranging from headache to meningitis or encephalitis. Symptoms include: headache, fever, meningeal signs, stupor, disorientation, coma, tremors, paresis (generalized), hypertonia, loss of coordination. This encephalitis cannot be distinguished clinically from other central nervous system infections. The case-fatality rate is approximately 10%. About 30% of the survivors will have neurological complications.

Laboratory Probable criteria:  Detection of response anti-viral antibody in acute phase through one of criteria for diagnosis the following tests: 1)  Elevated and stable specific JE antibody titres in serum through ELISA, haemagglutination-inhibition or virus neutalization assays, or 2) IgM antibody of JEV in serum.

Confirmed criteria:  Detection of the JEV antigen or genome in tissue, blood or other body fluid by immunochemistry or immunofluorescent or PCR test, or  JEV-specific IgM antibody in CSF, or  Fourfold or greater rise in JEV-specific antibody in paired sera (acute and convalescent phases) by IgM / IgG, ELISA, haemagglutination inhibition test or virus neutalization test, in a patient without recent vaccination history of yellow fever and whom cross reactions with other flaviviruses have been totally excluded.

Note: JE infections is common and the majority are asymptomatic. JE infections may occur concurrently with other central nervous system infection. Therefore, serological evidence of recent JE infection may not 44

indicate JE to be the main cause of the disease.

Case  Suspected: a clinically compatible case. classification  Probable: a suspected case compatible with probable laboratory diagnostic criteria.  Confirmed: a probable case compatible with confirmed laboratory diagnostic criteria.

Legionellosis (Legionnaires’ disease) ICD-9 482.8 ICD-10 A48.1

Pathogen Legionellae pneumophila

Clinical An illness characterized by an acute lower respiratory infection with focal description signs of pneumonia on clinical examination and/or radiological evidence of pneumonia.

 Presumptive: one or more of the following: Laboratory criteria for 1) Detection of specific legionella antigen in respiratory secretions. diagnosis 2) Direct fluorescent antibody (DFA) staining of the organism in respiratory secretions or lung tissue, using evaluated monoclonal reagents. 3) A fourfold or greater rise in specific serum antibody titre to legionella species other than Legionella pneumophila serogroup 1, using a locally validated serological test.

 Confirmative: one or more of the following:

1) By detection of Legionella pneumophila serogroup 1 antigen in urine using validated reagents. 2) By culture: isolation of any Legionella organism from respiratory secretions, lung tissue, pleural fluid, or other normally sterile fluid. 3) By seroconversion: fourfold or greater rise in specific serum antibody titer to Legionella pneumophila serogroup 1 using validated reagents.

Case  Probable: a case compatible with the clinical description, with classification presumptive laboratory results.  Confirmed: a case compatible with the clinical description, with confirmative laboratory results.

Leprosy (Hansen.s Disease) (ICD-9 030 ICD-10 A30)

Pathogen Mycobacterium leprae

Clinical This infectious disease usually affects the skin, peripheral nerves description and upper respiratory tract. It is characterized by mucous membranes atrophy, paralysis of peripheral nerves and muscle, bones and skeleton degeneration. Patients with this infectious disease are classified as

1) In lepromatous (multibacillary) leprosy, nodules, papules, macules and diffuse infiltrations are bilateral symmetrical and usually numerous and extensive; involvement of the nasal mucosa may lead to crusting, obstructed breathing and epistaxis; ocular involvement leads to iritis and keratitis

2) In tuberculoid (paucibacillary) leprosy, skin lesions are single or few, sharply demarcated, anaesthesic or hypoaesthesic, and bilateral asymmetrical, involvement of peripheral nerves tends to be severe

3) Borderline leprosy has features of both polar forms and is more labile

4) Indeterminate leprosy is characterized by hypopigmented maculae with ill-defined borders; if untreated, it may progress to tuberculoid, borderline or lepromatous disease

 Laboratory Alcohol-acid-fast bacilli in skin smears (made by the criteria for scrape-incisionmethod). diagnosis

Case  Probable: a clinically compatible case (without laboratory classification confirmed). According to the clinical Classification of WHO: 1) Paucibacillary leprosy: ≤ 5 patches or lesions on the skin. 47

2) Multibacillary leprosy: >5 patches or lesions on the skin.  Confirmed: a clinically compatible case that is laboratory confirmed.

Leptospirosis ( ICD-9 : 100 ; ICD-10: A27)

Pathogen Leptospira bacteria

Clinical The incubation period is usually 4-19 days, an average of 10 days. description The disease is characterized by fever, headache, chills, muscle pain and conjunctival suffusion. Sometimes with meningitis, skin rash, jaundice, kidney damage.

 Laboratory Isolation of pathogenic leptospires from clinical materials, or  criteria for Compare with acute and recovery stage, pathogenic Leptospira diagnosis agglutination test titer increased four times or more of two serum samples which are apart from two weeks and under the same laboratory examination, or  Immunofluorescence detection of the pathogenic leptospira from clinical samples.

 Case Probable: a clinical diagnostic case with serological results classification support (eg. detection of pathogenic leptospira of agglutination test titer ≧200 in one or more serum samples)  Confirmed: a clinical diagnostic case that is laboratory confirmed.

Malaria ( ICD-9 084 ICD-10 B50-B54 )

Pathogen Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale

Clinical The incubation period of the P. falciparum infection, P. vivax and description the P. ovale infection is commonly 7-14 days and that of the P. malariae is 7-30 days. The four species of malaria are manifested by fever, chills , headache, vomitting , diarrhea, cough, muscle pain, low back pain and sweating.

The most serious form of the disease is caused by P. falciparum (ICD-10 : B50). Manifested by various symptoms including: fever, chills , sweating, cough, diarrhea, headache, respiratory inhibition, jaundice, changes of the blood clotting, shock, renal failure, acute encephalitis, pulmonary edema and cerebral edema. Coma and death can be rapidly developed.

P. vivax (ICD-10:B51), P. malariae (ICD-10:B52), P. Ovale are the other forms of human malaria. The symptoms are usually not serious (except young children, the young, the elderly and the immunity deficiencies). Patterns of clinical manifestation are chronic and difficult to recover, especially the P. Malariae form. Manifested by periodic fever, chills and sweating every day, every alternative day.

Laboratory  Detection of malaria parasites in blood films. criteria for diagnosis

 Case Suspected: a clinically compatible case with travel history or classification resided in epidemic area but without laboratory confirmation.  Confirmed: a laboratory confirmed case (with or without clinical features).

Measles ( ICD-9 055 ICD-10 B05 )

Pathogen Measles virus

Clinical The incubation period is usually 10 days, but may range from 4 to description 18 days. It is acute infectious disease. The disease is characterized by high-grade fever (greater than 38.°C), Koplik‟s spots inside the mouth , a generalized maculopapular rash (lasting greater than 3 days), cough, coryza or conjunctivitis. The rash starts on the face and may last for 4 to 7 days. Leukopenia is common. Measles is highly infectious disease. The disease occur in adult and infant may be severe.

 All illness characterized by all the following: Clinical case definition 1) fever (greater than 38°C) 2) generalized maculopapular (i.e. non-vesicular) rash, and 3) cough, coryza or conjunctivitis

 Laboratory Isolation of measles virus from the clinical specimen, or  criteria for Presence of measles-specific IgM antibodies, or  diagnosis At least a fourfold increase in IgG antibody titre by any standard serologic assay.

 Case Suspected: any febrile illness accompanied by maculopapular classification rash and suspected by clinician.  Probable: a case that meets the clinical case definition, without laboratory confirmation and is epidemiologically linked to a confirmed case.  Confirmed: a case that is laboratory confirmed (exclude vaccine-induced case), or that meets the clinical case definition and is epidemiologically linked to a confirmed case.

Meningococcal disease ( ICD-9 036 ICD-10 A39 )

Pathogen Meningococcus (Neisseria meningitidis ; groups A, B, C, W-135, X, Y, Z )

Clinical case An acute bacterial infection and usually manifests with symptoms definition of meningitis (ICD-10: A39.0) or meningococcal meningitis sepsis (ICD10: A39.2-A39.4). Clinical features are acute onset, fever, severe headache, neck stiffness, nausea, vomiting, and it can rapidly develop purpura to the whole body, shock and death. Infection can occur only in nasopharynx.

 Laboratory Positive culture of pathogenic bacteria from serum samples or criteria for CSF, or  diagnosis Positive CSF antigen detection

 Case Suspected: a case that meets the clinical case definition but no classification laboratory confirmation.  Probable: a case that is compatible with the clinical description and turbid CSF (with or without positive Gram stain) or have epidemiological linkage to a confirmed case.  Confirmed: a suspected or probable case with laboratory confirmation.

Mumps ( ICD9 072 ICD10 B26 )

Pathogen Mumps virus (Paramyxovirus)

Clinical The incubation period is between 12 and 25 days, usually 18 days. description The infection is manifested by fever and single or multiple swelling of salivary gland(s), commonly parotids, and may present as orchitis (in males), oophoritis (in females) or aseptic meningitis (very rare complication).

 Clinical case Acute onset of fever, and  definition Unilateral or bilateral, single or multiple swelling of the salivary gland(s), with clear boundaries, and  The above signs last for at least 2 days, without other apparent cause.

Laboratory  Isolation of mumps virus from clinical specimen, or criteria for  Detection of mumps IgM antibody, or  diagnosis Significant rise between acute- and convalescent-phase titers in serum mumps IgM antibody level.

 Case Suspected: a case that meets the clinical case definition without classification laboratory confirmation and not linked to any confirmed case.  Confirmed: a case that is laboratory confirmed, or has clinically compatible illness and is epidemiologically linked to a confirmed case.

Other bacterial food-borne Intoxications ICD-9 005 ICD-10 A05

This group of diseases is caused by the following pathogens acquired by the consumption of contaminated water or food. Other gastroenteritis of unknown pathogens caused by the consumption of water and food are also included in this group.

Pathogen Bacillius cereus, Clostridium botulinum, Clostridium perfringens, Staphylococcus aureus, Vibrio parahaemolyticus

Clinical Refer to Table 2 description

Clinical case Foodborne diseases are caused by consumption of contaminated definition food. The causative agents include bacteria, viruses, parasites and chemicals, etc. In these diseases, toxins elaborated by bacteria are the main cause of clinical features. Among these, the most severe disease is botulism caused by Clostridium botulinum. It‟s clinical features include difficulty in swallowing and speaking, ocular disturbance (blurred or double vision), vomiting, diarrhoea or constipation. Its characteristic features include damage of bilateral cranial nerves and muscle weakness or paralysis and ultimately caused paralysis of breathing and death. The epidemiological features of some causative agents of ICD-10: A05 group related to foodborne diseases are listed in Table 2.

Laboratory  Isolation of causative agents in clinical specimens criteria for diagnosis

Case  Suspected : a clinically compatible case. classification  Probable: a clinically compatible case occurring in group or is 56

epidemiologically linked to confirmed cases.

 Confirmed: a clinically compatible case that is laboratory confirmed.

Notification All diseases described in this chapter are notifiable diseases. Probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC). Laboratories should notify the compatible case with laboratory diagnosis.

If any foodborne disease outbreak is suspected, vomitus and stool specimens are requested and immediate report to CDC should be made. 57

Table 2 Causative agents and clinical-epidemiological characteristics of common bacterial foodborne intoxications(1)

Bacteria Incubation Clinical Duration Reservoir Mode of period features transmission(2) Bacillius cereus 1-24 hr Nausea and 1-2 days Soil, fresh or Ingestion of vomiting, dried food (e.g. abdominal shellfish food boiled rice) pain, after diarrhoea re-heating or cooking for several hours Clostridium 6-96 hr Difficulty in 3-7 days Soil, marine Canned food botulinum swallowing (may sediments, (especially and last for a intestinal meat and speaking, few tracts of land vegetables) & ocular months) and marine smoked food disturbance animals (e.g. sausages, (blurred or hams, salmon, double etc.) vision), vomiting, diarrhoea or constipation Clostridium 6-24 hr Abdominal 1-2 days Soil and Raw food, perfringens pain, human, food not diarrhoea, intestinal thoroughly vomiting tracts of cow, cooked or pig, poultry, sufficiently fish re-heated (esp. meat), cross contamination of food Staphylococcus 1/2-8 hr Nausea, 1-2 days Human, milk Cross aureus abdominal (occasionally) contamination pain, of food; vomiting, Food not diarrhoea, properly froze mild fever, or thoroughly hypotension re-heated before preparation (meat, cheese, sandwich, etc) Vibrio 4-30 hr Diarrhoea, 1-7 days Organisms in Raw or not parahaemolyticus abdominal see bay, thoroughly 58

pain, nausea, marine cooked or vomiting, sediments, re-heated fish fever, amphibiam & and other headache fish marine products; Cross contamination of food (1) Other causative agents / diseases (Salmonella infection, Bacillary dysentery, Typhoid fever, etc) mentioned in the other chapters are not included. (2) Food that commonly causes transmission of the causative agents. 59

Other Viral Infection of the Central Nervous System (ICD-9 062-064 ICD-10 A83.1-A84)

Pathogen This chapter includes arboviral encephalitis other than Japanese Encephalitis and also those unknown cause of viral encephalitis.

Clinical Arboviral infection may result in febrile illness of variable severity associated description with neurological symptoms ranging from headache to aseptic meningitis or encephalitis. This viral encephalitis is difficult to distinguish clinically from other central nervous system infections. Symptoms can include headache, confusion, or change in other sensory nerves, nausea and vomiting. Signs include fever, pseudo-meningeal signs, cranial nerve palsies, paresis or paralysis, sensory deficits, abnormal reflexes, generalized convulsions, or abnormal movements and different levels of coma.

Laboratory 3) Four-fold or greater rise in virus-specific serum antibody titer, or 4) Isolation of virus from or demonstration of specific viral antigen or criteria for diagnosis genomic sequences in tissue, blood, CSF, or other body fluid, or 5) Virus-specific immunoglobulin M (IgM) antibodies demonstrated in CSF or serum by antibody-capture enzyme immunoassay (EIA), and confirmed by demonstration of virus-specific serum immunoglobulin G (IgG) antibodies in the same or a later specimen by another serologic assay (e.g., neutralization or hemagglutination inhibition).

Case  Suspected: a clinically compatible case, or case diagnosed by clinician classification as viral encephalitis with unknown pathogen.  Probable: a suspected case with single serological evidence.  Confirmed: a probable case with laboratory confirmation.

Notification Suspected, probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours.

Laboratories should notify the case that is compatible with laboratory diagnosis to CDC. 60

Other salmonella infections ( ICD-9 003 ICD-10 A02 )

Pathogen Salmonella enterifidis, S. Typhimurium

Clinical An illness is commonly manifested by Gastroenteritis (diarrheoa, description nausea and vomiting), usually with fever and severe headache. Dehydration in various degrees may present. The symptoms can be severe especially in young children and the elderly. Asymptomatic infections may occur, and the organism may cause extraintestinal infections.

Laboratory  Isolation of Salmonella spp. from stool or blood. criteria for diagnosis

Case  Probable: a clinically compatible case that is epidemiologically classification linked to a confirmed case.  Confirmed: a clinically compatible case that is laboratory confirmed.

Pertussis ( ICD-9 033 ICD-10 A37 )

Pathogen Bordetella pertussis

Clinical case The incubation period is between 4-12 days. It is an acute bacteria definition upper respiratory infectious disease. The infected person may initially cough lasting for 1 to 2 weeks, The cough gradually becomes paroxysms of coughing, inspiratory "whoop", post-tussive vomiting, Pertussis is a highly contagious disease. Secondary pneumonia is the main cause of death in infants who infected Bordetella pertussis.

 Laboratory Isolation of Bordetella pertussis, or  criteria for Detection of genomic sequences by polymerase chain reaction diagnosis (PCR)

 Case Probable: meets the clinical case definition, is not laboratory classification confirmed, and is not epidemiologically linked to a laboratory-confirmed case  Confirmed: laboratory confirmed , or a case that meets the clinical case definition and is epidemiologically linked to a laboratory-confirmed case

Plague ( ICD-9 020 ICD-10 A20 )

Pathogen Yersinia pestis (plague bacillue)

Clinical The incubation period is usually between 2-4 days, but can be less description than 1 day or up to 7days. The disease is characterized by fever, chills, headache, malaise, prostration, and leukocytosis. It manifests in one or more of the following principal clinical forms:

1) Painful regional lymphadenitis (bubonic plague)

2) Septicemia without an evident lymphadenitis (septicemic plague)

3) Pharyngitis and cervical lymphadenitis (pharyngeal plague)

4) Pneumonia (Plague pneumonia)

Plague pneumonia, resulting from hematogenous spread in bubonic or septicemic cases (secondary pneumonic plague) or inhalation of infectious droplets (primary pneumonic plague).A patient with pneumonic plague has cough with blood-stained sputum, shortness of breath

 Laboratory Passive haemagglutination (PHA) test, demonstrating an at least criteria for fourfoldchange in antibody titre, specific for F1 antigen of Y. diagnosis pestis, asdetermined by the haemagglutination inhibition test (HI) in paired sera. (suspected).  Isolation of Yersinia pestis in cultures from lymph nodes, blood, CSF or sputum (comfirmed)

 Case Suspected: a case compatible with the clinical description classification  Probable: a suspected case with

1) Positive direct fluorescent antibody (FA) test for Y. pestis in

clinical specimen or 63

2) Passive haemagglutination test, with antibody titre of at least

1:10, specific for the F1 antigen of Y.pestis as determined by the

haemagglutination inhibition test (HI) or

3) Epidemiological link with a confirmed case.

 Confirmed : a suspected or probable case that is laboratory-confirmed.

Rabies (ICD-9 071 ICD-10 A82)

Pathogen Rabies virus, a rhabdoviridus of the genus Lyssvirus

Clinical The incubation period is usually between 3-8 weeks, or as short as description 2 weeks or as long as several years. Rabies is an acute encephalomyelitis that is usually fatal. The clinical manifestation includes headache, fever, malaise, fear of water, hydrophobia excitability and nonspecific nervous system changes. It‟s often related to animal bites or scratches. The disease is characterized by frequent convulsions and paralysis of muscles, especially the respiratory muscles.

 Laboratory Detection of rabies antigens by immunofluorescent antibody criteria for (FA) test in clinical specimens, preferably brain tissue (collected diagnosis post mortem), skin or corneal smear (collected ante mortem)  Isolation of rabies virus from saliva, cerebrospinal fluid (CSF), or brain tissue, or  Identification of viral antigens by PCR on brain tissue or skin, cornea or saliva specimens.  The laboratory diagnosis criteria of animal rabies diagnosis may consider to perform: 1) Detection of rabies antigens by fluorescent antibody (FA) in brain system. 2) Virus isolation.

 Case Suspected: a clinically compatible case.  classification Probable: a clinically compatible case and has history of suspected rabid animal bite or scratch.  Confirmed: a clinically compatible case that is laboratory confirmed.

Note Precautionary measure includes reporting to IACM immediately so as to facilitate the capture and cage of the related animal, if being bitten by the suspected rabid animal. 66

Rotaviral enteritis ( ICD-9 : 008.61 ; ICD-10 : A08.0)

Pathogen Rotaviruses

Clinical Rotaviruses are a leading cause of severe diarrhoeal disease and description dehydration in infants and young children throughout the world. Most symptomatic episodes occur in young children between the ages of 3 months and 2 years. The virus spreads rapidly, presumably through person-to-person contact, airborne droplets, or possibly contact with contaminated toys. Symptoms usually appear approximately two to three days after infection, and include projectile vomiting and very watery diarrhoea, often with fever and abdominal pain. The first infection is usually the worst one.

Laboratory  Demonstration of rotavirus in stool or rectal swab by one criteria for immunological techniques and verified by another (EM, ELISA, diagnosis LA and other).  Serological evidence of recent infection  Demonstration of rotavirus in stool or in rectal swab by PCR techniques.

Case  Suspect cases: any cases compatible with clinical description classification  Probable cases: any cases compatible with clinical description and with one positive immunological test but without another.

 Confirmed cases: any cases compatible with clinical description and confirmed by laboratory test

Rubella (German measles) ( ICD-9 056 ICD-10 B06 )

Pathogen Rubella virus

An illness with the following characteristics: Clinical description  Acute onset and short duration, characterized by diffuse punctuate and maculopapular rash (similar to rash of measles and scarlet fever). Rashes often initiate in the face and spread all over the body within 24 hours. On the second and third day, rashes on the face and trunk disappear respectively;

 Arthralgia/arthritis, or conjunctivitis, particularly in women;

 Retro-auricular, occipital and retro-cervical lymphadenopathy (important clinical signs);

 Fever, over 37 ﾟ C but often less than 38.5 ﾟ C, in adults (not presented in children);

 Lymphocytopenia or thrombocytopenia may occur;

 More than half of the infections are subclinical.

 Clinical case Acute onset of diffuse punctuate and maculopapular rash lasting for or at least 3 days, and definition

 Retro-auricular, occipital and retro-cervical lymphadenopathy; and

 Arthralgia / arthritis, or conjunctivitis.

 Laboratory Isolation of rubella virus from clinical specimen, or  criteria for Detection of rubella-specific IgM antibody, or  diagnosis Significant rise between acute- and convalescent-phase titers in serum rubella IgG antibody level. 68

 Case Suspected: any generalized rash illness of acute onset without classification laboratory confirmation  Probable: a case that meets the clinical case definition without laboratory confirmation and not linked to confirmed cases.  Confirmed: a case that is laboratory-confirmed, or meets the clinical case definition and is epidemiologically linked to a confirmed case.

Scarlet fever ( ICD-9 : 034.1 ; ICD-10 : A38 )

Pathogen Group A (β hemolytic) streptococci

Clinical Scarlet fever is a form of streptococcal diseases characterized by a description sking rash, occurring when the infection strain producws a pyrogenic exotoxin (erythrogenic toxin) and the patient is sensitized by not immmune to teh toxin. Clinical characteristics may include all symptoms associated with a streptococcal sore throat (with a streptococcal wound, skin or puerperal infection) as well as enanthem, strawberry tongue and exanthem. The rash is usually a fine erythema, commonly punctate, blanching on pressure, often felt (like sandpaper) better than seen and appearing most often on the neck, chest, folds of the axilla, elbow, groin and inner surfaces of the thighs.

Laboratory  Isolation of pathogen, or criteria for  Demostration of antigen. diagnosis

Case  Suspected not applicable. classification  Probable cases compatible with clinical description without lab confirmation.  Confirmed Cases compatible with clinical description and cofirmed by laboratory examination.

SARS ICD-10 B97.2

Pathogen SARS coronavirus (SARS-CoV)

Clinical The mean incubation period is 5 days with the range of 2–10 days description although there are isolated reports of longer incubation periods. There have been no reports of transmission occurring before the onset of symptoms.

Week 1 of illness: Patients initially develop influenza-like prodromal symptoms. Presenting symptoms include fever, malaise, myalgia, headache, and rigors. No individual symptom or cluster of symptoms has proven specific. Although history of fever is the most frequently reported symptom, it may be absent on initial measurement. Week 2 of illness: Cough (initially dry), dyspnoea and diarrhoea may be present in the first week but more commonly reported in the second week of illness. Severe cases develop rapidly progressing respiratory distress and oxygen desaturation with about 20% requiring intensive care. Up to 70% of the patients develop diarrhoea which has been described as large volume and watery without blood or mucus. Transmission occurs mainly during the second week of illness. Case fatality ratio (CFR) of SARS is estimated to range from 0% to more than 50% depending on the age group affected and reporting centre, with an crude global CFR of approximately 9.6%.2 Higher mortality has also been associated with male sex and presence of co-morbidity in various studies.

Early chest radiograph or CT changes are observed in most of the patients as early as days 3-4 of illness in spite of the absence of respiratory signs. These typically show patchy consolidation starting with a unilateral peripheral lesion which progress to multiple lesions or ground glass appearance. Some lesions follow a shifting pattern. Features during the later stages have sometimes included spontaneous pneumothorax, pneumomediastinum, sub-pleural fibrosis and/or cystic changes. Lymphopenia is common on presentation and progresses during the 71

course of the illness. Sometimes thrombocytopenia and prolonged APTT are observed. Biochemical findings LDH is frequently high and some reports have suggested association with poor prognosis.

Clinical case  A history of fever, or documented fever ≥ 38 °C (100.4 °F). AND definition  One or more symptoms of lower respiratory tract illness (cough, difficulty breathing, shortness of breath), AND  Radiographic evidence of lung infiltrates consistent with pneumonia or ARDS or autopsy findings consistent with the pathology of pneumonia or ARDS without an identifiable cause. AND  No alternative diagnosis can fully explain the illness.

Laboratory Nucleic acid tests criteria for Reverse transcription polymerase chain reaction (RT-PCR), positive diagnosis for SARS-CoV using a validated method from:  At least two different clinical specimens (e.g. nasopharyngeal and stool), OR  The same clinical specimen collected on two or more occasions during the course of the illness (e.g. sequential nasopharyngeal aspirates), OR  Two different assays or repeat RT-PCR using a new RNA extract from the original clinical sample on each occasion of testing. Seroconversion by ELISA or IFA  Negative antibody test on acute sate serum followed by positive antibody test on convalescent phase serum tested in parallel. OR  Fourfold or greater rise in antibody titre between acute and convalescent phase sera tested in parallel. Virus isolation  Isolation in cell culture from any clinical specimen and identification of SARS-CoV using a validated method such as RT-PCR.

Case  Suspect case: cases compatible with clinical case definition. classification  Preliminary positive case of SARS: An individual with clinical evidence for SARS AND who meets the laboratory case definition of SARS-CoV infection where testing has only been performed at a national reference laboratory.  Probable case of SARS  An individual with clinical evidence of SARS epidemiologically linked to a „preliminary positive‟ or„confirmed‟ case of SARS. OR

 An „unverifiable‟ case of SARS if epidemiologically linked to a „preliminary positive‟ or „confirmed‟ case.  Confirmed case of SARS:  A „preliminary positive‟ case where testing performed at a national reference laboratory has been independently verified by a WHO International SARS Reference and Verification Laboratory. OR  A "preliminary positive" case of SARS where at least one case in the first chain of transmission identified in the country/area has been independently verified by a WHO International SARS Reference and Verification Laboratory. OR  An individual with clinical and epidemiological evidence* for SARS AND with preliminary laboratory evidence of SARS-CoV infection based on the following tests performed at a national reference laboratory or a designated sub-national laboratory:

a) A single positive antibody test for SARS-CoV, OR b) A positive PCR result for SARS-CoV on a single clinical specimen and assay.  Unverifiable case of SARS  An individual with clinical evidence of SARS but in whom initial laboratory results are negative, if done, and the patient is lost to follow up. OR  A deceased individual with a pre-morbid history of illness 73

compatible with SARS AND

a) whose autopsy findings are consistent with the pathology of pneumonia or ARDS but in whom SARS-CoV testing was not done or was incomplete. OR b) in whom neither an autopsy nor laboratory testing were performed.

Note Case definition and notification requirement in the sector applicable in the inter-epidemic period. Ref = WHO guidelines for the global surveillance of SARS Updated recommendations, October 2004

Shigellosis ( Bacillary dysentery ) ICD-9 004 ICD-10 A03

Pathogen A group of Shigella bacteria, such as Shigella dysenteriae, S. sonnei, S. Boydii, S. flexneri.

Clinical An illness of variable severity characterized by diarrhea, fever, description nausea, cramps, and tenesmus. The stool may contain blood and mucus. Mild and asymptomatic illness may occur. Complications include toxic dilatation of large intestine and acute kidney disease.

Laboratory  Isolation of Shigella from stool criteria for diagnosis

Case  Suspected : a clinically compatible case classification  Probable: a clinically compatible case that is epidemiologically linked to a confirmed case.  Confirmed: a clinically compatible case that is laboratory confirmed.

Notification Clinicians should deal with suspected cases for further examination to determine the diagnosis. Patients should be referred to an appropriate medical center for further examination by clinicians unconditionally. Probable and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Syphilis ( ICD-9 090-096 ICD-10 A50-52

Pathogen Treponema pallidum spirochete

Clinical The primary stage usually, but not necessarily, involves ulceration description of the external genital organs and local lymphadenopathy; secondary and tertiary syphilis show mainly dermatological and systemic manifestations.

Primary: A stage of infection with Treponema pallidum characterized by one or more chancres (ulcers); chancres might differ considerably in clinical appearance. Secondary: A stage of infection caused by T. pallidum and characterized by localized or diffuse mucocutaneous lesions, often with generalized lymphadenopathy. The primary chancre may still be present. Latent: A stage of infection caused by T. pallidum in which organisms persist in the body of the infected person without causing symptoms or signs. Latent syphilis is subdivided into early, late, and unknown categories based on the duration of infection.

Laboratory  A positive serology for syphilis (Rapid Plasma Reagin (RPR) or criteria for VDRL confirmed by TPHA (Treponema pallidum diagnosis haemagglutination antibodies) or FTA (fluorescent treponemal antibodyabsorption).

Case  Congenital syphilis: An infant with a positive serology, whether or classification not the mother had a positive serology during thepregnancy.  Acquired syphilis: All others.  Probable: a clinically compatible case with one or more ulcers (chancres) consistent with primary syphilis and a reactive serologic test (nontreponemal: Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR]; treponemal: 76

fluorescent treponemal antibody absorbed [FTA-ABS] or microhemagglutination assay for antibody to T. pallidum [MHA-TP])  Confirmed: a clinically compatible case that is laboratory confirmed

Notification Confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC. Abbreviation of name, sex and birth of patient should be reported but other identifiable details are not required.

Tetanus ICD-9 037, 771.3 ICD-10 A33-A35

Pathogen It is caused by the bacterium Clostridium tetani.

Clinical Acute onset of hypertonia and/or painful muscular contractions description (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause. There are three types of Tetanus, including tetanus neonatorum (ICD10:A33), obstetrics tetanus (ICD10:A34) and other tetanus (ICD10:A35). The incubation period is between 1 and 21 days, commonly about 14 days. But sometimes it can reach for several months. The tetanus neonatorum incubation period is equally 6 days, but it can be short to 3 days or extend to 28 days.

Laboratory  The diagnosis is purely clinical and does not depend upon criteria for laboratory or bacteriological confirmation. diagnosis

Case  Confirmed case: A clinically compatible case (laboratory classification confirmation is not required).

Tuberculosis ICD-9 010-018 ICD-10 A15-A19

Pathogen Tuberculosis is caused by Mycobacterium tuberculosis, M. africanum and M. bovis.

Clinical A chronic bacterial infection characterized pathologically by the description formation of granulomas. The most common site of infection is the lung, but other organs may be involved. Asymptomatic illness may occur at the start of infection. And the clinical performance depends on the location of the infection lesion.

Laboratory  Isolation of M. tuberculosis from a clinical specimen, or criteria for  Demonstration of at least two initial sputum smear examinations diagnosis (direct smear microscopy) positive for Acid-Fast Bacilli (AFB) when a culture has not been or cannot be obtained, or  Demonstration of M. tuberculosis from a clinical specimen by nucleic acid amplification test

Case  Suspected : case with appearances of signs and symptoms classification compatible with tuberculosis, especially with the long-term cough (more than two weeks)  Probable : a case with bacteriological positive, or with the diagnosis of tuberculosis determined by clinical doctors , a case has any prescription for the treatment of TB should be regarded as clinicians have made the diagnosis of tuberculosis

 Confirmed : a case that is laboratory confirmed Notification Clinicians should deal with suspected cases for further examination, especially tuberculosis sputum examination in order to determine the diagnosis. Patients should be referred to an appropriate medical center for further examination by clinicians unconditionally. Infection lesions, bacteriological and histological results should be indicated during declaration, in order to make appropriate case classification. 79

It is a notifiable communicable disease. Confirmed cases should be reported to the Center for Disease Control and Prevention (CDC). Besides, laboratories should report the laboratory confirmed case to CDC.

Note Case classification according to the infection lesion and the recurrence situation (from WHO)  Pulmonary tuberculosis

If possible TB diagnosis must be based on bacteriological examination of sputum. TB can be divided into: 1) Sputum smear positive (PTB+)  Tuberculosis in a patient with at least two initial sputum smear examinations (direct smear microscopy) positive for Acid-Fast Bacilli (AFB), or 3) Tuberculosis in a patient with one sputum examination positive for acid-fast bacilli and radiographic abnormalities consistent with active pulmonary tuberculosis as determined by the treating medical officer, or  Tuberculosis in a patient with one sputum specimen positive for acid-fast bacilli (direct smear microscopy) and at least one sputum that is culture positive for acid-fast bacilli. 2) Sputum smear negative (PTB-)  Tuberculosis in a patient with symptoms suggestive of tuberculosis and having three sputum specimens negative for acid-fast bacilli, and Radiographic abnormalities consistent with active pulmonary tuberculosis and lead to the decision of prescription of anti-tuberculosis by a physician  Patient with one sputum specimen negative for acid-fast bacilli (direct smear microscopy), but three sputum that is culture positive for acid-fast bacilli.  Extra-pulmonary tuberculosis 1) Tuberculosis of organs other than lungs: pleura, lymph 80

nodes, abdomen, genito-urinary tract, skin, joints and bones, tuberculous meningitis, etc. 2) Diagnosis should be based on one culture positive specimen from an extra-pulmonary site, or histological or strong clinical evidence consistent with active extra-pulmonary tuberculosis, followed by a decision by a medical officer to treat with a full course of anti-tuberculous therapy 3) Any patient diagnosed with both pulmonary and extra-pulmonary tuberculosis should be classified as a case of pulmonary tuberculosis  New case: A patient who has never had treatment for tuberculosis or took anti-tuberculous drugs for less than 4 weeks.  Relapse case: A patient previously treated for tuberculosis and declared cured by a medical officer after one full course of chemotherapy, but who reports back to the health service bacteriologically positive (smear or culture). 81

Typhoid and paratyphoid fevers ICD-9 002 ICD-10 A01

Pathogen Typhoid and paratyphoid fevers are caused by the bacteria Salmonella Typhi and Salmonella Paratyphi respectively.

Clinical Typhoid fever has an insidious onset characterized by sustained description fever, headache, malaise, anorexia, enlarged spleen, relative bradycardia, constipation or diarrhea, and nonproductive cough. However, many mild and atypical infections occur. Carriage of S. typhi may be prolonged. Paratyphoid fever presents with similar picture, but tends to be milder. When typhus and paratyphoid infection do not cause the whole body symptoms, they usually performance as gastroenteritis on the clinical.

Laboratory  Isolation of S. Typhi or S. Paratyphi from blood, stool, or other criteria for clinical specimen. diagnosis

Case  Probable: a clinically compatible case that is epidemiologically classification linked to a confirmed case in an outbreak.  Confirmed: a clinically compatible case that is laboratory confirmed.

Typhus (Scrub typhus) ICD-9 080-081.2 ICD-10 A75

Pathogen Orientia tsutsugamushi

Clinical The incubation period is between 9 and 12 days. A disease with a description primary punched out skin ulcer (eschar) where the bite(s) occurred, followed by acute onset fever (39℃-40.5℃) after several days, along with headache, profuse sweating, conjunctival injection and lymphadenopathy. Within a week, a dull maculo-papular rash appears on the trunk, extends to the extremities and disappears in few days. Cough is also common. Mortality, with 1-60% difference, is relevant to region, Rickettsia strains, infection history and the yes/no treatment. But if under the accurate diagnosis and appropriate treatment, mortality rate can be less than 1 %.

Laboratory  Isolation of Orientia tsutsugamushi by inoculation of patient blood criteria for in white mice (preferably treated with cyclophosphamide at 0.2 diagnosis mg/g intraperitoneally or intramuscularly on days 1, 2 and 4 after inoculation).  Serology: detection of specific IgM 1) at 1:100 or higher by Enzyme Immunoassay (EIA), or 2) 1:32 dilution or higher by Immunoperoxidase (IP), or 3) 1:10 dilution or higher by Indirect Immunofluorescence (IF).

Case  Suspected: a case that is compatible with the clinical description classification  Confirmed: a suspected case with laboratory confirmation

Viral hepatitis A ICD-9 070.1 ICD-10 B15

Pathogen Hepatitis A virus (HAV)

Clinical The incubation period is usually 28-30 days, but may range from description 14 days to 50 days. Hepatitis A is an acute illness with poor appetite, tiredness, nausea, vomiting, diarrhoea, fever, right upper abdominal discomfort, jaundice, tea-colored urine and elevated serum aminotransferase levels.

Laboratory  Immunoglobulin M (IgM) antibody to hepatitis A virus criteria for (anti-HAV) positive. diagnosis

Case  Suspected : a clinically compatible case. classification  Probable : not applicable.

 Confirmed: 1) a clinically compatible case that is laboratory confirmed (suitable for all types of infections), or 2) a clinically compatible case and is epidemiologically linked to one or more persons who have laboratory confirmed hepatitis A.

Viral hepatitis B ICD-9 070.3 ICD-10 B16

Pathogen Hepatitis B virus (HBV)

Clinical The incubation period is usually 60 to 90 days, but may range from description 45 days to 180 days. Hepatitis B is usually an asymptomatic chronic illness. Acute infection is characterized by poor appetite, tiredness, nausea, vomiting, diarrhoea, fever, right upper abdominal discomfort, jaundice, tea-colored urine and elevated serum aminotransferase levels.

Laboratory  Serum: criteria for 1) IgM antibody to hepatitis B core antigen (anti-HBc) positive diagnosis or/and, 2) Hepatitis B surface antigen (HBsAg) positive.

Case  Suspected: a clinically compatible case. classification  Confirmed: a clinically compatible case that is laboratory confirmed.

Viral hepatitis C virus ( ICD-9 070.51 ICD-10 B17.1

Pathogen Hepatitis C virus (HCV)

Clinical The incubation period is usually 40 to 60 days, but may range from description 14 days to 180 days. Clinical features are tiredness, general malaise, nausea, right upper abdominal discomfort, jaundice, tea-colored urine and elevated serum aminotransferase levels. Hepatitis C is transmitted mainly via skin contact with contaminated blood or via transfusion of blood products. Patients and carriers should use condoms for safe sexual behavior and their blood products must be well-managed for prevention.

Laboratory  Antibodies to hepatitis C virus (anti-HCV) positive criteria for diagnosis

Case  Suspected: a clinically compatible case classification  Confirmed: a clinically compatible case that is laboratory confirmed (suitable for all types of infections).

Notification Confirmed cases should be notified to Center for Disease Control and Prevention (CDC) by clinician within 24 hours.

Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Hepatitis D ( ICD-9 070.52 ICD-10 B17.0

Pathogen Hepatitis D virus (HDV)

Clinical The incubation period is usually 14 to 60 days. Hepatitis D is description transmitted through blood or sexual contact which is similar with Hepatitis B. Moreover, hepatitis D virus (HDV) is a defective virus that needs the presence of hepatitis B virus. The control measure may refer to hepatitis B.

Laboratory  Serum: criteria for 1) Antibodies to hepatitis B surface antigen (HBsAg) positive and diagnosis hepatitis D virus (HDV) positive, and/or 2) IgM antibody to hepatitis B core antigen (anti-HBc) positive and hepatitis D core antigen (anti-HDc) positive.

Case  Suspected: a clinically compatible case. classification  Confirmed: a clinically compatible case that is laboratory confirmed.

Hepatitis E ( ICD-9 070.55 ICD-10 B15-17.2

Pathogen Hepatitis E virus (HEV)

Clinical The incubation period is usually 25 to 40 days, but may range from description 14 days to 60 days. Clinical features are tiredness, general malaise, nausea, right upper abdominal discomfort, jaundice, tea-colored urine and elevated serum aminotransferase levels.

Laboratory  IgM antibody to hepatitis E virus (IgM anti-HEV) positive, and criteria for  IgM antibody to hepatitis A virus (IgM anti-HAV) negative diagnosis

Case  Suspected: a clinically compatible case classification  Probable: a clinically compatible case and is epidemiologically linked to confirmed cases.  Confirmed: a clinically compatible case that is laboratory confirmed, or without laboratory confirmation but is epidemiologically linked to one or more persons who are laboratory confirmed hepatitis E.

Notification Probable and Confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 24 hours.

Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Yellow fever ( ICD-9 060 ICD-10 A95

Pathogen Yellow fever virus

Clinical The incubation period is usually 3-6 days. Characterized by sudden description onset fever, chills, headache, backache, generalized myalgia, weakness, nausea, hepatitis, jaundice, albuminuria, and in some instances, renal failure, shock, and generalized haemorrhages (eg. epistaxis, gingival bleeding, hematemesis or melena). It has a high case-fatality rate.

Laboratory  Isolation of yellow fever virus, or criteria for  Detection of specific yellow fever antigen in tissues by diagnosis immunohistochemistry, or  Detection of yellow fever virus genomic sequences in blood or organs by PCR, or

 Presence of yellow fever specific IgM or a four-fold or greater rise in serum IgG levels in paired sera (acute and convalescent), or  Positive post-mortem liver histopathology.

Case  Suspected: a clinically compatible case that is not laboratory classification confirmed.  Confirmed: a clinically compatible case that is laboratory confirmed

Notification Suspected and confirmed cases should be notified to the Center for Disease Control and Prevention (CDC) by clinician within 1hour. Laboratories should notify the case that is compatible with laboratory diagnosis to CDC.

Reference

David L. Heymann (ed). Control of communicable diseases manual. 18th ed. Washington: American Public Health Association, 1995.

Centers for Disease Control and Prevention. Nationally Notifiable Infectious Diseases, United States 2008 - . Available on http://www.cdc.gov/ncphi/disss/nndss/phs/infdis2008.htm

Centers for Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1993;41(RR-17).

Centers for Disease Control and Prevention. 1994 revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR 1997;46 (RR-2).

World Health Organization. WHO Recommended surveillance standards. WHO/EMC/DIS/ /97.1, 1997