Epidemiological Bulletin Number 59 Week 19 (week ending 16 May 2010)

Foreword

This bulletin provides a weekly overview of the outbreaks and other important public health events occurring in . It includes disaggregated data to inform and improve the continuing public health response by the various partners. It also provides guidance to agencies on issues relating to data collection, analysis and interpretation, and suggests operational strategies on the basis of epidemiological patterns so far. The bulletin is published weekly. Note that the epidemiological week runs from Monday to Sunday. This edition covers week 19 (week ending 16 May 2010).

The C4 team welcomes feedback. Data provided by individual agencies is welcome but will be verified with MOHCW structures before publication.

Please send any comments and feedback to the Cholera Control and Command Centre

Email: [email protected].

Toll free number for alert by district and province is 08089001 or 08089002 or 08 089000

Acknowledgements

We are very grateful to MoHCW District Medical Officers, District and Provincial Surveillance Officers, Provincial Medical Directors, Directors of City Health departments, Environmental Heath Officers, and MoHCW's National Health Information Unit, who have helped to gather and share the bulk of the information presented here.

Likewise, we acknowledge agencies, including members of the Health and WASH clusters, who have kindly shared their data with our team. MoHCW recognizes and thanks the efforts made by NGOs and other partners assisting in the response and providing support to MoHCW.

Highlights of the week: • No cholera cases reported this week • Confirmed Measles Outbreaks reported in 50 districts • 6 Typhoid cases reported this week

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Figures The case definitions can be found in appendix 1 and detailed data by district are shown in appendix 2. See also summary tables (annex 1), maps (annex 2) and graphs (annex 3).

Cholera

15 out of the 62 districts in the country have been affected by the cholera outbreak that started on 4 February, 2010 compared to 54 districts last year at the same time. 477 cumulative suspected cholera cases, 68 laboratory confirmed cases and 15 deaths were reported by 16 May 2010 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) National Health Information Unit. The crude case fatality rate since the outbreak started stands at 2.6% which is 1.8% lower than that of last year. By week 19, 2009, 98 234 cumulative cases and 4 277 deaths had been reported since August 2008, with a crude case fatality rate of 4.4%.

Week 19 (10 - 16 May 2010)

No cholera cases and deaths were reported this week.

Geographical distribution of cases

The cases reported so far came from the following districts: , , , , Chivi, Chimanimani, , , Hurungwe, Kadoma, , Makonde, Mwenezi, Plumtree and UMP.

Urban/Rural distribution of cases

62.7% of the cases currently reported are from rural areas. In comparison, during the corresponding week in 2009, 34.4% cases came from urban areas and 65.6 % from rural areas.

Assessments & response

Surveillance, case management and investigation of alerts continued in all the provinces.

Measles

7 754 suspected cases and 517 deaths (of which 512 were community deaths) were reported since the beginning of the outbreak in September 2009. 1 401 blood specimens were received by the polio-measles laboratory and 508 cases have been confirmed to be Measles IgM positive.

Vaccination Status of Measles Cases

5 317 (69%) cases were not vaccinated, 1 691(22%) had unknown vaccination status and 746 (10%) cases had been vaccinated at least once. Only 50 (9.9%) of the total positive cases had been vaccinated. See Table 7 for more details.

IgM Positive Cases by Age Group

69 (13.6%) of the positive IgM cases were below 9 months, 41 (8.1%) in the 9 – 12 months age group, 102 (20.1%) were in the 1-5 years age group, 221 (43.5 %) were in the 5 -14 years age group and 75 (14.8%) in the above 14 Years age group. Hence 398 (78.3%) of the positive cases were above the routine immunisation age ( 9 months -12 months)

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 The district measles IgM positive attack rates ranged from 0.4 to 25.3 per 100 000 and the attack rate for all the affected districts is 4.2 per 100 000. The lowest attack rate was recorded in and the highest was recorded in .

See table 3 for detailed distribution of the IgM positive cases by agegroup and and attack rates by district.

Week 19 (10 - 16 May 2010)

21 specimens were received by the laboratory during the week. 12 of the specimens were IgM positive. The positive cases were from: Beitbridge -1, Harare-3, -1,Rushinga-2 and Zaka 5. 2 of the positive cases had been vaccinated this month. See table 4 for detailed distribution.

Geographical distribution of cases

Since September 2009, 59 districts out of 62, have had at least 1 laboratory confirmed measles case namely: Beitbridge, Bindura, Bikita, Bubi, Buhera, , Centenary, Chegutu, Chikomba, Chimanimani, Chiredzi ,Chirumhanzu, , Chivi, Gokwe North, Gokwe South, Goromonzi, Guruve,, Gutu, Harare (including ) ,Hurungwe, , Hwedza, , Kadoma , , Lupane,Makoni, Makonde, , Mangwe, Masvingo, Mazowe, Mt. Darwin, , Mutasa, Murehwa, , Mwenezi, Nyanga, ,Seke, , Umguza, UMP, Zaka, Zvimba and . All districts have reported suspected measles cases.

Confirmed laboratory Outbreaks

The number of districts with laboratory confirmed measles outbreaks have gone up by 3 to 50 from last week’s figure. The districts with confirmed outbreaks are shaded in table 3.

Assessments & response

Vaccination and surveillance continued in all affected Districts. Supervisors from provinces and districts were trained on microplanning for the joint Child Health and Immunisation Days. Orientation of health facilities staff on what to do during the campaign has started. Distribution of vaccines, IEC materials, data collection has commenced. Typhoid

Since the typhoid outbreak started on 3 February 2010, 446 cases and 8 deaths were reported by 16 May, 2010. 43 samples were laboratory confirmed to be Salmonella typhi, the cause of typhoid fever from 44 samples tested.

Week 19 (10 - 16 May 2010)

Six cases of Typhoid were reported from Mabvuku in the week.

Geographical distribution of cases

The cases were reported from mainly Harare surburbs and areas in the environs of Harare namely Bhobho Farm, Caledonia, Chishawasha, Epworth, Gwebi College, , Hunyani(Norton), Order Farm , Zimre Park, Zengeza 3 and Zengeza 5. 282 cases (63%) of the cases were from Mabvuku and 83 cases (19 %) were from Tafara. Hence Mabvuku and Tafara account for 82% of the cases. Nyamaturi Street was the most affected contributing 21% of the cases.Map 3 shows the distribution of the cases by surburb.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3

Assessments & response

Surveillance, health promotion and case management continued. EHTs that had been seconded to Mabvuku from other areas in Harare have returned to their stations.

Malaria

18 out of the 62 rural districts in the country have reported some malaria outbreaks to date. In week 18 a total of 10 676 cases and 31 deaths were reported, with 1 423 (13%) and 2 deaths being amongst the under 5s. The highest number of cases were reported in Mashonaland East province (3 509 cases) and Mashonaland Central (2 501 cases).

Geographical distribution of cases

The outbreaks have been confined to the districts in rural provinces namely: Beitbridge, Bikita, Binga, Buhera, Bulilima, Chiredzi, Hurungwe, Hwedza, Kariba, Mazowe, Mbire, Mudzi, Murewa, Mutoko, Mwenezi and Gokwe South. See Map 4 for spatial distribution of the outbreaks.

Assessments & response

The outbreaks have been attributed to late and prolonged rains. The increase in number of cases seeking treatment at health facilities also followed the discontinuation of chloroquine holders services due to change of first line drug used to treat malaria. The newly introduced first line drug, Coartemether is a registered as a prescription only drug and can only be dispensed by nurses and doctors for the time being. The thresholds being used were calculated using health facility data only (excluding cases which were being treated by

Community based Workers) were an underestimate of the true malaria burden and have thus been easily exceeded, as all those cases which were previously being seen by the VHW are all coming to the health facilities. Whilst the IRS coverages for the past spraying season were high (86% for both Room and population coverages) and over 500 000 LLINs have been distributed in these disticts the behaiour of the community members (sleeping outside sprayed structures, and not using LLINs cosnistently) in some areas and reduced population immunity because malaria seasons have been light in recent years could also explain some of the outbreaks.

Case Management training has taken place and is continuing in all provinces. Coartemether and RDTs have been distributed to affected health facilities. In some districts temporary treatment camps have been set up in affected areas that are far from static health centres. In some cases larviciding is also being used to control the epidemics. EHTs and other health staff have been deployed in affected areas.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4 Annex 1: Summary Tables

Table 1: Cumulative Cholera cases and deaths reported by district as of week 19, 2010

District Suspected Confirmed Discarded Total Deaths Attack Suspected Confirmed Cases Cases Cases Cases Rate/100000 Cases Cases reported Reported this week this week Shamva 0 0 2022 0 1.88 Harare 020 Urban 0 0 2 0 0.13 Bulilima 0 0 0101 0 0.99 Chimanimani 200 0 0 2 1.65 Bindura 0 0 04040 2.6 Makonde 0 0 31040 1.4 Mwenezi 0 0 0505 0 3.66 Masvingo 0 0 91 10 1 3.5 Chivi 0 0 11 2 0 13 0 7.71 Beitbridge 16 1 0 0 0 17 0 15.14 Chegutu 0 0 19 13 32 2 13.12 Chiredzi 0 0 45 9 0 54 2 21.31 Buhera 0 0 66 1 0 67 0 28.12 Kadoma 0 0 136 24 0 160 4 62.55 Hurungwe 0 0 165 4 169 5 54.51 Uzumba 300 Maramba Pfungwe 0 31 0 0 477 68 2 545 15 12.52

Table 2: Age and Sex breakdown of cumulative cholera linelisted cases for the period week 17, 2010

Under 5 30 Years and Years 5-14 Years 15-29 Years over F e F F M m M e M e M a a a m a m a l l l al l al l Fem District e e e e e e e ale Chiredzi 2 2 5 3 6 9 6 8 Chivi 1 1 2 4 Harare 2 Masvingo 1 2 3 Mwenezi 1 2 1 Beitbridge 1 Total 2 2 5 4 6 12 2 16

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 5

Table 3: Distribution of Measles IgM Positive by Agegroup and District of residence since September 2009-16 May, 2010

District < 9 9 -12 1-5 5-14 >14 TOTAL Pop Attack months months years years years Rate Per 100 000 Beitbridge 0 0 2 2 0 4 112318.2 3.56 Bikita 0 0 2 6 0 8 169943.5 4.71 Bindura 0 2 2 0 1 5 190440 2.63 Binga 0 1 0 2 0 3 129951.5 2.31 Bubi 1 0 2 7 3 13 51323.12 25.33 Buhera 0 1 3 2 0 6 235934.1 2.54 Bulawayo 7 6 2 5 2 22 732715 3 Centenary 0 0 0 1 0 1 116707 0.86 Chegutu 1 0 3 7 0 11 243812.8 4.51 Chikomba 1 1 2 3 0 7 130211.4 5.38 Chimanimani 0 0 1 1 2 4 124850.1 3.2 Chipinge 0 0 2 5 2 9 304263.4 2.96 Chiredzi 1 0 0 0 0 1 250901.1 0.4 Chirumanzu 0 0 0 3 0 3 76266.68 3.93 Chitungwiza 1 0 0 4 1 6 346578.5 1.73 Chivi 1 0 2 1 0 4 168535.8 2.37 Gokwe north 0 0 0 2 0 2 232120.1 0.86 Gokwe south 1 1 5 12 1 20 317948.4 6.29 Goromonzi 1 1 1 6 0 9 167043.6 5.39 Guruve 1 0 0 1 0 2 200652.3 1 Gutu 0 0 2 5 0 7 214986 3.26 0 1 0 0 2 3 140794.1 2.13 Gweru 1 0 0 2 0 3 243793.3 1.23 Harare 29 17 13 42 30 131 1579679 8.29 Hurungwe 2 1 2 3 0 8 310019.7 2.58 Hwange 3 0 1 0 5 9 109303.6 8.23 Hwedza 0 0 3 5 0 8 76533.06 10.45 Insiza 1 0 0 3 0 4 92716.36 4.31 Kadoma 1 0 1 5 0 7 253273.8 2.76 Kariba 0 0 0 2 1 3 63665.48 4.71 Kwekwe 1 0 2 4 0 7 271330.7 2.58 Lupane 1 1 0 0 2 4 106843.3 3.74 Makonde 0 0 2 3 1 6 125731.5 4.77 Makoni 1 0 6 3 2 12 268541 4.47 Mangwe 0 1 0 1 1 3 84638.25 3.54 Marondera 2 0 2 6 1 11 111350 9.88 Masvingo 1 1 0 2 0 4 210579.9 1.9 Matobo 0 0 0 2 1 3 107985.7 2.78 Mazowe 1 0 0 2 1 4 211078 1.9

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 6 Mt darwin 0 0 1 5 0 6 216558.3 2.77 Mudzi 0 0 1 3 0 4 137419.9 2.91 Murehwa 0 1 0 4 1 6 175603.6 3.42 Mutare 1 0 2 4 1 8 421187.3 1.9 Mutasa 0 0 3 4 0 7 180453.7 3.88 Mutoko 0 0 2 2 1 5 175603.6 2.85 Mwenezi 1 1 2 1 0 5 136697.7 3.66 Nkayi 0 0 0 0 1 1 121525.8 0.82 Nyanga 1 0 3 1 2 7 125739 5.57 Rushinga 0 0 1 2 0 3 72753.89 4.12 Seke 2 0 6 6 2 16 83296.59 19.21 Shamva 0 0 0 1 0 1 106139.4 0.94 Shurugwi 0 0 1 1 0 2 95713.7 2.09 Tsholotsho 0 0 0 1 0 1 129597.4 0.77 Umguza 1 0 0 2 1 4 80169.3 4.99 Umzingwane 0 1 0 1 0 2 200444.4 1 UMP 0 1 3 3 4 11 91798.37 11.98

Zaka 2 0 3 1 1 7 200444.4 3.49 Zvimba 1 2 3 6 1 13 239054.7 5.44 Zvishavane 0 0 8 13 1 22 110566.1 19.9 TOTAL 69 41 102 221 75 508 11986126 4.24

Table 4: Distribution of Confirmed measles cases by agegroup by district reported in week 18, 10-16 May 2010.

District < 9 months 1-5 years 5-14 years >14 years TOTAL Beitbridge 0 0 1 0 1 Harare 1 0 0 2 3 Kariba 0 0 0 1 1 Rushinga 0 0 2 0 2 Zaka 1 3 0 1 5 TOTAL 2 3 3 4 12

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7

Table 5: Distribution of Community and Institutional Measles Deaths attributed to

Measles as of 16 May 2010

Community Institutional Total District Deaths Deaths Deaths Bikita 11 0 11 Bindura 10 0 10 Buhera 92 4 96 Chegutu 2 0 2 Chimanimani 3 0 3 Chipinge 3 0 3 Gokwe North 18 1 19 Gokwe South 6 0 6 Goromonzi 46 0 46 Insiza 4 0 4 Kadoma 1 0 1 Makoni 24 5 29 Marondera 20 0 20 Mudzi 31 0 31 Murehwa 50 0 50 Mutare 47 0 47 Mutoko 46 0 46 Mutasa 10 0 10 Nyanga 9 0 9 Seke 17 2 19 UMP 55 0 55 Total 505 12 517

Table 6: Some Key Measles Indicators as of 2 May 2010

Indicator Value

Suspected Cases 7 754

Blood Specimens received by Laboratory 1 401

Confirmed Cases 508

Deaths 517

Districts with laboratory confirmed outbreaks 50 Affected

Overall Attack Rate of Lab Confirmed cases 4.2/100 000

Confirmed Cases that were vaccinated 50

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8

Table 7: Vaccination Status of Measles Cases by District

Not District Unknown Vaccinated TOTAL Vaccinated

Beitbridge 0 10 8 18 Bikita 0 27 1 28 Bindura 0 10 3 13 Binga 03912 Bubi 0 14 3 17 Buhera 788 586 1 1375 Bulawayo 0522072 Bulilima 0202 Centenary 0314 Chegutu 0 19 5 24

Chikomba 0 18 7 25 Chimanimani 0 12 1 13 0112 Chipinge 0 30 7 37 Chiredzi 0101 Chirumanzu 0505 Chitungwiza 1 74 8 83 Chivi 0 12 4 16 Gokwe North 0 275 26 301 Gokwe South 0 54 1 55 Goromonzi 50 86 18 154 Guruve 08210 Gutu 0 12 0 12 Gwanda 06713 Gweru 0 19 3 22 Harare 36 1632 222 1890 Hurungwe 1 10 2 13 Hwange 0 10 8 18 Hwedza 0 20 3 23 Insiza 0516 Kadoma 0671279 Kariba 0303 Kwekwe 0552782 Lupane 0 11 3 14

Makonde 0 27 4 31 Makoni 0 229 5 234 Mangwe 0325 Marondera 0841296 Source: Ministry of Health and Child Welfare Rapid Disease Notification System 9 Not District Unknown Vaccinated TOTAL Vaccinated

Masvingo 0 17 6 23 Matobo 0022 Mazowe 0 11 7 18 Mberengwa 0202 Mt Darwin 0 10 4 14 Mudzi 55 39 7 101 Murehwa 7 10 5 22 Mutare 0 205 2 207 Mutasa 0 56 2 58 Mutoko 16 17 0 33 Mwenezi 0628 Nkayi 0448 Nyanga 0 35 7 42 Rushinga 0516 Ruwa 0303 Seke 11 1296 225 1532 Shamva 0303 Shurugwi 06713 Tsholotsho 01910 Umguza 09312 UMP 460 10 5 475 Umzingwane 0314 Zaka 0101 Zvimba 0 37 9 46 Zvishavane 0 36 1 37 TOTAL 1425 5317 746 7488

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 10 Annex 2: Maps

Map 1: Comparison of cumulative cholera cases by district as of week 19, 2009 and 2010

2010 2009

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 11 Map 2: Comparison of Cumulative Measles IgM positive cases and Suspected Measles case by district reported this year, as at 16 May 2010

Confirmed Cases Suspected Measles Cases

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 12

Map 3: Distribution of Cumulative Typhoid Cases in Harare as of week 19, 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 13

Map 4: Distribution of Malaria Outbreaks as of week 19, 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 14 Annex 3: Graphs

Graph 1:Ranking of District Cumulative Cholera Cases Reported as at week 18, 2010

Hurungwe

Kadoma

Buhera

Chiredzi

Chegutu

Beitbridge

Chivi

Masvingo District Mwenezi

Makonde

Bindura

Ump

Shamva

Chimanimani

Harare Urban

0 20 40 60 80 100 120 140 160 180 Cholera Cases

Graph 2: Cumulative Cholera Cases by week for the years 2009 and 2010

Last Epidemic Cases Present Epidemic Cases

9000 200

8000 180

160 7000

140 6000

120 5000 100 4000 80

2008/2009 Cholera2008/2009 Cases 3000 Cholera2009/2010 Cases 60

2000 40

1000 20

0 0 w34 w35 w36 w37 w38 w39 w40 w41 w42 w43 w44 w45 w46 w47 w48 w49 w50 w51 w52 w53 w1 w2 w3 w4 w5 w6 w7 w8 w9 w10 w11 w12 w13 w14 w15 w16 w17 w18 w19 w20 w21 w22 w23 w24 w25 w26 w27 w28 w29 w30

Epi Week Number

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 15

Graph 3:Cholera Epidemic Curve Week 5-Week 18, 2010

200

180

160

140

120

100

Cholera Cases 80

60

40

20

0 123456789101112131415161718 Week of Onset

Graph 4:Ranking of Confirmed Measles Igm Cases by District Reported from September 2009 to 9 May 2010

140

120

100

80

60

40

20

0 CENTENARY CHIREDZI NKAYI RUSHINGA SHAMVA TSHOLOTSHO NORTH GOKWE GURUVE KARIBA SHURUGWI UMZINGWANE ZAKA BEITBRIDGE BINGA CHIRUMHANZU GWANDA GWERU MANGWE MATOBO CHIMANIMANI CHIVI INSIZA LUPANE MASVINGO MAZOWE MUDZI UMGUZA BINDURA MUTOKO MWENEZI BUHERA CHITUNGWIZA MAKONDE DARWIN MT. MUREHWA CHIKOMBA GUTU KADOMA KWEKWE MUTASA NYANGA BIKITA HURUNGWE HWEDZA MUTARE CHIPINGE GOROMONZI HWANGE CHEGUTU MARONDERA UMP MAKONI BUBI ZVIMBA SEKE SOUTH GOKWE BULAWAYO ZVISHAVANE URBAN HARARE

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 16 Graph 5:Ranking of Suspected Measles Cases by District Reported from September 2009 to 9 May 2010

1600

1400

1200

1000

800

600

400

200

0 Chiredzi Zaka Bulilima Chinhoyi Matobo Mberengwa Shamva Kariba Ruwa Umguza Umzingwane Centenary Chirumanzu Gutu Hurungwe Insiza Mangwe Rushinga Nkayi Mwenezi Gwanda Lupane Chikomba Guruve Tsholotsho Chimaniman Chivi Binga Beitbridge Bindura Mazowe Shurugwi Bubi Mt Darwin Hwange Makonde Hwedza Gweru Chegutu Masvingo Murehwa Bikita Zvishavane Zvimba Chitungwiza Mutoko Chipinge Mutasa Nyanga Gokwe Bulawayo Kadoma Kwekwe Marondera Mudzi Goromonzi Mutare Makoni North Gokwe UMP Harare Seke Buhera

Graph 5:Distribution of Suspected Measles Cases by Week, as at week 18, 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 17 Graph 6:Distribution of Typhoid Cases by Day of Onset , 3 Feb -16 May 2010

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 18 Appendix 1: Case Definitions

Cholera The Zimbabwe cholera state definition states that "In an area where there is a cholera epidemic, a patient aged 2 years or more develops acute watery diarrhoea, with or without vomiting". ‘’A confirmed cholera case is when Vibrio cholerae is isolated from any patient with diarrhoea”. This is adapted from the WHO case definition for cholera. The inclusion of all ages in the case definition somewhat reduces specificity, that is, inclusion of more non-cholera childhood diarrhoea cases. It, however, does not impede meaningful interpretation of trends. Teams should monitor any shift in the age distribution of cases, which might indicate a changing proportion of non-cholera cases among patients seen.

Influenza A H1N1 Influenza A and B are two of the three types of influenza viruses associated with annual outbreaks and epidemics of influenza. Only influenza A virus can cause pandemics. The Zimbabwe IDSR technical guidelines define influenza case by a new sub type (including Avian flu Influenza A H5N1 and Swine flu Influenza A H1N1) as; ‘’Any person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing AND notion of exposures in the 7 days prior to symptom onset.’’

Probable case definition: Any person meeting the criteria for a suspected case AND positive laboratory confirmation of an influenza A infection but insufficient laboratory evidence for H1N1 infection.

Confirmed H1N1 case: A person meeting the criteria for a suspected or probable case AND a positive result conducted in a national, regional or international influenza laboratory whose H1N1 test results are accepted by WHO as confirmatory.

There may be difficulty in telling apart mild cases of pandemic influenza from the seasonal influenza.

Suspected measles:

Any person with fever and maculopapular rash and cough OR Coryza (running nose) OR conjunctivitis (Red eyes) OR clinician suspects measles.

Measles Outbreak Definition:

A suspected outbreak is where you have a cluster of at least 5 suspected measles cases in a facility or district within a month whilst a confirmed outbreak is where you have a cluster of at least 3 confirmed measles IgM positive cases.

Lab confirmed: Suspected case of measles with positive serum IgM antibody, with no history of measles vaccination in the past 4 weeks.

Confirmed by epidemiologic linkage: Suspected case of measles not investigated serologically but has possibility of contact with a laboratory-confirmed case whose rash onset was within the preceding 30 days (same / adjacent districts with plausible transmission) Source: Ministry of Health and Child Welfare Rapid Disease Notification System 19

Typhoid

Suspect Typhoid Case: Any person with gradual onset of steadily increasing and then persistently high fever, chills, malaise, headache, sore throat, cough, and sometimes abdominal pain and constipation or diarhoea.

Confirmed Typhoid case: Suspect case confirmed by isolation of Salmonella Typhi from Blood, Bone marrow, bowel fluid or stool.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 20