Glimpses of IDSP Works, West Bengal Done by IDSP Units in WB, 2011

2012

Glimpses of IDSP works, West Bengal Done by IDSP units in WB, 2011

Team IDSP, SSU Swasthya Bhaban 3/28/2012

Preface

This is a presentation of cumulative efforts of work done by the State Surveillance Unit along with all District Surveillance Units across West Bengal working in tandem for IDSP as a team. The compiled works which relates to the range from Outbreak Investigation, Data Management up to the stretch of detailed Entomological Survey and Lab Investigations. The compilations are fetched from the experience and /or achievements discussed by the various units of the State at Annual Meet 2012 held at Swasthya Bhaban.

The presentation is also enriched with varied techniques, though as we say “Team Work”, it ultimately comes to a nut shell and published as a collaborative artifact.

Hope this would help the readers for better understanding of not only the works of IDSP but a common message to all-

“TEAM WORK”…

We recognize and commend the diligent input of the Team IDSP SSU, WB lying behind this compilation. Without them letting their hair down, this publication would not have materialized...

Addl. DHS( PH & CD)

& State Surveillance Officer, IDSP, West Bengal Index

Article Page No.

Role of IEC and BCC in controlling Chikungunya outbreaks, Jalpaiguri: An experience in 2011 ------1-2

Outbreak Trend Analysis of Anthrax in Murshidabad from 2007-2011: A brief epidemiological report ------3-4

Epidemiological investigation of repeated Dengue and Chikungunya outbreaks at Domjur, Howrah, 2011 5-6

Japanese Encephalitis surveillance under IDSP, Darjeeling, 2011 ------7-8

Epidemiological investigation identified the main source……...a diarrhoeal outbreak in Malda , 2011 -- 9-10

Inclusion of Municipalities & Pathological Lab.(Pvt.) makes a difference………………... Nadia, 2011 --- 11-12

An evaluation of IDSP activities; ……….knowledge & practices of the health workers, Hooghly, 2011 -- 13

Community behavior - a major factor behind Cholera outbreak, Bankura , 2011 ------14-15

Identification of a cluster of kala-azar cases pre-empted an outbreak in a tribal village, Birbhum, 2011 - 16-17

Investigation determined contaminated water …….cause of a diarrhoeal outbreak at Burdwan , 2011 -- 18-19

Improvement in IDSP reporting and performance, Cooch Behar, 2011 ------20-21

Rapid response to a food-borne diarrhoeal outbreak in “Badamile Mission”, Dakshin Dinajpur, 2011 --- 22-23

Consistency of the reporting units…: A success story of KMC, 2011 ------24

Investigation detected Vibrio parahaemolyticus in a food poisoning outbreak in North 24Pgs, 2011 ----- 25-26

Impact of intervention of LLIN in a Malaria Endemic block, Paschim Medinipur, 2009 – 2011 ------27-28

Unknown fever in Bhagawanpur-I Block, Purba Medinipur, 2011 ------29-30

An effort to improve IDSP reporting by reporting units and maintaining its consistency: Purulia , 2011 - 31-32

A search for the gaps in data reporting for improvement in malaria surveillance, South 24 Pgs, 2011 -- 33-34

Implication of case definition and consistency of reporting in generation of EWS, Uttar Dinajpur, 2011 35-36

The scenario of Cholera disease in West Bengal over the last three years ------37-38

Man-made containers…………..are major causes for VBDs: Entomological experience in WB, 2011 --- 39-40

Role of IEC and BCC in controlling Chikungunya outbreak, Jalpaiguri: An experience in Jalpaiguri, 2011 Dr. Debasis Mandal1, Satinath Bhuniya2, Aparna Dutta3

1. Dy CMOH-II, Jalpaiguri, 2. Epidemiologist, DSU, Jalpaiguri; 3. Data Manager, DSU, Jalpaiguri

Background: An outbreak of chikungunya fever characterized by joint pain, swelling and or rash occurred in the Tuslipara Tea Garden area (between 26047’36”N and 089012’26”E, altitude-700ft.) under Madarihat block of Jalpaiguri district, West Bengal near Bhutan International Boarder in the month of November 2011. Information of fever outbreak was reported by the Block Health department to the District Surveillance Unit within 48 hours of the onset of the outbreak. Subsequently dengue and chikungunya outbreak was also reported from the adjoining three Tea Garden areas of the same block situated in lower altitude (409 ft.) in the month of December 2011. This report illustrates in brief the results of epidemiological & entomological investigation and control measures undertaken during the chikungunya outbreak at Tulsipara Tea Garden area. Methods: (i) House to house search of fever cases was done and along with line listing during the outbreak. (ii) Blood samples were collected from suspected chikungunya/ dengue cases for lab confirmation at the School of Tropical Medicine, Kolkata, WB. (iii) Entomological investigation like larval survey was conducted in the affected area in consecutive four weeks. Containers cleaning in a weekly pulse mode along with larval survey were done during the period. Video clipping of the larvae collected from the containers was sent to the CRME-ICMR, Madurai and State Entomological section, IDSP, WB for confirmation. Preserved adult mosquitoes were used for species identification by the Scientist of CRME. Results: A number of 780 suspected Chikungunya cases were reported from Tulsipara Tea Garden locality within a period of 39 days with an attack rate of 17.8. Amongst the cases 52% are female

Fig: Epi-curve of Chikungunya Outbreak at Tulsipara TG (N=780) 140 Treatment & IEC

120 Pulse cleaning started cleaning & spray 100 started

60 No case found No. of cases of No. 40

5/11/2011 8/12/2011 3/11/2011 7/11/2011 9/11/2011 2/12/2011 4/12/2011 6/12/2011

11/11/2011 13/11/2011 15/11/2011 17/11/2011 19/11/2011 21/11/2011 23/11/2011 25/11/2011 27/11/2011 29/11/2011 31/11/2011 10/12/2011 12/12/2011 14/12/2011

Date and remaining 48% are male. More than 50% of the cases occurred within 9 days of the onset of outbreak.

Serologically, one sample out of ten was found to be Chikungunya reactive from Tulsipara Tea Garden area.

After one month another five samples out of ten from adjoining three TG areas were found to be only 1

Chikungunya IgM reactive and four samples found both Chikungunya and Dengue IgM reactive at the School of Page

Tropical Medicine, Kolkata. Entomological investigation reveals that the main breeding sources of the mosquitoes were the domestic and peri-domestic containers like cement tanks, plastic containers, metal containers, tyers, earthen pots, tree stumps and discarded containers. Aedes aegyptii was predominantly present in the outbreak affected area. Initially the House Index was 78.43% and Container Index was 80.88% and both were extremely higher than the threshold values. Both the indices started to decline with continuous containers cleaning in a weekly ‘Pulse’ mode, as a result number of cases also started to decline.

Fig: House Index, Container Index and Fever cases during conjecutive cleanings at Tulsipara TG, Madarihat, Jal

HH Index Container Index No. of Cases in between two cleanings 90.00 426 450 80.00 400 70.00 350 60.00 227 300 50.00 250 40.00 200 30.00 75 150 20.00 100 Index (%) Index 41 10.00 11 50 cases Fever of No. 0.00 0 1st Cleaning: 1st Pulse: 2nd Pulse: 3rd Pulse: 4th Pulse: 11th Nov'11 22nd Nov'11 29th Nov'11 6th Dec'11 13th Dec'11

Container No. of HH found positive for larvae Date of Cleaning HH Index Index House Index = ------× 100 1st Cleaning: 11th No. of HH inspected Nov'11 78.43 80.88 1st Pulse: 22nd Nov'11 43.41 44.19 No. of containers found positive for larvae 2nd Pulse: 29th Nov'11 2.95 2.82 Container Index = ------× 100 3rd Pulse: 6th Dec'11 0.52 0.47 No. of containers inspected 4th Pulse: 13th Dec'11 0 0

Discussion & conclusion: To our best knowledge this outbreak of chikungunya was reported for the first time in the health record of Jalpaiguri. The causative organism was probably imported from some local migrant labours, working in Kerala (which is an endemic district for chikungunya), who had visited their native place of the affected block of the village during the Diwali celebration. High density of Aedes aegyptii and its profuse available of breeding site played a major role in rapid transmission of chikungunya in the affected area. Prompt control measures indicate that the ‘weekly pulse cleaning’ and covering all the potential (man-made) breeding sites of mosquitoes played a crucial role in controlling the transmission of the disease in the outbreak affected area within a month with a comparatively decreasing attack rate. Applying the same strategy another Dengue-Chikungunya outbreak in the adjoining three Tea Garden areas was controlled within a short time with an attack rate of less than three per hundred populations.

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Outbreak trend analysis of Anthrax in Murshidabad from 2007-2011: A brief epidemiological report.

Dr.B.P Shaw1, Nizamuddin Mondal2

1. Dy CMOH-II, Murshidabad, 2. Epidemiologist, DSU, Murshidabad;

Murshidabad is one of the large districts in Mid Bengal, surrounded 110 km by Bangladesh in the East, and 50 km by Jharkhand at North East, Nadia & Burdwan in South, Birbhum in the West and Malda and the Ganges in the North (Padma & Bhagirathi). Heavy rainfall, hot humid weather and mostly alluvial soil have made this district a victim of vector borne diseases. District has a very poor rank (15th out of 17) in the Human Development Index (HDI). In the Gender Development Index (GDI) its rank is 16th out of 17.

The district has been reporting cutaneous anthrax on regular basis for the last 10-12 yrs. From the period 2007 to 2011, 532 cutaneous anthrax cases have been reported. All these cases have been reported from 10 blocks out of 26 blocks. Nearly 26 Gram Panchayets have been affected, some of the Gram Panchayets have reported a single outbreak and some of them have reported more than 5 outbreaks

Fig-1: Reported anthrax cases 2007-2011, Murshidabad

45 250 40 35 200 30 150 25 20 100 15

10 50 5 0 0

Jalngi Kandi Domkol Nowda Berhampur Nabagram Raninager-IRaninager-II Hariharpara Bhababangola-1

No. of Outbreak Average case / outbreak No. of cases

Fig-2: Block wise outbreak and reported cases 2007-2011 in the last 5 yrs

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Fig- 3: Month wise outbreak and cases peroutbreak, 2007-2011, Murshidabd

Salient observation: Maximum number of cases Table- 1: Age and sex distribution of cases of anthrax (225) reported in the year 2007(figure-1). Domkol outbreaks, Murshidabad District, 2007 to 2011 Age Male Female Total % of all had been badly affected in this period (225) cases group (in cases (figure-2) followed by Hariharpara. Least affected years) block was Jalangi which had reported only 9 cases 0 to <5 7 3 10 1.8 5 to<10 15 15 30 5.6 in this period. Figure 3 reflects an interesting 10 to <15 25 17 42 7.8 finding. Analysis of the outbreak trend over the last 15 to <25 71 51 122 22.9 5 years reveals that highest number of outbreak 25 and > 197 131 328 61.6 with higher number of cases has been reported Total 315 217 532 100 mainly in the month of July when compared to outbreaks occurring in January – April period or Oct-Nov period. This indicates a seasonal pattern of the disease. Interestingly no report of outbreak has been found in the month of December. Age and gender analysis reflects, males are mostly affected (may be due to the high risk of exposure) and adult age group are reported to be more affected, though 15% cases have been found below 15yrs age group, is a matter of concern and it explains the socio- economic status of the district.

Recommendation: The above observation suggests that continuous ingenious transmission might be an important factor of the outbreak though importation from other parts of the district or neighbouring states should be considered. Butchering, lynching of dead animals and preparation of hide are done usually by males. This is a possible explanation for the predilection of cutaneous anthrax for males, hence awareness to the villagers a)regarding handling of the meat, b) how to handle the domestic animals and the symptomatic features of their illness c) how to dispose the diseased dead animals is strongly recommended.

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Epidemiological investigation of repeated Dengue and Chikungunya outbreaks at Domjur, Howrah, 2011

Dr.Prasun Das 1 Dr.Suchandra Mitra (Chaudhury)2,

1. Dy CMOH-II, Howrah 2. Epidemiologist, DSU, Howrah

Introduction and Background: Of all the vector borne diseases, Dengue and Chikungunya are very common. Both dengue and chikungunya are Aedes mosquito transmitted viral disease. Chikungunya is self-limiting but debilitating non-fatal disease whereas Dengue becomes dangerous and life-threatening in its severe form. Regular cases of dengue and chikungunya are being reported every year from Howrah district. In Howrah District, in 2009 one Dengue and Chikungunya outbreak had been reported and 3 blocks namely Domjur, Bally Jagacha and Panchla were affected. In 2011 the Domjur block with some adjacent areas of Panchla block had again suffered a severe Chikungunya/ Dengue outbreak affecting a population of 229. . Table:1 Objectives: Estimate the magnitude of the outbreak, manage the cases and propose recommendations.

Methods: On 5th September 2011 one fever outbreak from vill.Harisabha, SC-South Jhaparda, Block-Domjur had been notified. We initiated epidemiological investigation on 7thSeptember.Descriptive epidemiology of the disease is studied to control transmission, and recommend control measures of the disease. Data Collection: Data collected on the basis of age, sex, date of onset, symptoms and signs, outcome following the cases definition (Acute fever of 2-7 days duration with at least two of the following : Arthralgia, rash, headache and haemorrhagic manifestations) Data Source: Door to door case search and two health camp organised by Block Health Authority with the help of District Health Authority. Entomological Surveillance data, conducted by State Surveillance unit also collected. Data analysis by time, place and person are given as following: Result & Observation: Laboratory reports: Total 61 samples collected and all the serum samples are tested at School of Tropical Medicine, Kolkata. Out of 61 samples 13 reactive for Dengue and 11 reactive for Chikungunya.

Table:2

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Some Epidemiological observation and analysis:

Distribution of cases by date of fever onset, Domjur, Howrah, West Bengal, 2011

Fig:1 Fig:2(above) & Fig:3(below) Entomological Surveillance Reports:Positive water containers with Aedes albopictus larvae and water logged ditches were found, also water immersed paddy fields were observed by SSU Entomological surveillance team.

Table:3(below)

Discussion: The Domjur and Panchla block of Howrah district are highly endemic. Regular high number cases with dengue/ chikungunya outbreak are repeatedly reported from the blocks. Fig 2: indicates, that the15-45 age group and males in compare to the females are mostly affected. High HI, CI, BI index (Fig 4) indicates the presence of potential breeding sources and chance of high transmission. Recommendations:

a) Strengthen vector control measures through environment management i.e. source reduction-detection & elimination of mosquito breeding sources by management of roof tops, and sunshades .Proper covering of stored water containers, Removal of disposable containers, etc. b) Personal protection, Biological control (Use of larvivorous fishes in ornamental tanks, fountains, etc), Chemical control(Use of chemical larvicides like abate in big breeding containers and Aerosol space spray during day time).c) Conduct IEC / BCC for community mobilization and inter-sectoral convergence . d) Strengthen active surveillance of fever cases and capacity building for better case management. Conclusion: Repeated outbreak of dengue and chikungunya affected parts of Domjur and adjacent areas of Panchla block of Howrah district, in 2009 and again in this year (between August and October 2011) during the immediate post monsoon period. Several containers on the domestic and peri-domestic areas were found to be positive. Regular surveillance of fever, fortnight entomological surveillance along with IEC and BCC is required to control

transmission and prevent outbreak of dengue and chikungunya in these endemic blocks of Howrah district. 6

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Japanese Encephalitis surveillance under IDSP, Darjeeling, 2011

Dr. Tulshi Pramanik1,Dibyendu Bhatta2

1. DY.C.M.O.H II, Darjeeling, 2. Data Manager, DSU, Darjeeling

Demography: a) Location Latitude: 27.13°N to 26.27°N, Longitude- 88.53°E to 87.59°E b) Area 3,194 Sq Km c) Population 17,98,260(2011 estimate) d) Sub-Divisions 4( 3 in Hills) e) Municipal Bodies 5 ( Including one corporation in Siliguri) f) Blocks 12 ( SMP-4; DGHC-8) g) Gram Panchayats 134 (SMP-22; DGHC-112) h) Health Infrastructure 2 DH( Darjeeling DH, Siliguri DH), 2 SDH( Kalimpong & Kurseong SDH), 12 BPHCs, 22 PHCs i) Subcentres 246 (SMP-63; DGHC-183)

Two suspected cases reported from a private hospital in Siliguri on 06-07-11 through the weekly IDSP reporting system. CSF & Serum samples were sent to Virus unit of NICED, Kolkata (ICMR). Lab confirmation of 1 case as JE (Japanese encephalitis) was reported on 09-07-11. She belonged to the district of Coochbehar. SSU and Dy.CMOH-II, Coochbehar were notified immediately. Field investigation held in the area of the other case was found to be a resident of Siliguri. All Private & Govt Hospitals again directed to report AES cases immediately to the IDSP cell apart from routine weekly reporting. Arrangements put in place to send clinical samples on a weekly basis with flexibility to send on a daily/alternate day basis as per need. AES Sentinel surveillance strengthened at NBMC&H with active support of the departments of Community Medicine, Microbiology, Medicine and Paediatrics. Meeting held with Siliguri Municipal Corporation and Malathion provided to them. Reports of lab confirmed JE and line list of AES cases from other districts admitted at NBMC&H & Pvt hospitals regularly communicated to respective districts. 620 cases of AES, were reported from NBMC&H in 2011.

JE Surveillance Report during the year 2011:

Sample No of JE +ve Positivity Rate(%) Death due to JE CFR(%) Collection Cases 144 37 25.7 3 8.1

Place distribution of JE +cases during the Year 2011:

14 12 10 8 JE +ve Cases 6 4 No of +ve Case +ve of No 2 0 Darjeeling Jalpaiguri Cooch Behar U Dinajpur D Dinajpur Malda Nepal Assam

Name of the Place

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Action Taken:  One JE confirmed case from Pelkujote of Kawakhari Sub-centre of Matigara block in Darjeeling district  Community survey done: 350 houses visited . > 95% had bed nets and used daily. LLIN given to the households having no bed nets . No piggery found in the vicinity . Ducks reared in 21% of the households . The JE patient was alive but had residual paralysis  Fever surveillance done . 18 fever cases – all negative for malaria ; no feature of JE in them.  IRS done with DDT.  Awareness drive involving Panchayat functionaries.

Entomological Survey : An entomological survey for Japanese Encephalitis in North Bengal was done by a CRME team from Madurai. They collected 18 species of mosquito out of which only one species, “Culex pseudovishnui”, collected from Khuthirampally of Jalpaiguri district was found positive for JE virus.

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Epidemiological investigation identified the main source and helped control of a diarrhoeal outbreak in Malda District, 2011 Dr. Rabiul Islam Gayen1, Arun Baidya2, Mamun Haque3 1. Dy CMOH-II, Malda, 2. Epidemiologist, DSU, Malda, 3. Data Manager, DSU, Malda

Introduction: HCPur-II Block Block, An outbreak of acute diarrhoea occurred in Chaksatan Village in Malda dist Harischandrapur-II Block on 5th Dec 2011. The village is situated in a very remote area adjacent to Bihar border. The nearest subcenter is 9 kms away from the village. The first information was sent by the BMOH on 6/12/11. Objective: We investigated the reported outbreak in order to: (1) assess the situation,

Outbreak identify the source of infection and mode of transmission (2) suggest effective place control measures. Descriptive epidemiology: Case definition: A case of diarrhoea was defined as the occurrence of acute watery diarrhoea (passage of 3 or more loose or watery stools in the past 24 hours) in Chaksatan Village.

The District RRT and local health workers searched door-to-door for cases. We visited the index case. We collected rectal swabs from three areas and sent those to NICED, Kolkata in cold chain. The results were found as V. cholerae negative.

Environmental investigations

As the descriptive epidemiology pointed to a contaminated pond and tube wells as the potential source of the outbreak, the water contamination and sanitation situation was reviewed in a group meeting with the villagers and through our observation. We interviewed the primary case and his family to determine whether this patient could have constituted a source of infection for the community. Table-1: Attack rates of acute diarrhoea by age and sex, Chaksatan, Malda Analysis Age (years) Populn. # cases Attack Rate On comparison to surveillance data of the preceding 0-4 112 19 17.0 weeks and previous years the episode was clearly 5-9 129 15 11.6 an outbreak. The index case washed his clothes in 10-14 135 2 1.5 the contaminated pond. The tube wells were 15-44 485 2 0.41 unprotected and no single tube well in the village >45 196 5 2.6 had a platform and a brim. Sex Distribution Male 548 23 4.2 Female 509 20 3.9

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Forty-three cases were identified among the 1057 residents of the village (attack rate 4.0%). There were two deaths with no or quack treatment before our investigation. All the cases had watery stools while some of them had vomiting also. A few cases had pneumonia. None had blood in stools. The attack rate was high among children below 10 years and in the elderly. There was no such difference by sex, although males had a slight higher attack rate (Table-1). Fig. 1.1: Acute Diarrhoeal cases by Date of Onset, th Chaksatan village, M alda, Dec 2011 (n=43) There was an initial case on 5 December, followed by a 14 rapid increase in the number of cases leading to a peak 12 10 th on 9 December and then a sharp decrease (Fig. 1.1). 8 This led to suspect a common source of the outbreak. 6

No.of cases 4 2 Most of the cases were clustered near the ‘C’ pond 0 located close to the residence of the index case-patient 5/12 6/12 7/12 8/12 9/12 10/12 11/12 12/12 13/12 14/12 15/12 16/12 (Fig. 1.2). The index case’s family told that Date of Onset he soiled his clothes and washed those clothes in that pond on 05.12.11. Though Fig. 1.2: Spot Map of outbreak Chak Satan Village the location of some of the diarrhoea C Pond cases suggested contaminated tube wells C PAD to be the source of infection, cases were PAD DY DY drastically reduced only after the use of C- FIEL Kacc FIEL pond was strictly stopped on 09.12.11. D ha D Thus, the main source of the outbreak Road seemed to be the contaminated pond. P o PADn Control measures: DYd PAD FIEL Tube wells were disinfected. Disinfection DY Pra D D was tried also for the contaminated pond, FIEL ma a Le nik Affecte although on the basis of our observation D s d House Par 2ge p (4 use of the pond had to be banned later. A a Personnd a 1 ) Person health camp was arranged and sufficient r Unaffec(2 PAD a tedPer primary care medicine like ORS etc. was P DY o Indson kept with the ASHA. Health education was FIEL n exs) House with > 2 cases House with 2 casesd House with 1 case provided on issues like hand washing D de x practice, safety of food stuffs and water, Paddy field Pond Index case prompt use of ORS in diarrhoea and early admission of dehydrated patients in the hospital. The Gram Panchayat Pradhan was encouraged to initiate construction of brim and platform in every tube wells with proper drainage system.

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Inclusion of Municipalities & Private Pathological Laboratories makes a difference in disease surveillance, Nadia, 2011 Dr. Netai Ch. Mondol1 , Shantanu Chakraborty2 1. Dy CMOH-II, Nadia, 2. Data Manager, DSU, Nadia;

The objective of the project was to identify impending out break & containment measure accordingly & also to know the disease pattern in the community. Hence 477 Sub Centre, 79 PHC / BPHC /RH /SGH /SDH/DH / Municipality, 62 Government & Private laboratories are working as an IDSP reporting units in the district. The reporting system has been enriched after the involvement of Private Pathologies in L reporting Unit and Municipalities in P reporting unit in IDSP reporting system. In the year 2010 the reporting system covers mostly the rural areas but more than 18% population living in rural areas covered. In discussion with CMOH, a meeting with 42 pathology laboratories, 8 municipalities & 2 Notified areas has been organised & subsequently MOU has been signed. Thus all 42 private pathology laboratories as L unit & 10 Municipal/ Notified area clinic as P unit started reporting since 1st week of 2011. Also to mention that 6 private pathology labs were already involved since 2009. The annual report shows number of Fever cases, Malaria, Typhoid Fever, and Viral Hepatitis B & C has been increased almost double as compared to 2010. Details of analysis show this is due to involvement of private Pathology lab as well as Municipality in IDSP. L Register (for maintaining records of L form) & Certificate of appreciation has been given to all private pathology laboratories in a annual review meeting held in the district HQ in presence of CMOH & other district level officers. IDSP report shows, Nadia District is consistent in IDSP reporting in respect of portal reporting indicator –as PHC/BPHC are reported (P & L report) > 81.53 %, Government Hospital are reported(P & L report) >92.85%. & Private Lab are reported (L report) >100%. In the month of November & December 10 private practitioners has been identified & sensitized through a personal visit. Training of these private practitioners has been planned & after the training they will start reporting as per IDSP guideline as P reporting unit. Two sub centre – Mandia Sub centre in Chapra block & Belghoria GP HQ Sub centre in Santipur block for community surveillance pilot under IDSP. Sensitization meeting with community volunteers of two identified S/c has been done. Training will be done shortly. It is expected that the new initiative will give us an impetus on actual pattern of disease (symptom based) in this two identified community. Also a gap of regular reporting through health workers from S/C & that of from the community by the identified community volunteers to be identified. Definitely IDSP has given the district a scope to identify impending out break as well as actual disease pattern in the community through weekly reporting. Though DSU, Nadia has fulfilled more than 80% of the IDSP project, still there are gaps especially in quality issue which needs to be addressed for further improve

Achievement in 2011 at a glance  Training of 81 Medical Officers, 49 Nurses & 67 pharmacists & 38 DEO in IDSP done in 7 batches.  Sensitization cum Training of 8 Analysis on Malaria Surveillance Total Malaria Municipal Health Officers & 16 Municipal Govt Lab. Private Lab. Sl. positive Year No. Malaria Malaria Malaria Sanitary inspectors on IDSP. PV PF PV PF PV PF positive positive positive  Sensitization of 10 private practitioners 1 2009 1337 1070 267 919 773 146 418 297 121 2 2010 1451 1223 228 988 848 140 463 375 88 on IDSP through personnel visit.

3 2011 1800 1546 254 533 443 90 1267 1103 164  Involvement & inclusion of 42 private

pathology unit as L reporting unit( MOU signed).

 Involvement of Health clinics in 8 Municipality & 2 Notified Area as P reporting unit. 11 Page

 One half yearly & one annual review meeting done with all BMOH/ Supdt/ Municipality &Private Pathology Lab.  5 Sensitization meeting of 52 MOs, 45 Staff nurse, 7 DEO & 7 pharmacists done in 3 SGH & 2 SDH.  Identification of 2 Sub centre for community based surveillance & sensitization of Community volunteers from these 2 sub centre area.

Inclusion of Municipalities & Private Pathological laboratories makes a difference in disease profile as compared to previous years

Year wise Typhoid Surveillance under IDSP Trend of Malaria cases as reported by Govt. vs Pvt.in last 3 yrs( Based on L form report) units in last 3 yrs.

1400 1200 1000 12000 800 2009 10000 2010 600 8000 2011 2009 400 2010 6000 200 2011 4000 0 Govt Private 2000

0 Trend shows huge no Typhoid cases reported in 2011 by private pathology lab as compared to 2009 & 2010.

Trend of Malaria cases reported from IDSP reporting

1600 1400 1200 1000 2009 800 2010 600 2011 400 200 0 Total Trend shows huge no Malaria cases reported in 2011 by private pathology lab as compared to 2009 & 2010. Actual no. of Malaria cases found to be 3.4 times more than the no. reported from Govt. labs.

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An evaluation of IDSP activities; with respect to knowledge & practices of the Health Workers, Hooghly District, 2011

Dr. Debasish Roy1 , Mamun Islam2

1. Dy CMOH-II, Hooghly, 2. Data Manger, DSU, Hooghly

Introduction No study was undertaken regarding the Integrated Disease Surveillance Project (IDSP) since 2007 in Hooghly District. We evaluated the IDSP with special emphasis on the attributes of the system and in consistent with the knowledge, attitude and practices of the health care providers in rural areas in 2011. Methodology We sampled 132 ANMs of the subcentres by multistage sampling methodology and collected data by interviewing them by a pre-test semi-structured questionnaire during the period Oct, 2011 to Jan, 2012. We also examined the reports and registers from those subcentres, BPHCs and the District data to compare and validate the findings. We identified some indicators upon which we analyzed the data (mainly proportion of responses) Result Of the collected data, we observed the proportion of responses from the interviewee that:  74% knew the case definition,

 98.5 % timely reported the health events,

 91 % had completeness in reporting and

 Only 74% had the ability to detect the outbreak (sensitivity of the system) within expected time.

 But the reliability of the system are only 63 % (# 84 out of 132 ANMs) respectively.

Conclusion  Lack of training of health care workers, poor monitoring and supervision and failure to detect early warning signals weakened the programme.

 We recommended strengthening training and surveillance activities, monitoring and supervision.

 Distribution of educational material to the periphery will help the health care workers to detect early warning signals and transmit the information early.

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Community behaviour - a major factor behind a cholera outbreak, Bankura District, 2011

Dr.D. Roy1, Moumita Roy (Chakrabarty)2, Ripan Midya3, Apurba Bandyopadhyay4, Biswajit Patra5

1. Dy CMOH-II, Bankura 2. Epidemiologist, DSU, Bankura, 3. Data Manager, DSU, Bankura, 4. DEO, DSU, Bankura, 5. H.A.(M), Bankura

INTRODUCTION: 51 outbreaks (ADD, Food Poisoning, ChickenPox, Dengue, Chikungunya, Measles, Mumps etc.) are reported in 2011by the district, which is 26% of the state total (197). Out of 51 reported outbreaks , 33 (65%) were ADD outbreaks. Out of the 22 blocks in the district 13 blocks (59%) got affected in these outbreaks.

BACKGROUND: The present investigation was conducted at Mandarboni village under Kotalpukur Subcentre in Barjora Block. Population at risk was 2100. Date of onset of the outbreak was 11.08.2011 and date of reporting was 13.08.211. Symptoms of the patients were loose watery stools & in some cases vomiting & high fever.

OBJECTIVES: Our investigation aimed at finding the cause of the outbreak, determining the aetiology, reducing morbidity and preventing future outbreaks.

MATERIALS & METHODS: Materials required for collection of samples were- i) Sterile Rectal swab,

ii) Media Required: Carry –Blair Medium.

iii) Sterile 500 ml Container to collect water samples for MPN Count.

Specimen Collection: Rectal swabs were collected from patients with acute diarrhoea and not under treatment with any antibiotic. The samples were sent in cold chain (2- 80C) to NICED, Kolkata for lab confirmation. Water samples were collected from the suspected water sources i.e. from 2 ponds &1 tube well and then sent to PHE Lab, Bankura for MPN count.

EPIDEMIOLOGICAL OBSERVATION:  Total 193 cases occurred. Among them 47 cases were hospitalised. District RRT visited along with Block RRT.

 People between age range 0 - <10 yrs and males were more affected. Among females the age-group of 20-40 yrs were more affected.

 People were found to have the habit of open defecation and using the same pond water for washing clothes of diarrhoea patients, washing utensils, bathing cattle and practising daily morning activities (like brushing, bathing, toilet). A temporary toilet was placed at the edge of the pond.

• People dumped waste paper plates, glasses near the edge of the pond. Other kinds of biodegradable

stuffs were also heaped around.

• Tubewells which are the main source of drinking water are placed very close to cattle sheds. The place 14

was also non hygeinic and was likely to cause contamination of the tubewells. Page

RESULTS: • 1 of 2 rectal swab samples confirmed Vibrio Cholarae O1 Ogawa on lab investigation.

• 3 water Samples after lab investigation confirms T.C. : 500 / 100 ml and F.C. : 4/100 ml for TW , & T.C. : 500 / 100 ml and F.C. : 17 / 100 ml for pond & T.C. : 500/100 ml & F.C 23/100 ml for ditch.

DISCUSSION: The index case occurred on 09.08.2011. He used the pond and contaminated it. Male children of between 0-<10 years were severely affected as they used to play around the sewage drain and catch fish from the ditch or pond. Cases of age group between 10-<20 years, both male and female, were equally affected probably because most of them used the contaminated pond for bathing and other morning activities. In the age group of 20-<50 years female patients were more affected probably because most of them were housewives and used the pond water for washing clothes, utensils and other activities.

ACTION TAKEN: People were not aware about personal hygiene and as because the pond was used for fisheries so villagers refused disinfecting the pond. After that our District RRT along with Block RRT prepared bleaching powder sachet & distributed the same to the villagers. They instructed them not to use the tube well water for drinking purpose until disinfected. But as there was no other drinking water source, so after talking to the Gram Panchayet, temporary alternative arrangement for drinking water had been done. Case management was done in the village. Tube wells were disinfected. Health education was imparted regarding proper sanitation, hygiene and food habit.

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Identification of a cluster of kala-azar cases pre-empted an outbreak in a tribal village, Birbhum District, 2011 Dr. Dilip Kr. Dutta1 ,Prabhakar Sarkar2, Sudip Basani3 1. Dy CMOH-II, Birbhum, 2. Epidemiologist, DSU, Birbhum, Data Manager, DSU, Birbhum

I. General Information: State: West Bengal, District: Birbhum, BPHC: Mollarpur, Block: Mayureswar-I, SC: Ghoshgram, Vill: Ghoshgram (Adibasipara) II. Background Information: Source of information- Kala-azar Treatment Supervisor. Affected area: Vill- Ghoshgram (Adibasipara), SC- Goshgram, GP- Baroturigram, Mayureswar-I Block. Date of Investigation: After receipt of information by DSU, Birbhum from Kala-azar Treatment Supervisor on 23.11.11, District RRT visited the affected area with Block RRT on the same day. Total Population: 123, Total Kala-azar cases: 10 (Male: 8, Female: 2). III. Case Definition of Kala-azar:  A persons in Adibasipara of Ghoshgram SC area with fever for more than two weeks duration not

responding to anti-malarials and antibiotics with splenomegaly was a suspected case of Kala-azar.

 A suspected case who tested positive on rK39 test was taken as a confirmed case.

IV. Details of Investigation: During the period of Kala-azar fortnight from 01st Nov to 14th Nov 2011 fever cases were reported from Ghoshgram SC. On 17th Nov-2011 two persons suffering from fever for few days were tested with rK39 and found positive. After that day few more fever cases reported. They were all agricultural labour. On 23rd Nov- 2011 after receiving information from Kala-azar Treatment Supervisor, BMOH of Mollarpur BPHC made necessary arrangements for rK39 tests in Mollarpur BPHC. On that day 15 fever cases were tested with rK39, out of which 8 cases were found positive. Cases presented with anaemia and weight loss also and some of them with swelling of abdomen and blackening of the skin. None of the cases had any history of migration. No PKDL case was detected.

V. History of Kala-azar in Mayureswar-I Block & Ghoshgram (Adibasipara): First Kala-azar case detected in 2006. No cases reported in 2007, 2008 & 2009. 2 cases reported in 2010. In the month of June’2011 one case reported from Adibasipara under Ghoshgram SC, one cases reported from Kaharashibpur under Malanchi SC, in Oct’ 2011 one case found from Adibasipara under Ghoshgram SC and in Nov’2011 during Kala-azar fortnight weeks again 10 cases reported from Adibasipara under Ghoshgram SC

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VI. Descriptive Epidemiology: o Fever and Kala-azar positive cases by duration o Spot Map

Suffering from fever

Total 0 – 11- 16- 21- 26- 6-10 5 15 20 25 30 days days days days days days Fever 1 13 1 3 7 0 25 Cases Kala- azar 0 0 0 3 7 0 10

Cases o o Sex ratio of Fever Cases & Kala-azar cases

VII. Probable Factor contributing to the rise of cases:

. Socioeconomic status: Most of the people were very poor; they lived in mud house. . Many of them were addicted to alcohol and other substances.

IX. Lab investigation: Out of 25 fever cases 10 cases were found rK39 positive. X. Conclusion: The sudden finding of a lot of cases at one place indicates the need to have a regular case detection system and surveillance, in absence of which cases would accrue and present like outbreaks from time to time.

XI. Recommendations:  IRS to be done regularly.  Housing condition to be improved.  IEC should be strengthened by Health Workers.  Active surveillance and proper supervision in Kala-azar affected villages/ areas.  Early case detection and prompt treatment.

XII. Measures taken to control the Outbreak: . Health camp organized by Mollarpur BPHC. . Mass Blood Slide collection and RDK test done to exclude malaria. . rK 39 tests done on the clinically suspected cases. . 2nd Round Spray work done. . Miltefocin treatment started for all patients.

. LLIN distributed.

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Contamination of water sources – a main cause of a diarrhoeal outbreak in a rural block of Burdwan District, 2011 Dr. Sharmistha Mitra1, Sahelee Bhattacharya2 1. Dy CMOH-II, Burdwan, 2. Epidemiologist, DSU, Burdwan;

Introduction: Diarrhoea is defined as the passage of loose or watery stools more than three times in a day. In India diarrhoeal disease is a major health problem.  On 13 April 2011, a primary health centre in Belkash village (with a population of 1140 in 2011) of Borsul Block reported a cluster of acute diarrhoea with vomiting.  Next day, District RRT initiated an investigation in the notified outbreak.  The objectives of the investigation were to determine the extent of the outbreak, identify the source of infection and formulate practical recommendations for control.

Descriptive Epidemiology: Case definition: The occurrence of more than three watery stools in 24 hours among residents of the village.  RRT team: Medical officer, epidemiologist, and laboratory technicians  Case search: Active case search was done. The District and Block RRTs collected information on symptoms and personal history from the case-patients and created a line- list.  An epidemic curve was constructed to describe the development of the outbreak.  The index case was identified and his family was interviewed to explore the inititation of the outbreak.

Laboratory Procedure:  Rectal swabs were collected and were sent to the Microbiology Lab of Burdwan Medical College.  Water samples were also collected and sent to the District Public Health laboratory.  Both confirmed the presence of coliform in the samples.

Results: 154 cases were identified among the 1140 residents of the village (attack rate: 13.5%), along with a death (case fatality rate: 0.64%). Apart from diarrhoea, 21% of the cases had vomiting also and 11% had pain in abdomen. Headache and blood in stool was each complained by 1.2% both and 0.64% suffered from fever.  Attack rate was comparatively high among the young adults and females.  The first case occurred on 11th April, followed by a rapid increase leading to a peak on 15th April and then a progressive decrease. The last case was on 20th April.  Most of the cases were clustered around the common pond located beside the residence of the index case.

Acute Diarrhoeal diseases (ADD) outbreak in Kotal para, Belkash SC, Borsul Block was due to:  Poor hygienic condition.

 Practice of washing soiled clothes in the common pond.

 Regular use of pond water for washing utensils.

 Close proximity of the public tube-wells and the common pond. 18

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 Contamination of the tube-wells due to damaged platform and brims.

 No purification of drinking water.

Interventions It was found in the investigation that the pond water as well as one of the nearby public tube wells were highly unsatisfactory for public use. Inter-sectoral coordination meetings were conducted with the Panchayat members and P.H.E Department. The recommendations were:

• Short Term- 1. Provision of round-the-clock care to the community through depot holders.

2. Warning the public against use of the pond and the tube-wells until disinfected.

3. Chlorination of the pond and tube-wells used regularly by the community.

• Long Term- 1. Making the tube-wells safe by construction of a platform and brims.

2. Communication with the community people along with the community leaders and Panchayat members to stop washing utensils in the pond and to keep ponds and tube-wells safe.

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Improvement in IDSP reporting and performance, Cooch Behar, 2011

Dr.J.Sarkar1, Tapan Sarkar2, Iqbal Ahmed3 1. Dy.CMOH-II, Cooch Behar, 2. Data Manager, DSU, Coochbehar, 3. DEO, DSU, Cooch Behar

IDSP reports are an important tool for early identification of case clustering or outbreaks of diseases and trigger for prompt action. In 2009, average reporting status in our district was : S form 63%, P form 61% and L form 90%. We decided to improve reporting compliance to a target of at least 80%.

First of all we grouped the Subcentres (SC) into three categories : Category- I (57 SCs) reporting > 90% weeks, Category- II (164 SCs) reporting < 60% weeks and Category-III (185 SCs) reporting < 30% weeks in the year. We also found out that 106 SCs had never reported. No multipurpose health workers (MPHW) were posted there. MPHWs of 243 SCs were untrained and had little idea of IDSP. MPHWs of 57 SCs were already trained and knew the significance of IDSP. We planned to depute a single MPHW in each vacant SC by relocation when 93 MPHWs were recruited. We planned a multiple training schedule for all MPHWs. Training was imparted twice for MPHWs of SCs in Category II & III.

Similarly it was revealed that out of 56 units for P form return, 15 had no Medical Officers. 20 MOs were untrained and only the remaining 21 MOs were trained. We could fill up most of the vacant PHCs by new MOs and complete MOs’ training on IDSP. We trained medical Laboratory Technicians too. As a result reporting status improved year by year. Now in the year 2011 reporting status scaled up to S form- 96%, P from- 94% and L form- 100%. Two PHCs still do not have an MO.

We utilized IDSP to capture four clusters of malaria cases, two clustering situations for diarrhea and a new emergence of Japanese encephalitis (JE). We sent serum samples from 91 cases of AES, which were tested in NICED / North Bengal Medical College. 31 of those were confirmed as JE. 6 JE deaths were reported in the district. We performed mass survey around all confirmed JE cases. IEC were done for the community. The JE situation was thus controlled. Medical Officers and Paramedical Staff were trained on JE/AES. BMOHs, BPHNs and PHNs were instructed to train MPHWs and ASHAs. We identified and arranged alternative staff, where necessary, to send reports in time from all units.

Strengths of the programme in the district: 1. The field workers, MOs, BMOHs and ACMOHs are taking responsibility in IDSP. 2. District level Health officials, general administration, panchayet members are co-operative. 3. State monitoring officers for IDSP are encouraging and careful and keeping contact with us in time. 4. Medical Officers are trained to perform outbreak investigations. Doctors and concerned staff of major private health facilities are trained on IDSP reporting.

Weakness and limitations of IDSP in the district: 1. Shortage of manpower still at the periphery. - We are partly filling up the vacancies by local contractual appointment and/or relocation of staff.

2. One data entry operator required for district reporting unit. - We had applied for that.

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3. Internet facility poor in a number of blocks. - We have informed it to the BSNL Office and alternatively we provide usb data card to the blocks.

4. Block DEOs seem to be overburdened by multiple works. - To encourage and recognize good work in IDSP, we have given rewards and certificates to the excellent performer DEOs in 2010. It is to be continued for every year and we also like to honour other good performing staff of the district.

5. The knowledge, attitude and practice on IDSP of various staff involved are not known. - We are going to organize a KAP study.

6. P and L reports, although started to come from private health facilities, not yet quite regular or on time. - We like to improve it by more effort and close interaction.

Requirement for further sustained action on IDSP in the district: 1. State level action requested to fill up the positions still vacant.

2. State officials’ visit to the district at least once in a quarter.

3. Sustenance of fund flow for I.D.S.P.

4. Recognition of good work by higher authority from time to time.

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Rapid response to a food-borne diarrhoeal outbreak in “Badamile Mission”, Dakshin Dinajpur District, 2011

Dr. Gourab Roy1, Uttam Ghosh2 1. Dy CMOH-II, Dakshin Dinajpur, 2. Data Manger, DSU Dakshin Dinajpur

Background:

The outbreak log book report reveals that Dakshin Dinajpur is an endemic district of diarrhoeal (9/13 outbreak).

A brief report on a prompt response of the RRT team in the Badamile Mission had been documented here.

Details of investigation:

On 1st April 2011, 145 children of Badamile Mission reported profuse watery diarrhoea followed by severe dehydration of which 91 were admitted to the hospital.

Epidemiological investigation:

The RRT team initiated immediate investigation of the outbreak. They found that on 1st April the resident children partook food supplied by the mission. A total of 151 cases occurred, the last case occurring on 2nd April.

There was no death in the outbreak.

The RRT suspected the probable reasons for the food to be contaminated were : a) Cow shed and poultry nearby the kitchen. b) Pond water used for mouth washing and cleaning of utensils.

Public Health Activities :

 Temporary medical camp was set in the mission.

 Govt. vehicle was provided for transportation of patients to Balurghat dist. Hospital.

 Disinfection of the nearby pond.

 Medical Team supported by Kamarpara PHC.

 Medicine distributed : ORS, Ciprofloxacin, Norfloxacin, Metronidazole, Domperidon etc.

 IEC was done to generate hygienic sense among the mass.

 Request to report the cases to Block HQ.

Recommendations

 Investigation on the role of various domestic uses of ponds to prevent future outbreaks.

 Use of tubewell water for drinking, cooking, mouth washing and cleaning of utensils was suggested to

the residents. 22 Page

 Emphasis generated to remove cow shed and poultry from near the kitchen.

 Arrangement for rapid laboratory tests during an outbreak to confirm the diagnosis.

Conclusion:

Prompt reporting and thereafter immediate action of the RRT were successful in controlling a diarrhoeal outbreak among 151 children. However a regular monitoring and IEC are required to prevent diarrhoeal outbreaks in the district.

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Consistency of the reporting units helps in better surveillance and effective control of a disease: A success story of KMC, 2011.

Dr.Basudeb Mukhopadhyay1, Mr.Joydeep Roy 2

1. Municipal Surveillance Officer, KMC, 2. Data Manager, IDSP, KMC

Introduction: IDSP project and its reporting formats had been planned in such a technical manner, that its data base can provide the accurate scenario of a particular disease in a particular region. Consistency of its reporting units plays a major role in maintaining a disease status and recommending effective control measures. KMC (Kolkata Municipal Corporation) had made an effort in monitoring and maintaining the same in their P, L and S format in 2011 in order to improve disease surveillance. Methods: In order to maintain consistency in reporting (P, L, S) we took the following initiatives: 1. Reports received by mail, messenger and fax. 2. Initially an appeal was made to all private set-ups to share information. 3. Mpl. Commissioner issued a letter mentioning Section 471 of KMC Act 1980 wherein information on dangerous diseases is to be given to KMC. 4. If there is delay in reporting from any unit, the staffs of IDSP contact it over telephone or personally goes to the reporting unit.

Result: The immediate results were observed in the reporting formats as under: (A) P Form submission status in the year 2011:- 1. More than 97% of the Dispensaries of KMC are reporting ≥ 80% of time. 2. All the private setups are reporting ≥ 80% of time. 3. About 57% of govt. setups are reporting ≥ 80% of time. (B) L Form submission status in the year 2011:- 1. Total RUs are 218 i.e. highest no. of RUs among all districts of W.B. 2. Out of 137 RUs of KMC, all reported ≥ 80% of time. 3. Among govt. setups, more than 85% reported ≥ 80% of time. 4. Private RUs are 74 i.e. highest no. of RUs among all districts of W.B. > 86% RUs reported ≥ 80% of time. (C) S Form submission status of 2011:- 1. More than 90% of RUs are reporting ≥ 80% of time.

Outcome of the effort: While 17 outbreaks were recorded in the year 2010, the no. of outbreaks recorded in year 2011 was 24. Since patients from outside KMC area utilize the health set-ups in KMC area, the address of the patients are verified and Ward wise line list of cases made, on the basis of which disease control activity is efficiently carried out. Thus while in the year 2010, as per report of Malaria Clinics of KMC the SPR was 27.2%, percentage of PV was 85.3% and percentage of PF was 14.2%, there was a decrease in the year 2011; i.e. SPR was 17.5%, PV was 89.9% and PF was 9.7%. Line list for other vector borne diseases viz. Dengue and Chikungunya are also done that helps to accomplish effective vector control activity. Conclusion: Thus it can be concluded that better and consistent reporting unit maintenance can lead to better surveillance

which can directly result in better control and improved disease scenario.

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Investigation detected Vibrio parahaemolyticus in a food poisoning outbreak in North 24-Parganas, 2011 Dr. Bimal Krishna Paul1, Tanbir Hussain2 1. Dy CMOH-II, North 24 Parganas, 2. Data Manager, DSU North 24 Parganas;

Introduction: 1. An outbreak of Acute Diarrhoeal Disease occurred on 22.06.11. 2. Place - Iswarigacha Village under Beraberi Gram Panchayat in Habra-II Block. 3. The outbreak was investigated on 23 .06.11

Objectives: 1. To confirm the outbreak 2. To control the outbreak 3. To prevent future outbreaks

Background of the Outbreak: 1. About 650 peoples attended a funeral ceremony on 21.06.11 at Iswarigacha and shared common food. 2. Index case on 22.06.11 at 4.00a.m. 3. Total 44 people were affected. 4. Some were admitted and rest were treated and sent back home. 5. Main symptoms were watery stool, vomiting, and pain abdomen in some cases.

Map1: Map of the outbreak village and its surrounds

Epidemiological Investigation:  Case Definition: Any person residing at Iswarigacha who had watery stool, vomiting with or without pain abdomen in between 22.06.11 and 26.06.11.  Case Search: Active search of cases done. Searched cases from hospital also.  Collection of samples: Three Rectal swabs and water samples were collected & sent to NICED, Kolkata on 23.06.11. Water samples collected from tap (Food materials and served water were not available for sampling).  Data analysis: Male-female ratio were analyzed (Fig-2).  Management: Out of 44 cases 35 were treated in hospital rest were treated at OPD & emergency.

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Result:

 Collected water was free from contamination. Sex Distribution of effected persons  Vibrio paraheamolyticus was found in the three rectal swabs.

Conclusion:  A food poisoning outbreak due to Vibrio paraheamolyticus occurred on 22.06.11 at Iswarigacha under Beraberi G.P. of Habra – II block.  The outbreak was declared over on Male 26.06.11. Femal e Fig-2: Distribution of affected persons by sex Male- 14 (32.8%) Female-30 (68.2%) Recommendation:  To avoid consumption of raw, undercooked or stale food materials.  Food handlers should be made aware about the danger of consumption of raw or undercooked food.

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Impact of intervention of LLIN (Long Lasting Insecticidal Bed Net) in a malaria endemic block, Paschim Medinipur, 2009 – 2011 Dr. Pralay Acharya1, Raja Dasgupta2 1. Dy CMOH-II, Paschim Midnapore, 2. Data Manager, DSU Paschim Midnapore;

Background of Binpur – II Block: Binpur-II is identified as a remote and backward block of Paschim Medinipur most of the block is covered with jungle. For the past few years it is affected by LWE activity and facing its consequences. The population of the block is 164227 (2011 Census) among which literacy and economic position is poor. Most of the people are farmer and have no fixed job. As a border block it has migratory population and there are operational difficulties.

Analysis of the records reveals that during the year 2006 – 2009 ABER has decreased by 3%, API has decreased by 29% and SPR has reduced by 15% and PF% reduced by 6%. So, indicators indicate improvement of malarial situation in Binpur-II block in the period 2006-2009.

To improve the malarial situation further long-lasting insecticidal bed nets (LLIN) distribution was started in September 2009 in different phase. The whole block was covered with LLIN.

Chart of a LLIN Distribution Status: LLIN LLIN LLIN LLIN Population Population Total Name of No. Provided in Provided in supply in requirement Covered in Covered in Pupation the Block of SC Year, 2009- Year 2010- 2011- for full 2009-2010 2010-2011 Covered 2010 2011 2012 coverage

Binpur-II 36 44,000 1,29,987 75,000 25,249 1,55,236 62,610 Nil

Discussion: After distribution of LLIN surveillance on Malaria was strengthen in Binpur-II block. So, majority of the people began to use LLIN. As a result during the period 2009 to 2011 ABER reduced by 3% (Now it is 11%), API reduced by 16% and SPR reduced by 10% and PF % reduced by 3 %. So, there was improvement of malarial situation in Binpur- II Block following LLIN distribution. To compare the improvement we analyzed record of Jamboni block which is malaria prone adjacent to Binpur-II and LLIN was not distributed there at that time. It was found that during the period 2009 & 2011 the malarial situation in Jamboni block remain more or

less unchanged.

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Conclusion: So, it can be concluded that intervention of LLIN distribution resulted in a good out come in malarial situation though there are operational difficulties, shortage of human resource, existence of migratory population and many other difficulties.

Recommendation: Now it can be recommended that use of LLIN is to be strengthened in Binpur-II block. It requires more stress on IEC activities, increase of human resources, stresses of inter-sectoral coordination. LLIN distribution can be recommended in other blocks of Jhargram subdivision.

Key Points:

 LLIN is useful for Jungle-Mahal blocks to prevent malarial transmission.  IEC activities for use of LLIN in every house.  Strengthen inter-sectoral coordination for improvement of socio-economic condition and literacy rate.

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Unknown fever in Bhagawanpur-I Block, Purba Medinipur, 2011 Dr. Dilip Kumar Biswas1, Surajita Banerjee2 1. Dy. Chief Medical Officer of Health-II, Purba Medinipur, 2. Entomologist, SSU, IDSP

Background Unknown fever cases were reported at Nilkantapur Village under Dwarikapur Sub-center (SC) of Bhagawanpur-I Block, Purba Medinipur District on 03.10.2011. We visited the village with the objective (1) to search for fever cases, (2) to identify the aetiology, (3) to confirm the outbreak and (4) to propose control measures.

Methods Descriptive Epidemiology: We searched for cases of fever with rash, joint pain and haemorrhagic manifestation (if any) in the area of Dwarikapur SC occurring during the period of 01.10.2011 to 31.10.2011 through house to house survey. We collected information regarding age, sex, date of onset of fever, treatment history and the socio-economic status of case-patients. We also looked for migration history of people. We collected blood slides for detection of malarial parasite (MP) and venous blood specimens for detection of dengue & chikungunya IgM antibody. Entomological survey was also conducted.

Map of Bhagabanpur-I Block showing the affected Sub Centre

Result

Total 200 cases were reported during the month of October-‘11. Overall attack rate was 3.2% (200/6162).

Attack rate was more among the females (3.8%) than in the males (2.7 %). Proportional Attack rate below the age of 14 years was 23 % (46/200). 29

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Laboratory report : Out of 8 serum specimens, two were positive for chikungunya and two were positive for dengue. No malarial parasite was detected in the blood slides.

Entomological survey report No larvae were found in the containers. There was presence of azolla in the ponds and water bodies.

House Index (HI), Container Index (CI) and Breateux Index (BI)

# containers Houses Containers # houses Name of the place inspected positive positive for HI CI BI inspected Dry Wet for larvae larvae Bhagwanpur-I Block, 42 16 4 0 0 0 0 0 Dwarikapur SC

Breeding of mosquito larvae in ponds & cesspools

# ponds # cesspools # ponds # cesspools Remark Name of the place inspected inspected positive positive (Larvae found)

Bhagwanpur-I Block, Anopheles, Culex 6 8 1 4 Dwarikapur SC few in number

Conclusion & Recommendation Earlier the fever that was notified as unknown fever, later was found to be dengue and Chikungunya. Though vectors of malaria and Japanese encephalitis were identified, there was no Aedes vector. Presence of azolla in the ponds might have minimized mosquito breeding in the ponds.

Extensive IEC activities were done regarding vector borne diseases. Use of mosquitoes net, cleaning of jungles & ponds etc. were stressed upon. Medical teams were sent for treatment of patients locally. The incident of fever finally subsided on 3rd November, 2011.

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An effort to improve IDSP reporting by reporting units and maintaining its consistency: Purulia District, 2011 Dr.Anil Kr. Dutta1, Samrat Sen2, Vidyasagar Singha3 1. Dy CMOH-II, Purulia, 2. Data Manger, DSU, Purulia, 3. Data Entry DSU, Purulia

Introduction: IDSP state level review meeting helps to discuss, and sensitize the District Surveillance Unit members, which helps in rectification of reporting and thereby improvement of disease surveillance in the districts. This year Purulia district had made an effort to improve the reporting status after the review meeting.

Objective: To improve the consistency of IDSP reporting by the reporting units.

Methods: The following key measures were taken to meet the objective : A. (1) Man to Man authoritative explanation of the IDSP criteria. (2) Follow up in review meetings at district level like Monthly MIES Meeting, Public Health Meeting etc. (3) Creation of Contact Database of every staff of periphery for immediate communication if Weekly report is not submitted in time. (4) Appreciation of good performing peripheral staffs. (5) Regular visit to BPHC, PHC & SC to check the Registers for data validation and updating. (6) Regular data analysis at DSU and feedback to lower level. (7) Time to time feedback to DSO regarding defaulter reporting units. B. Involvement of Private Sector (Lab) under IDSP: The District Surveillance Unit (DSU), Purulia has taken the initiative for involvement of Private Sector Labs in IDSP to start weekly reporting in 2011. A district level meeting with representatives of Private Clinics / Diagnostic Centres was arranged on 02.09.2011. MoU was signed successfully with Siddartha Diagnostic Centre, Subarna Diagnostic Centre and Aviskar Diagnostic Centre on 02.09.2011.

Result and Discussion: A noticeable improvement was found in the reporting consistency as shown in table 1& 2. In P-form reporting from PHCs, the no. of consistent reporting units increased from 32 (in 2010) to 55 (in 2011, after the State Review meeting), achieving the overall consistency. Though the consistency of the Government hospitals was already achieved in 2010(5 units), addition of one more unit was made for capturing more data. Three private labs were included in L-form reporting units. They started reporting from September 2011. The improvement and maintenance of consistency of the reporting units has a direct impact in the surveillance and prediction of disease trends. The weekly L data of malaria, when compared between 2010 and 2011, showed reduction in Pf cases and deaths. Reported malaria cases were also less in two endemic blocks viz. Kashipur and Neturia. Consistency of reporting units along with a decrease in case load supports a real decline in disease incidence.

Conclusion:

Review meetings and monitoring had a positive impact on IDSP reporting which again helped in proper analysis of the data. However further improvement in involvement of the private sector in P-form reporting and achieving 31

consistency in reporting from private sector units are needed for more accuracy in the surveillance programme. Page

Form P TABLE : 1 PHC Govt. Hospital / ID Hospitals / CHC / Medical College Private Sector

Year

80% 80%

- -

Sl. No. Sl. Total No. of RU’s Total No. of RU’s No. of units reported time >=80% Standard for consistency Total No. of RU’s No. of units reported time >=80% No. of units reported between 50% time No. Consistent units of Standard for consistency Total no. of RU’s No. of units reported time >=80% No. of units reported between 50% time No. Consistent units of Standard for consistency 2010

74 67 32 54 7 4 1 5 4 0 0 0 0 0 1 2011 74 67 40 54 7 5 0 5 4 0 0 0 0 0 2 2011 After IDSP 74 67 55 54 7 5 1 6 4 0 0 0 0 0 3 Training at State Level Form L PHC(Lab.) Govt. Hospital(Lab.) / ID Hospitals(Lab.) / CHC(Lab.) / Private Sector (Lab.)

TABLE : 2 Medical College(Lab.)

Year

80% 80%

- -

Sl. No. Sl. Total No. of RU’s Total No. of RU’s No. of units reported time >=80% Standard for consistency Total No. of RU’s No. of units reported time >=80% No. of units reported between 50% time No. Consistent of units Standard for consistency Total no. of RU’s No. of units reported time >=80% No. of units reported between 50% time No. Consistent units Standard for consistency 2010

23 18 10 14 5 3 1 4 4 0 0 0 0 0 1 2011 25 18 17 14 7 6 0 6 4 0 0 0 0 0 2 2011 After IDSP 3 Training 28 18 17 14 7 6 0 6 4 3 0 0 0 2 at State Level

Data Analysis in Malaria: Data Source - Weekly IDSP Report (LAB) from RUs

% Pf Case Load in Purulia District % Pf Case Load in Purulia District

NETURIA-32% NETURIA-22% PURULIA RNPUR II-2% MUNICIPALITY PURULIA RNPUR II-15% MUNICIPALITY JOYPUR- 2010 53% PARA-19% JOYPUR- 2011 45% PARA-4% JHALDA – II- KASHIPUR-30% JHALDA – II- 57.4% 47% KASHIPUR-19%

JHALDA – 34.2% ARSHA- 87% HURA-38% JHALDA – I-45% HURA-42% -I ARSHA- 87% -I

BAGMUNDI-98% PUNCHA-42.5% BAGMUNDI-98% PUNCHA-28%

BARABAZAR- MANBAZAR I-67% BARABAZAR- MANBAZAR I-48% 63% >70% - High >70% - High 67% 30-70% - Medium 30-70% - Medium <30% - Low Pf % <30% - Low Pf % BANDWAN-90% BANDWAN-95%

Week wise Malaria Compared with 2010-11, PURULIA, W.B.

MALARIA-2010 DISTRICT: PURULIA 250 200 150 100 50 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

MALARIA-2011 DISTRICT: PURULIA 250 200 150 100 50 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52

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A search for the gaps in data reporting for improvement in malaria surveillance, South 24 Parganas, 2011

Dr.Debasis Halder1, Niladri Sekhar Karmakar2 1. Dy. CMOH-II, South 24 Parganas, 2. Data Manger, DSU, South 24 Parganas;

Introduction: Reporting proper data of a particular block plays a significant role in the prediction of a disease status and initiation of early warning signal in the region. So any gap in the data will lead to misjudgement of the accurate situation and delay in response. Objective: Two data sets of the same disease were collected from IDSP and NVBDCP and compared to check for the discrepancy (if any). Method: The malaria data of L reports of IDSP and malaria reports of NVBDCP(M-4 reports) were compared for January –September, 2011 for all the rural blocks in the district. Monthly mean of no. of malaria positives were calculated along with 95% confidence interval (CI) for the purpose of comparison. Result and Observation: The Mean and 95 % CI value of IDSP and NVBDCP data sets were different in amany blocks. A noticeable discrepancy was observed in Canning-I of Canning SD, with nil report in IDSP while the data of NVBDCP showed a definite incidence (Mean value 22, CI-15-30). Similar discrepancies were also in Budge Budge I of Sadar SD and Magrahat I and Mandirbazar of Diamond harbour SD. However, the data collected from Kakdwip SD showed nil report both in IDSP and NVBDCP.

Fig: Canning Sub Division Fig: Baruipur Sub Division

Fig: Sadar Sub Division Fig: Diamond Harbour Sub Division

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Discussion: Surveillance data plays a key role in the prediction of a disease occurrence. L-report of IDSP and M-4 report of NVBDCP are both generated at the block level (BMOH). Yet data sets of the same disease showed different situation/ status when two different data sets (IDSP & NVBDCP) were compared. The difference in two sets can create confusion and delay in initiating early warning signal. Again zero report in a subdivision for a common disease like malaria suggests the possibility of a gap in detection or reporting.

Conclusion: Gap in the reporting data should be overcome. Accuracy and consistency in the different data sets should be maintained in a particular block. The Health Workers and Lab. Technicians in the blocks should be trained and sensitized thoroughly regarding the capture of data of a disease. Regular monitoring of these data sets is required, as this will then help in getting the true picture of a disease scenario, initiation of early warning signal and taking of timely control measures.

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Implication of case definition and consistency of reporting in generation of Early Warning Signals, Uttar Dinajpur, 2011 Dr. Ajay Chakrabarty1, Tuhin Chatterjee2 1. Dy CMOH-II, Uttar Dinajpur, 2. Data Manager, DSU, Uttar Dinajpur Introduction: Detection of early warning signals of epidemic prone diseases will help to initiate an effective response in a timely manner. We can meet the above by ensuring the timely and consistent reporting of the Reporting Units and analyzing those data in a proper way. Our Objective: We wanted to analyze the quality of our reporting system. So we explored some of the prerequisites of the system as follows:  Capturing of data and record keeping  Proper application of case definition  Consistent & timely reporting of all the reporting units  Data transmission and data based action

Method: We had analyzed the data of P & L forms for last 6 months using Epi Info (version 3.5.1.8).  Capturing of data and record keeping :

For OPD reporting: The reporting of Hemtabad (Population: 1.2 Lacs ) is good as they are reporting an average of 1000 cases per week in the IDSP ‘P’ form compared to an average of 1100 cases per week by RT-7 report, where as Islampur (Population: 2.42 Lacs) is reporting an average of 500 cases per week in the IDSP ‘P’ form compared to an average of 2600 cases as per RT-7(Communicable disease) report.

16000

14000 13610 Av OPD Av ER

12000

10545

10000 8875 8531

8000 7142 6442

6000

4401 3911 4000 3374 2902 2079 2223 2000 1211 (Avg. 1000 cases) 654 340 158 279 392 0 Itahar Raiganj Hemtabad Dalua Ramganj Lodhan Chakulia Kanki Bangalbari Average monthly OPD attendance according to the RT7 Report of last two years

(Avg. 500 cases) Page

 Implication of proper of case definition :

Wrong case definition of Bacillary Dysentery had been found out: Islampur block and Raiganj block were reporting a huge number of Bacillary Dysentery (BD) cases each week in P form. We found that they were not applying the proper case definition. In the monthly MIES meeting we discussed the matter with the BMOHs and with the MOs when we visited the Raiganj block in October, 2011. The number of BD cases decreased in Raiganj block, they started to apply the proper case definition of BD but Islampur did not improve due the lack of supervision from district (avg. 50 cases per week).

Islampur (Avg. 50 cases per week) Raiganj (Cases decreased since Oct, 2011)

 Consistent & timely reporting of all the reporting units : We evaluated the consistency of the reporting units for ‘L’ form reporting in last one year. Reporting of Islampur Sub Divisional Hospital was very poor. After the visit of District Data Manager in June, 2011, reporting improved.

Reporting improved Very Poor Reporting

Number of times each reporting units reported for the year 2011 for L form

Reporting improved after visit in June Inconsistent Reporting Consistent Reporting

Islampur Sub-Divn. Hospital Lodhan BPHC Raiganj District Hospital

Discussion: Hemtabad block of the Uttar Dinajpur district was found to be a consistent reporting unit, while Islampur and Raiganj blocks were not consistent and did not applied proper cases definition. After intervention

by the DSU team and proper training, reports improved and the spurious case load decreased drastically.

Conclusion: Proper application of case definition and consistent reporting reflect an actual scenario of the disease in a block, which can help in developing an early warning signal of the particular disease. 36

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The scenario of Cholera disease in West Bengal over the last three years (2009-2011) Mr. Palash Mondal1, Mr. Satyajit Ghosh2, Dr. Dipankar Maji3, Dr. Shantanu Halder4 1. Microbiologist, SSU, IDSP, WB 2. PA to Addl. DHS (PH&CD), IDSP, WB, 3. Nodal Officer, IDSP, WB 4. State Surveillance Officer, IDSP, WB

Background: West Bengal is known to be the common cholera outbreak prone state in India. This water borne disease is principaly caused by Vibrio cholerae and some time (very rarely) by Vibrio parahaemolyticus. Identification of this disease is mainly done in National Institute of Cholera and Enteric Diseases (NICED), Beliaghata, Kolkata. Methods: For the analysis of the cholera data we took the line list from the Dept. of Bacteriology, NICED of the past three years and try to figure out the seasonal pattern of the enteric disease. In NICED, stool sample of the suspected cases from various part of WB, is been sent in Cary Blair media (Transport media), where the test for Cholera, Shigella & Salmonella is done. Sero typing of the suspected cases is also done here.

No of Sample Vibrio *Positivity cases tested cholerae Rate (%) 2009 1388 431 31.05 2010 681 150 22.03 2011 656 146 22.26 Table 1: Cholera cases & positivity rate* of Cholera in WB in last 3 yrs (NICED)

Graph 1: Cholera cases & positivity rate* of Cholera in WB in last 3 yrs (NICED) * [Positivity Rate = (No. of positive cases) X 100 / No. of sample tested]

No of Cholera outbreak in WB, 2011 8

Outbreaks where biological samples were collected 8

Outbreaks where biological samples collected within 4 days 7 Final report received 7 Total no of stool sample collected from all the outbreak regions 27 Total no of lab confirmed positive cases from all the outbreak 17

regions

Table 2: Cholera outbreak data sheet of WB, 2011 37

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120 2009 2010 2011 100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Graph 2: Monthly distribution of Cholera cases in WB in last 3 yrs (NICED)

Results: Positivity rate of cholera reduced in last three years. The positivity rate of 2010 & 2011 is same but lower than the positivity rate of 2009 (Table-1). The Test reports also reflect that various cholera strains, serotypes and biotypes are predominant in the state such as Vibrio paraheamolyticus, V. cholerae O1-Inaba, V. cholerae O1-Ogawa, V. cholerae Non-O1 non etc. Maximum no of cholera cases are occurring in the month of April (Except 2009, where it is 2nd highest & the maximum no. of cases occurs in the month of July,). In West Bengal, major cases of cholera are reported in summer (i.e. early pre-monsoon) and continue till post monsoon season. The cholera cases drastically fall in the winter season, though the disease still persists during this season. From the line-list it was also found that in 2011, six cases of cholera caused by Vibrio paraheamolyticus, had occurred in West Bengal. Discussion & Conclusion: Though the positivity rate of cholera in 2010 and 2011 is found to be decreasing when compared with 2009 (from 31% to 22%) but the positivity rate of 22% is still a matter of concern in a cholera prone state like West Bengal. The onset of this water borne disease is found to be from early summer and continues post-monsoon season. So, occurrence rate of cholera in WB is higher during summer and rainy season when compared to winter or spring. The recently the strains of Vibrio paraheamolyticus reported from several parts of West Bengal as the causative organism draws our attention in the recommendation of the control measure. Recommendation: Hence an identification of the high reporting / endemic block is necessary. A careful monitoring of those regions and regular water testing is recommended. The entire write-up is based on the data collected from National Institute of Cholera and Enteric Diseases (NICED), Beliaghata, Kolkata. So the data reflects only a part of a cholera status of West Bengal.

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Man-made containers / human behavior are major causes of vector borne diseases: Entomological experience in West Bengal, 2011

Dr. Surajita Banerjee1, Shubhashish Roy2, Sanjib Kr. Saha3

1. Entomologist, IDSP, SSU, WB. 2. Data Manager, IDSP, SSU, WB 3. Data Entry Operator, IDSP, SSU, WB

Background : The seasonal trends of the vector borne disease (mainly Dengue, Chikungunya, Japanese Encephalitis) in West Bengal over the past year 2010-2011 depicts diseases are not limited to monsoon or immediate post-monsoon period, as cases had been reported throughout the year with peaks in autumn and early winter. In 2011, lesser no. of Dengue cases has been reported in comparison to 2010. However, an outbreak was reported in Domjur Block (in Howrah district). Unlike Dengue, sero confirmed cases of Chikungunya have increased from 231 to 956 in 2010 and 2011 respectively, with outbreak in four districts i.e. Jalpaiguri, Howrah, Burdwan and Hooghly in 2011. Again, spurt of Japanese Encephalitis cases were observed in 2011 in North Bengal with highest number of cases reported from Jalpaiguri.

No. of reported dengue cases, WB No. of reported chikungunya cases, WB

Objective: To undergo the entomological survey of the adult and larvae and identify the breeding sources.

Methods: Entomological surveillance (both adult and larvae) was done in the outbreak and high reporting regions. Vector breeding status was determined there in terms of House Index (HI), Container Index (CI) and Breatuex Index (BI) and suitable control measures were recommended.

Observations & Results: Larvae, though found in several domestic, peridomestic containers, ponds and cesspools but the identified breeding sources were man-made e.g cement pot, coconut sell, tyres, battery shell, disposable containers, etc). The larval indices were either high or even higher than the threshold value with BI more than 100 in Howrah and Hooghly districts. The identified adult mosquito species in Dengue/ Chikungunya regions were: Aedes albopictus & Aedes aegyptii in the urban and rural areas respectively. Vectors found in JE affected region of D.Dinajpur were: C.tritaeniorhynchus, C.gelidus,Mansonia uniformis, Anopheles vagus, Mansonia anulifera.

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After identifying the breeding sources and the responsible species, control measures were suggested in three strategies: a) Short Term measures: Covering of all containers, using of mosquito proofing net in the over head tank and spraying of kerosene where removal of water was not possibl.

b) Long Term measures: Culture of Azolla and Larvivorous fish in the unused water bodies and paddy field. c) Personal Protection: Use of bed net (even during day sleep), protective clothing, mosquito repellent, smoking of neem leaves can be done.

Discussion: The entomological surveillance in several districts reveals that very common man made breeding sources are mainly responsible for the high larval indices which may result in outbreak. Hence regular entomological surveillance is required. Behavioural change is the main factor and the mass should be made aware to remove the breeding sources. Since the entomological manpower is very less in our State, the Epidemiologists and Data Managers, of the IDSP team can help and work hand in hand to identify the breeding sources and initiate proper action in destroying the same and take part in IEC. The seasonal trends of the diseases suggest that we have to remain vigilant throughout the year. Our experience from the precedent shows that the district, Nadia after receiving the entomological survey report took careful steps in mass awareness which resulted in the reduction of the larval indices in the follow up study after two months. Another experience in Jalpaiguri, where the epidemiologist immediately shared his observations via emails and video clippings of the larvae and breeding sources, confirmed the species by the SSU and the Centre for Research of Medical Entomology, Madurai. Relevant actions were taken by the DSU to control transmission.

Conclusion: Regular entomological surveillance is necessary throughout the year. Vector control strategies should be realistic and of low cost, as the villagers are mostly poor. Active involvement of the health personnel (Epidemiologists and Data Managers along with Entomologist) is required in the entomological surveillance as regular vector surveillance is necessary. Mass awareness and community involvement is the most significant factor to reduce the vector breeding sources in order to control vector borne disease and prevent outbreak.

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