On Epidemic – Prone Diseases, Deaths and Public Health Events

020 Week Number 3 of 2 (Week Ending 1 9 - 01 -2 0 ) Of2222022 0

five years of age. The deaths were reported from Parirenyatwa Group of Hospitals (1), Central Hospital (1) in Harare HIGHLIGHTS OF THE WEEK Province, UBH (1) in Province, and Mhondoro  nCoV2019 update in the next bulletin District (1) in West Province. The Provinces that  (4) Diarrhoea deaths reported the highest number of diarrhoea cases were  (7) Malaria deaths Mashonaland West (1 545) and Manicaland (1 266). The cumulative figures for common diarrhoea are 27 394 cases and  (29) Anthrax cases 20 deaths. The cumulative CFR is 0.07%.  (7) Rabies cases  (1) Rabies death Trends of diarrhoea cases

COMPLETENESS AND TIMELINESS National completeness and timeliness for week 3 decreased 40000 from 96% to 91% and 83% to 61% respectively. The decreases 30000 are attributed to the DHIS2 which was down for the most part Cases 20000 of the week. 10000 National Completeness 0 100 1 4 7 10 13 16 19 22 25 28 31 34 37 404346 49 52 80 Weeks 60 40 2020 2019 2018 20

%Completeness 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 DYSENTERY 570 clinical dysentery cases and 3 deaths were reported this Week Numbers week. The deaths were reported from (2) in 2020 2019 Matabeleland North Province and District (1) in . The provinces that reported the highest TYPHOID number of cases were Mashonaland West (125) and Masvingo 43 new suspected typhoid cases and no deaths were reported (96). The cumulative figures for dysentery are 2 014 cases and this week. The suspected cases were reported from Harare 4 deaths. The cumulative CFR is 0.2%. Central Hospital (3), West South West District (30), Southern District (9) in and (1) in Trends of dysentery cases Masvingo Province. The cumulative figures for typhoid are 151 cases and no deaths. 1500 1000 CHOLERA

Cases 500 No new suspected cases of cholera and deaths were reported this week. The last confirmed cholera case was reported on 12 0 March 2019 in District in Mashonaland Central 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 Province. Weeks

COMMON DIARRHOEA 2020 2019 2018 8 689 common diarrhoea cases and 4 deaths were reported this week. Of the reported cases, 3 825 (44%) were from the under

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MALARIA SNAKE BITES 3 401 malaria cases and 7 deaths were reported this week. Of 167 snake bite cases and 1 death were reported this week. The the reported cases, 441 (13%) were from the under five years cumulative figures for snake bites are 450 cases with 2 deaths. of age. The deaths were reported from The cumulative CFR is 0.44%. (2), District (1), (1) in , (2) in Mashonaland Central Province PLAGUE and District (1) in Matabeleland South Province. No suspected case of plague was reported this week. The provinces that reported the highest number of cases were Manicaland (2 043) and Mashonaland Central (619). The COMMON COLD/INFLUENZA cumulative figures for malaria are 11 066 and 15 deaths. The 1 918 suspected influenza cases and no deaths were reported cumulative CFR is 0.14%. this week. The cumulative figures for common cold/influenza are 6 855 and no deaths.

Trends of Malaria Cases PANDEMIC INFLUENZA (H1N1)

18000 No case of Pandemic Influenza (H1N1) was reported since 16000 week 44 of 2010. 14000 12000 10000 MEASLES 8000 No new suspected measles case was reported this week through Cases 6000 4000 the Weekly Disease Surveillance System (WDSS). The 2000 cumulative case of suspected measles is 1. 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 No new-suspected case of measles was reported this week Weeks 2020 2019 2018 through the Case Based Surveillance System (CBSS).

All provinces are being reminded to investigate all malaria AFP /SUSPECTED POLIOMYELITIS deaths No new AFP case was reported this week through the Weekly Disease Surveillance System. ANTHRAX 29 new anthrax cases and no deaths were reported this week. No new case of AFP was reported this week through the The cases were reported from (6) in CBSS. The cumulative cases of suspected AFP is 1. , District (9) in Manicaland Province, Gutu District (1), (2), NEONATAL TETANUS (NNT) (2) in Masvingo Province, District (2) in No new case of suspected NNT was reported this week through Mashonaland East Province and (7) in both the Weekly Disease Surveillance System and Case Based Mashonaland West Province. The cumulative figures for Surveillance System. anthrax are 144 cases and 1 death. The cumulative CFR is 0.69%. MENINGOCOCCAL MENINGITIS No new case of suspected meningococcal meningitis was DOG BITES reported this week. 503 dog bite cases and no deaths were reported this week. Of these cases, 119 (23.6%) were bitten by vaccinated dogs, 109 MATERNAL DEATHS (21.7%) by unvaccinated dogs and 275 (54.7%) by dogs of 1 maternal death was reported this week. The death was unknown status. The highest number of cases reported this week were from Mashonaland West Province (79) and reported from Guruve District in Mashonaland Central Mashonaland East Province (79). The cumulative figures for Province. The cumulative figures for maternal deaths are 23. dog bite are 1 505 cases and no deaths. HUMAN AFRICAN TRYPANOSOMIASIS RABIES No cases of suspected human trypanosomiais were reported this week. 7 new suspected rabies cases and 1 death was reported this week. The cases and death were from (8) in Mashonaland West Province. The cumulative figures for rabies are 8 cases and 1 death. The cumulative CFR is 12.5%.

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WEEKLY DISEASE SURVEILLANCE TABLE FOR WEEK 3 ENDING 19-01-20

AFP

NNT

Rabies Plague

hoea <5cases hoea >5cases hoea

Measles

Cholera

Anthrax Typhoid

hoea <5deaths hoea >5deaths hoea

Expected

Dog bites Dog

Influenza

Dysentery

Submitted

Timeliness

rr rr

Snake Bites Snake

rr rr

Completeness

Maternal Deaths Maternal

Dia Dia

C. Malaria <5cases C. Malaria >5cases C. Malaria

Dia Dia

C. Malaria <5 deaths <5 C. Malaria deaths >5 C. Malaria

Chikomba 34 2 1 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 6 6 Goromonzi 31 31 153 0 150 0 14 3 0 17 0 0 0 0 20 2 0 0 0 0 0 0 0 100 97 Hwedza 15 11 35 0 29 0 2 2 0 4 0 0 0 0 7 1 0 0 0 0 0 0 0 73 73 Marondera 24 24 75 0 99 0 2 0 0 4 0 0 0 0 13 3 0 0 2 0 0 0 128 100 83 Mudzi 28 28 81 0 95 0 9 12 0 139 0 0 0 0 7 0 0 0 0 0 0 0 163 100 100 Murewa 29 28 94 0 131 0 9 4 0 41 0 0 0 0 16 9 0 0 0 0 0 0 0 97 97 27 26 47 0 92 0 4 11 0 108 0 0 0 0 4 5 0 0 0 0 0 0 172 96 96 Seke 17 17 76 0 79 0 1 1 0 7 0 0 0 0 10 2 0 0 0 0 0 0 60 100 0 UMP 21 4 5 0 12 0 4 1 0 3 0 0 0 0 2 0 0 0 0 0 0 0 25 19 5 Mash East 226 171 567 0 692 0 45 34 0 323 0 0 0 0 79 22 0 0 2 0 0 0 562 76 65 22 9 59 0 32 0 6 2 0 17 0 0 0 0 2 0 0 0 0 0 0 0 0 41 0 Centenary 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Guruve 22 22 63 0 84 0 0 8 1 95 1 0 0 0 2 5 0 0 0 0 1 0 0 100 100 Mazowe 34 34 165 0 159 0 29 1 0 18 0 0 0 0 9 6 0 0 0 0 0 0 130 100 0 Mbire 13 13 74 0 74 0 3 9 0 42 0 0 0 0 2 3 0 0 0 0 0 0 50 100 0 Mount Darwin 24 24 88 0 111 0 14 23 0 295 0 0 0 0 6 9 0 0 0 0 0 0 68 100 4 Rushinga 13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Shamva 18 12 93 0 81 0 19 4 0 105 0 0 0 0 0 2 0 0 0 0 0 0 98 67 17

Mash Central 160 114 542 0 541 0 71 47 1 572 1 0 0 0 21 25 0 0 0 0 1 0 346 71 16 Binga 17 17 39 0 61 0 23 1 0 0 0 0 0 0 7 1 0 0 0 0 0 0 2 100 18 Bubi 11 11 23 0 17 0 0 0 0 3 0 0 0 0 1 0 0 0 0 0 0 0 0 100 73 46 46 85 0 96 0 12 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 Lupane 14 14 20 0 22 0 5 0 0 2 0 0 0 0 3 0 0 0 0 0 0 0 0 100 100 Nkayi 18 18 26 0 38 0 5 0 0 0 0 0 0 0 9 3 0 0 0 0 0 0 0 100 0 Tsholotsho 21 21 47 0 54 0 2 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 100 43 Umguza 26 26 27 0 82 0 7 0 0 2 0 0 0 0 2 0 0 0 0 0 0 0 0 100 0 Mat North 153 153 267 0 370 0 54 2 0 8 0 0 0 0 23 4 0 0 0 0 0 0 2 100 52 Chirumhanzu 19 19 21 0 27 0 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 100 100 Gokwe North 22 22 73 0 103 0 9 0 0 8 0 0 0 0 5 1 0 0 6 0 0 0 0 100 100 Gokwe South 36 36 72 0 63 0 5 1 0 2 0 0 0 0 14 8 0 0 0 0 0 0 0 100 100 35 35 63 0 62 0 3 1 0 1 0 0 0 0 8 4 0 0 0 0 0 0 0 100 100 45 45 65 0 82 0 9 0 0 2 0 0 0 0 13 10 0 0 0 0 0 0 0 100 100

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WEEKLY DISEASE SURVEILLANCE TABLE FOR WEEK 3 ENDING 19-01-20

AFP

NNT

Rabies Plague

hoea <5cases hoea >5cases hoea

Measles

Cholera

Anthrax Typhoid

hoea <5deaths hoea >5deaths hoea

Expected

Dog bites Dog

Influenza

Dysentery

Submitted

Timeliness

rr rr

Snake Bites Snake

rr rr

Completeness

Maternal Deaths Maternal

Dia Dia

C. Malaria <5cases C. Malaria >5cases C. Malaria

Dia Dia

C. Malaria <5 deaths <5 C. Malaria deaths >5 C. Malaria

Mberengwa 36 33 44 0 72 0 15 0 0 0 0 0 0 0 13 1 0 0 0 0 0 0 0 92 39 30 30 14 0 33 0 0 0 0 1 0 0 0 0 10 4 0 0 0 0 0 0 0 100 0 27 27 37 0 90 0 5 0 0 0 0 0 0 0 10 2 0 0 0 0 0 0 0 100 100

Midlands 250 247 389 0 532 0 46 3 0 14 0 0 0 0 74 31 0 0 6 0 0 0 0 99 79 Buhera 33 33 49 0 111 0 15 3 0 45 0 0 0 0 19 5 0 0 9 0 0 0 150 100 3 Chimanimani 26 26 50 0 46 0 18 75 0 252 2 0 0 0 5 0 0 0 0 0 0 0 98 100 100 50 50 90 0 73 0 18 24 0 100 0 0 0 0 0 0 0 0 0 0 0 0 0 100 0 Makoni 57 53 91 0 118 0 3 15 0 136 1 0 0 0 16 4 0 0 0 0 0 0 69 93 93 Mutare City 8 8 21 0 10 0 0 3 0 57 0 0 0 0 2 0 0 0 0 0 0 0 0 100 0 Mutare 46 46 76 0 163 0 22 44 0 299 1 0 0 0 10 2 0 0 0 0 0 0 143 100 100 Mutasa 45 44 81 0 122 0 11 139 0 688 0 0 0 0 9 4 0 0 0 0 0 0 148 98 98 Nyanga 28 28 58 0 107 0 7 28 0 135 0 0 0 0 3 2 0 0 0 0 0 0 7 100 4 Manicaland 293 288 516 0 750 0 94 331 0 1712 4 0 0 0 64 17 0 0 9 0 0 0 615 98 58 40 40 134 0 108 0 10 0 0 4 0 0 0 0 19 0 0 0 0 0 0 0 0 100 100 Hurungwe 38 38 159 0 139 0 34 7 0 124 0 0 0 0 11 17 0 0 0 0 0 0 0 100 95 13 12 109 0 127 0 16 0 0 10 0 0 0 0 1 1 0 0 0 0 0 0 0 92 92 Makonde 40 31 110 0 137 0 20 1 0 32 0 0 0 0 11 6 0 0 7 0 0 0 149 78 78 Mhondoro 20 20 42 1 68 0 6 0 0 1 0 0 0 0 4 2 0 0 0 0 0 0 0 100 90 Sanyati 26 26 63 0 98 0 18 1 0 5 0 0 0 0 6 3 0 0 0 0 0 0 200 100 50 Zvimba 35 35 113 0 138 0 21 4 0 17 0 0 0 0 27 9 7 0 0 0 0 0 22 100 3 Mash West 212 202 730 1 815 0 125 13 0 193 0 0 0 0 79 38 7 0 7 0 0 0 371 95 71 Beit Bridge 23 23 51 0 66 0 1 1 0 4 1 0 0 0 13 0 0 0 0 0 0 0 0 100 0 Bulilima 16 16 15 0 35 0 1 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 100 100 30 30 26 0 55 0 3 2 0 3 0 0 0 0 7 2 0 0 0 0 0 0 0 100 100 17 17 19 0 17 0 4 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 100 100 Matobo 18 17 20 0 16 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 94 94 Mangwe 17 5 16 0 11 0 4 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 29 29 17 17 21 0 26 0 3 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 100 94 Mat South 138 125 168 0 226 0 16 3 0 8 1 0 0 0 34 5 0 0 0 0 0 0 0 91 73 Bikita 26 22 47 0 60 0 25 3 0 14 0 0 0 0 11 2 0 0 2 0 0 0 0 85 4 35 32 102 0 218 0 12 3 0 61 0 0 0 0 7 3 0 0 0 0 0 0 0 91 31 Chivi 23 23 34 0 67 0 10 0 0 4 0 0 0 0 11 1 0 0 2 0 0 0 0 100 96 Gutu 30 30 51 0 71 0 7 0 0 6 0 0 0 0 8 3 0 0 1 1 0 0 0 100 100

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WEEKLY DISEASE SURVEILLANCE TABLE FOR WEEK 3 ENDING 19-01-20

AFP

NNT

Rabies Plague

hoea <5cases hoea >5cases hoea

Measles

Cholera

Anthrax Typhoid

hoea <5deaths hoea >5deaths hoea

Expected

Dog bites Dog

Influenza

Dysentery

Submitted

Timeliness

rr rr

Snake Bites Snake

rr rr

Completeness

Maternal Deaths Maternal

Dia Dia

C. Malaria <5cases C. Malaria >5cases C. Malaria

Dia Dia

C. Malaria <5 deaths <5 C. Malaria deaths >5 C. Malaria

Masvingo 43 41 45 0 90 0 11 0 0 1 0 0 0 0 15 9 0 0 0 0 0 0 0 95 0 Mwenezi 22 16 26 0 65 0 8 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 73 68 Zaka 25 25 53 0 75 0 23 1 0 5 0 0 0 0 18 6 0 0 0 0 0 0 0 100 88 Masvingo 204 189 358 0 646 0 96 7 0 91 0 0 0 0 73 24 0 0 5 1 0 0 0 93 50 Eastern 3 3 5 0 2 0 0 0 0 2 0 0 0 0 2 0 0 0 0 0 0 0 0 100 100 South Eastern 6 6 14 0 17 0 0 0 0 2 0 0 0 0 1 0 0 0 0 0 0 0 0 100 100 North Western 6 5 18 0 10 0 1 1 0 5 0 0 0 0 2 0 0 0 0 0 0 0 0 80 80 Northern 3 3 17 0 13 0 2 0 0 4 0 0 0 0 2 0 0 0 0 0 0 0 0 100 100 South Western 5 5 13 0 13 0 0 0 0 2 0 0 0 0 2 0 0 0 0 0 0 0 0 100 100 Southern 7 7 26 0 45 0 7 0 0 5 0 0 0 0 15 0 0 0 0 9 0 0 0 100 100 West South West 5 4 27 0 39 0 2 0 0 4 0 0 0 0 6 0 0 0 0 30 0 0 0 80 80 Western 4 3 10 0 13 0 2 0 0 9 0 0 0 0 2 0 0 0 0 0 0 0 0 75 75 Harare Province 39 36 130 0 152 0 14 1 0 33 0 0 0 0 32 0 0 0 0 39 0 0 0 92 92 Emakhandeni District 7 7 32 0 19 0 5 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 100 100 Nkulumane District 6 6 12 0 11 0 0 0 0 1 0 0 0 0 3 0 0 0 0 0 0 0 0 100 100 Northern Suburbs District 8 8 4 0 18 0 4 0 0 1 0 0 0 0 3 0 0 0 0 0 0 0 0 100 100 Byo Province 21 21 48 0 48 0 9 0 0 2 0 0 0 0 10 0 0 0 0 0 0 0 0 100 100 Urban District 9 6 62 0 48 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 67 67 UBH 1 1 0 0 7 1 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 100 0 Ingutsheni 1 1 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100 100 Mpilo 1 1 11 0 5 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 100 100 Parirenyatwa Group of Hospitals 1 1 9 0 1 1 0 0 0 1 0 0 0 0 4 0 0 0 0 0 0 0 0 100 0 Harare Central Hospital 1 1 28 1 29 0 0 0 0 2 0 0 0 0 7 1 0 0 0 3 0 0 22 100 33 Chitungwiza Central Hospital 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 1711 1557 3825 2 4864 2 570 441 1 2960 6 0 0 0 503 167 7 0 29 43 1 0 1918 91 61

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STANDARD CASEDEFINITIONS DISEASES / CONDITIONS DEFINITIONS No Cholera Area: any patient age 5 years or more with severe dehydration or death from acute watery diarrhoea Suspected Case Cholera If There Is A Cholera Epidemic: any person age 2 years or more with acute watery diarrhoea, with or without vomiting Confirmed Case A suspected case in which Vibrio cholerae O1 or O139 has been isolated in the stool Suspected Case A person with diarrhoea and visible blood in the stool Dysentery Confirmed Case Suspected case with stool culture positive forShigelladysenteriae type 1 Suspected Case Any person with gradual onset of steadily increasing and then persistently high fever, chills, malaise, headache, sore throat, cough, and, Typhoid sometimes, abdominal pain and constipation or diarrhea Confirmed Case Suspected case confirmed by isolation of Salmonella typhi from blood, bone marrow, bowel fluid or stool , urine Suspected Case Any person living in a malaria area or history of travelling in a malaria area within the last 6weeks, presenting with fever , malaise, chills, and rigors, without signs of severe disease such as vital organ dysfunction

Malaria Confirmed Case Uncomplicated Cases: A suspected uncomplicated malaria with laboratory diagnosis by malaria blood slide or RDT for malaria parasites Complicated Cases: A patient hospitalized with P. falciparum asexual parasitaemia as confirmed by laboratory tests with accompanying symptoms of severe disease (vital organ dysfunction)

Suspected Cases a. Cutaneous form: Any person with skin lesion evolving over 1 to 6 days from a papular through a vesicular stage, to a depressed black eschar invariably accompanied by oedema that may be mild to extensive b. Gastro-intestinal: Any person with abdominal distress characterized by nausea, vomiting, anorexia and followed by fever c. Pulmonary (inhalation): any person with brief prodrome resembling acute viral respiratory illness, followed by rapid onset of hypoxia, dyspnoea and high temperature, with X-ray evidence of mediastinal widening Anthrax d. Meningeal: Any person with acute onset of high fever possibly with convulsions, loss of consciousness, meningeal signs and symptoms; commonly noted in all systemic infections Confirmed Case A confirmed case of anthrax in a human can be defined as a clinically compatible case of cutaneous, inhalational or gastrointestinal illness that is laboratory-confirmed by: a. isolation of B. anthracis from an affected tissue or site; or b. Other laboratory evidence of B. anthracis infection based on at least two Supportive laboratory tests.

Suspected Case A person with one or more of the following: headache, neck pain, nausea, fever, fear of water, anxiety, agitation, abnormal tingling sensations or pain at the wound site, when contact with a rabid animal is suspected. Rabies Confirmed Case A suspected case that is laboratory confirmed Suspected Case Severe malaise, prostration and very painful swelling of lymph nodes, or cough with blood stained sputum, chest pain, and difficulty in breathing. Plague Confirmed Case Suspected case confirmed by isolation of Yersinia pestis from blood or aspiration of buboes, or epidemiologic link to confirmed cases or outbreak.

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DISEASES / CONDITIONS DEFINITIONS Suspected Case A person with sudden onset of fever (> 38 C) AND cough or sore throat in the absence of other diagnoses Influenza Confirmed Case Is a case that meets the clinical case definition and is laboratory confirmed (laboratory results must be positive for influenza virus). SARI Any severely ill person presenting with manifestations of acute lower respiratory infection with:  Sudden onset of fever (>38ºC) and  Cough or sore throat and  Shortness of breath, or difficulty breathing with or without clinical or radiologic findings of pneumonia

Suspected Case Any individual with a history of fever, or documented fever 38 °C and  One or more symptoms of lower respiratory tract illness (cough, difficulty breathing, shortness of breath) and  Radiographic evidence of lung infiltrates consistent with pneumonia or Acute SARS Respiratory Disease Syndrome (ARDS) or autopsy findings consistent with the pathology of pneumonia or ARDS without an identifiable cause and  No alternative diagnosis can fully explain the illness Confirmed Case An individual who tests positive for SARS-CoV infection by the WHO recommended testing procedure Suspected Case Any person with fever and maculopapular (non-vesicular) generalized rash and cough, coryza or conjunctivitis (red eyes) or any person in whom a clinician suspects measles Measles Confirmed Case A suspected case with laboratory confirmation (positive IgM antibody) or epidemiological link to confirmed cases in an outbreak

Acute Flaccid Suspected Case Any child under 15 years of age with acute flaccid paralysis including Guillain-Barré Syndrome or any person with paralytic illness at Paralysis (AFP)/ any age in whom the clinician suspects poliomyelitis Poliomyelitis Confirmed Case A suspected case with virus isolation in stool Any newborn with a normal ability to suck and cry during the first two days of life, and who, between the 3rd and 28th day of age, cannot Neonatal Tetanus (NNT) suck normally, and becomes stiff or has convulsions or both. It can result in death

Any person with sudden onset of fever (>38.5ºC rectal or 38.0ºC axillary) and one of the following signs: neck stiffness, altered Suspected Case Meningitis consciousness or other meningeal signs Confirmed Case A suspected case confirmed by isolation of N. meningitidisfrom CSF or blood. The death of a woman while pregnant or within 42 days of the delivery termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental Maternal Death causes

Any person presenting with an acute onset of fever (≥38°C) with any of the following additional symptoms: severe headache, Ebola muscle pain, vomiting, diarrhoea, abdominal pain, or unexplained hemorrhage.

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