WORLD HEALTH ORGANIZATION

Response to Shigellosis Outbreak Sierra Leone February 2000

Preliminary report and recommendations of mission to Sierra Leone28/1/00 - 5/2/00 (a final report will be made when all results from the field and

laboratory are available)

------------------------------------------------------------------------------------------------------------------------Dr Mike Ryan, Medical officerCommunicable Diseases Surveillance and ResponseTel +41 22 791 3691 Fax: +41 22 791 4198 e-mail: ryanm@who.int

TABLE OF CONTENTS

Page1. Background 32. Objectives of the mission 33. Work Process 34. Field Response 45. Epidemiological Data 76. Laboratory data 97. Sub-Regional issues 98. Drug policy issues 99. Opportunities for further research 1010. Follow up activities 1011. Recommendations 10

LIST OF ANNEXES

Annex 1 Case Management algorithm 11Annex 2 Patient Treatment Coupon 12Annex 3 Feeding during and after Diarrhoea 13Annex 4 Public Health Action to Control Shigellosis in Sierra Leone 14Annex 5 Laboratory Request Form 15Annex 6+7 Surveillance Forms 16Annex 8 Record review form 18Annex 9 Assessment of Dehydration 19Annex 10 Guidelines for management of dehydration 20

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1. Background

In late 1999 an outbreak of bloody diarrhoea was detected in the Western Area of Sierra Leone. At that time Shigella flexneri was isolated by IP Abidjan. The outbreak has continued to spread and is now affecting all districts. On 29 December 1999, Institut Pasteur (IP) Paris isolated Shigella dysenterie type 1 (Sd1) with a further 10 isolates in the first three weeks of 2000 from cases in Kenema District (Eastern Region), Moyambe District (Southern Region) and Koinadugu District (Northern Region).

The MoH and WHO continued to receive reports of bloody diarrhoea. However, the true situation was unclear as the surveillance system is functioning very poorly and some areas are very difficult to access due to security reasons. The emergence of Shigella dysenterie type 1 was of great concern to the MoH, WHO and the NGOs.

WHO received an official request for assistance from the Government of Sierra Leone on the 25th January 2000. WHO AFRO and HQ fielded a two-person team (Professor Koumare, Dr. Mike Ryan). The team left for the field on 27 th January and had a preliminary briefing together in Conakry before travelling to Freetown together. A consultant seconded to MSF-F from Epicentre (Dr. Phillipe Guerrin) joined the team in Freetown.

2. Objectives of mission

The objective of the mission was to support the WRO and the Ministry of Health in Sierra Leone to:

assess the extent, impact and exact pathogens causing of the outbreak in 9 accesible districts.

provide training in case management to district health workers distribute drugs and equipment for outbreak response educate the population on how to avoid infection institute intra-epidemic surveillance for bloody diarrhoea

3. Work Process

On arrival on 28th January the WHO team were briefed by Dr. Wurie, DPC/WRO and a series of meetings planned with the Director General of Medical Services (Dr. Kamara), the DPC/MOH (Dr. Thuray) and health NGOs active in the health area.

A meeting of the Epidemic Response Committee was held on Monday 31st and the current situation discussed. It was decided that a small technical group would meet intensively over two days to plan a field assessment and response. This group consisted on MoH, WHO and two NGOs (MSF-F and MERLIN).

A series of intensive planning meeting were held on Tuesday and Wednesday with the production of a national plan for outbreak response including logistic arrangements. During these two days Professor Koumare commenced training of staff at the medical laboratory at the Connaught Hospital in Freetown. The WHO team had brought enough laboratory materials for the collection, transport, isolation and serotyping of up to 600 specimens.

The team had also hand carried 3,000 tablets of nalidixic acid and WHO provided a further 100,000 tablets arrived by air and sea over the subsequent days. In addition WHO provided $10,000 for the overall field response, to procure ORS, IV fluids and carry out health education campaigns

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4. Field Response

By Friday Feb 4th all arrangements had been put in place for 4 teams to leave for the field visiting all regions spending 4-6 days with the following objectives;

To train PHU and Hospital health care workers in the diagnosis treatment, registration and reporting of bloody diarrhoea/shigellosis

To distribute antibiotics (Nalidixic Acid), IV fluids, ORS and health education material to hospitals and PHUs

To collect quantitative information on bloody diarrhoea from registers in PHCUs from June 1999 to February 2000

To systematically collect stool specimens from new cases and transport them in Cary Blair medium in a cold chain to Freetown (Connaught Hospital) where WHO has equipped and trained the staff in the recognition of shigella sp.

To institute intra-epidemic surveillance of bloody diarrhoea at PHUs and hospitals using existing surveillance officers used in AFP surveillance

4.1 Diagnosis and Case Management

The case definition to be used was: "Diarrhoea with visible blood in the stools observed by a health care worker "

Treatment centres: Patients will be treated at PHUs where there is a Clinical Health Officer (CHO), Nurse Dispenser or a SECHN (State Enrolled Community Health Nurse).

Selection of cases for treatment:: Nalidixic acid is in limited supply. Therefore treatment for the moment will be reserved for only "High Risk" patients. All diarrhoea cases with bloody diarrhoea should be examined and asssessed. The criteria for the use of Nalidixic Acid are

Severe illness (dehydration, temperature >38.5C, altered consciousness convulsion, coma) OR

Age less than 5 years or over 50 years OR Malnourishment (visble wasting and/or bipedal oedema)

If the patient fulfills ANY of the above criteriae then use the treatment algorithm provided in Annex 1:

See Treatment Algorithm (ANNEX 1)

Note: If it is not possible to keep the patient for the full 5 days then they should be discharged with enough antibiotics to finish therapy. A relative should be instructed on the number and timing of tablets and should observe the patient taking the tablets. A patient treatment coupon should be given to the relative to give to the "Blue Flag" village volunteer who will ensure that the antibiotic course is finished.

If the patient is NOT "High Risk and does not meet the criteria for antibiotic therapy then1. Give supportive therapy according to level of dehydration (ORS) 2. Encourage the patient to continue feeding3. Give health education4. Discharge the patient and tell then to return if their condition does not improve

IT IS VERY IMPORTANT THAT ALL PATIENTS COMPLETETHERAPY WITH NALIDIXIC ACID FOR A FULL FIVE DAYS !

Completion of the full five days will help the patient to make a full recovery and will also help to prevent shigella becoming resistant to Nalidixic acid.

THEREFORE

ALL TREATMENT WITH NALIDIXIC ACID MUST BE SUPERVISED !

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4.2 Health Education

This activity is planned in collaboration with Mr B.A. Kawa from the Health Education Department. Public health messages have been selected for dissemination by radio poster and community meetings.

Existing posters will be adapted and printed Posters will be taken to the field by teams as well as health education materials for

community workers. Radio messages will be disseminated on national radio and on local FM radio where

available

Sample Messages

TO PROTECT FROM BLOODY DIARRHOEA AND DYSENTERY

Wash hands with soap and water- After using the toilet, changing nappies or cleaning child- Before preparing food and eating

Always use a latrine when going to the toilet

Eat only fruits that have been freshly peeled

Cook all meats, fish and vegetables thoroughly

Make water safe for drinking by boiling

Store drinking water in a clean container with a small opeing or cover- Pour water from the container - do not dip a cup in the container

4.3 Specimen collection and Laboratory Testing

The field teams will collect at least 20 samples per district. Specimens will be collected according to the following criteria

case with current bloody diarrhoea onset of illness < 4 days who have not received antimicrobials for this illness

1. Before sampling the specimen containers with Cary-Blair medium should be cooled in a cool box to +4c. The liquid medium will become semi-solid and the cooler temperature facilitates the viability of the organism later.

2. Collect fresh stool in sterile petri dish (dishes will be provided to each team). 3. Verify that the stool is characteristic (presence of blood).4. With the spoon contained in the faecal specimen container, take a small amount of bloody

part of the stools.5. Place the spoon in the container which already contains the Cary-Blair transport medium

and screw tightly shut. (make sure that the faecal specimen itself rests in the Cary-Blair medium)

6. On the container please with an indellible pen write the patient name, village and the date7. The samples should be placed in a vaccine carrier and kept at 4 Celsius.8. For each patient from whom a sample is collected please fill in a lab request form (see

Annex 3)

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4.4 Data collection in the Field

While visiting health facilities one team member should look through the case registers if available and extract information on cases of bloody diarrhoea (June 1999 - January 2000)A table for each PHU visited should be completed (see Annex 8: record review form)

These data wil be anaysed in the field and copies taken back to the national MoH for further analysis

4.5 On-going intra-epidemic surveillanceThere is a need to collect on-going data on the evolution of the outbreak. AFP surveillance officers will be used to collect weekly data from PHUs on Bloody diarrhoea and watery diarrhoea. These data will be aggregated and analysed by the DMO team and also reported to MoH Freeown via radio.

1. A bloody diarrhoea surveillance form will be filled in at all centres providing treatment of cases.

2. Each form will cover one week and will be completed daily3. Surveillance officers will visit on a weekly basis and collect aggregate data for the week

Training in how to complete forms will be provided. See Annex 6 + 7 for data recording and collection forms

4.6 Logistics and Supplies Needed

LogisticsFour investigation teams will be required in the field for 4-6 days. The teams plan to leave for the field on Sunday February 6th. Each team will have a vehicle from national level and one from the district. The teams will consist of national and district MoH staff and international staff as required. The teams will require vehicles, fuel, accomodation and DSA. In addition they will take health education materials, IV fluids, ORS, antibiotics and basic medications to treat other illnesses in the villages visited. Data entry and analysis will take place afterwards in Freetown as well as laboratory investigations.

Supplies needed

1. Fuel 100 gallons @5,000 per gallon 2. 1000 copies of standard case management protocol + alogrithm3. Nalidixic acic (50,000 x 500mgs) 4. ORS (20,000 packets)5. IV fluids (ringers lactate x 1 litre) + giving sets (900)6. Additional cannulae (200)7. 20,000 packets of ORS8. Health Education Posters (1,000)9. Health Education Handouts (1,000)10. Sterile Petri dishes (x 300)11. Sool specimen containers with Cary-Blair medium (x 300)12. Ice packs (x 100)13. Cool boxes/Vaccine carriers (x 20)14. UNICEF Vaccine shippers (x 8) 15. Laboratory request forms (x 200)16. Record review forms (x 500)17. PHU bloody diarrhoea recording forms (x 2000)18. Weekly bloody diarrhoea forms- Surveillance Officer (x 300)19. Notepads, pens and pencils (x 1000)20. Rulers (x 200)21. A4 paper (x 5 reams)

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5. Epidemiological data

At time of writing the 4 investigations teams are just back from the field and the data collected has not yet been analysed. However, a review of available data was carried out and is presented here for background. More detailed data will be preseted later as soon at it is available (see Final Report)

The team reviewed available data from the Ministry of Health on reported cases of "bloody diarrhoea" since January 1999. It must be noted that in none epidemic periods many cases of bloody diarrhoea in Sierra Leone may be caused by schistosomiasis which is endemic.

However, it is clear that "bloody diarrhoea" became an increasing problem in many districts of Sierra Leone relatively early in 1999. Figure 1 shows reported cases of "bloody diarrhoea reported by month in 4 districts. It can be noted that there was a rise in reportes cases over the months of February to July with a plateau after this. Shigella flexneri was isolated in IP Abidjan from cases in the Western area (1 case in Port Loko districts and 2 cases in IDP camps near Freetown). At this time there were very few reports of fatalities but evidence to confirm this finding.

These data are supported by data produced by MERLIN which shows similar patterns in Freetown and Newtown over the period July to November 1999.

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R ep o rted C ases o f B lo d d y D iarrh o ea b y M o n th W e s tern A rea an d D is tric ts o f B o , B o n th e , K o in a d u gu an d P u jeh a m ,

S ie rra L e o n e , 1 999

0

20 0

40 0

60 0

80 0

100 0

120 0

140 0

160 0

Ja n F eb M ar Apr M ay Jun Jul Aug S e pt Oc t No v D e cM onth

Rep

orte

d C

ases

<5>5

Figure 1

Figure 2

Clearly "bloody diarrhoea" was becoming an increasing problem in many districts. NGOs began treating patients with Nalidixic acid with reports of good clinical efficacy. Again there were no data to support these reports.

In November and December MSF- France based in Kenema district (Eastern Region) experienced a sharp increase of cases of "bloody diarrhoea" (Figure 3)

On 29 December 1999, IP Paris isolated Shigella dysenterie type 1 sensitive to Nalidixic acid and ciprofloxacin. By special agreement with eth Ministry of health MSF had instituted supervised therapy with Ciprofloxacin for five days in all severe and "high-risk" patients. They reported an ovearll case-fatality rate of 4.2%. However the oveall trend in CFR was downwards. This was attributed by MSF to the introduction of ciprofloxacin therapy.

Table 1

A further 10 isolates of Sd1 were made in the first three weeks of January 2000 from cases in Kenema District (Eastern Region), Moyamba District (Southern Region) and Koinadugu District (Northern Region).

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C a ses o f B lo ody D ia rrhoe a R ep o rte d by M S F4 C h ie fd om s in K en em a D is tric t- S ie rra L e one

27 No v 199 9 - 2 3 J an 20 00

0

100

200

300

400

500

600

700

800

900

1999 /48 1999/49 1999/50 1999/51 1999/52 1999/53 2000 /1 2000 /2 2000 /3

W e e k

Rep

orte

d C

ases

5+< 5

Bloody diarrhoea in three chiefdoms of Kenema District (Southern Region)

New Cases Deaths Case fatality ratioCumulative attack ratio

Period - year/weekno < 5 5+ Total < 5 5+ Total < 5 5+ Total1999/48 5 7 12 0 0 0 0.0 0.0 0.0 01999/49 31 58 89 0 0 0 0.0 0.0 0.0 0.21999/50 71 176 247 10 11 21 14.1 6.3 8.5 0.61999/51 68 167 235 11 12 23 16.2 7.2 9.8 11999/52 247 567 814 28 23 51 11.3 4.1 6.3 2.51999/53 234 583 817 11 7 18 4.7 1.2 2.2 42000/1 72 204 276 1 2 3 1.4 1.0 1.1 4.52000/2 75 390 465 3 1 4 4.0 0.3 0.9 5.32000/3 36 185 221 5 8 13 13.9 4.3 5.9 5.7Total 9 weeks 839 2337 3176 69 64 133 8.2 2.7 4.2

Overal Case Fatality ratio = 4.2%Population covered by services 55,875 in Chiefdoms of Gaura, Dama, Tunkia

Source- MSF-FRANCE

Figure 3

6. Laboratory Data

Figure 4 shows the geographiical distribution of isolates of Shigella sp in Sierra Leone since November 1999. The districts ….

The laboratory at Connaught Hospital, Freetown has now been trained on how to isolate and serotype Shigella sp.with supplies and training provided by WHO. The teams who went to the field have returned with 82 samples which were taken according to strict protocols of patient selection and specimen transport. This resulted in 72/82 confirmations of Shigella dysenteriae type 1 sensitive to nalidixic acid and ciprofloxacin.

It is planned to continue with systematic surveys to track the pathohgen and its sensitivity patterns.

7. Sub-regional issues

Reports have been received of outbreaks of dysentery in Conakry and in the Western part of Liberia. In addition during 1999 14 of 16 countries in the West African sub-region have isolated Sd1. Clearly the problem of Sd1 has emerged in West Africa and is now affecting many countries. This requires a region-wide response to reduce case fatality and to interupt spread of the organism.

The WHO West African Epidemic Response Team will need immediate support if they are to effectively assist coutries in combatting this epidemic. There is an urgent need for an epidemiological assessment of the situation in all countries of West Africa.

8. Drug Policy Issues

The outbreak in Sierra Leone has raised some pertinent questions regarding the WHO drug policy for epidemic shigellosis. Sd1 is a strain capable of causing high case fatlaity (20%) and also deveopls resistance relatively quickly. At present the organism remains sensitive to Nalidixic Acid and Ciprofloxacin.

The current WHO policy is that Nalidixic acid is the first line treatment for shigellosis with ciprofloxacin as second line. Nalidixic acid is 10 times cheaper which makes it more available to MoHs for use. However the two drugs are from the same family and the mutation required

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Figure 4

Koinadugu

Western Area

Kenema

Moyamba

for nalidixic acid resistance is one that is also required for ciprofloxacin resistance. This raises the question of whether sequential use of the drugs would lead to the rapid emergence of ciprofloxacin resistance. Bayer have provided ciprofloxacin to MSF at one tenth the cost in emergency situations (approx 1 USD per course). A similar arrangement is not is place with WHO.

WHO needs to rapidly reassess the current treatment guidelines for epidemic Sd1 and either reaffirm the current advice or make any rational changes that are nercessary after discussions with relevant experts and with the drug companies.

9. Opportunities for Further Research

The fact that MSF are using ciprofloxacin in defined areas of Sierra Leone may allow the opportunity to collect quantitative information on the effcicay of the drug and the emergence of resistance and allow for comparisons with nalidixic acid. It is unlikely that a controlled trial could be carried out but and observational study may be possible. Dr. Phillipe Guerin from Epicentre will liase with MoH, MSF, MERLIN and WHO on the fesability of such studies.

10. Follow up activities (surveillance and preparedness)

This outbreaks represents only one of the many communicable disease threats to the population of Sierra Leone. There has been a complete collapse of public health infrastructure which is slowly being rehabilitated with the collaboration of the MoH, WHO, other UNOs and NGOs.

It is critical that the basic epidemic surveillance and response capacity within Sierra Leone is strengthened. WHO/AFRO has been engaged in training epidemiology and laboratory staff in the country and there are many enthusiastic people with the MoH and the health service who want to move forward with a project to strengthen surveillance and response.

A project proposal is being drafted and will be shared with interested donors for funding. This project will be supported by the WRO, The West African Epidemic Response Team, AFRO and HQ.

11. Recommendations

WHO should continue to support the MOH Sierra Leone in responding to the epidemic WHO should support the MoH in implementation of intra-epidemic surveillance for "bloody

diarrhoea" throughout Sierra Leone (using AFP surveillance officers) WHO should support the development and implementation of a long term project to

strengthen surveillance and response in Sierra Leone WHO should work with the MOH and NGOs to design studies that will gather important

data on the efficacy of drug therapy and the emergence of resistance WHO should urgently assess the epidemiological situation of Sd1 in West African

countries WHO should provide further support to the West African Epidemic Response team to

enable them to assist member states in epidemic response WHO should support national laboratories in the collection of specimens and confirmation

of shgigellosis WHO should urgently review drug policy in treatment of shigellosis

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ANNEX 1: Diagnosis and Treatment of Bloody Diarrhoea (CHC and Hospital)

Bloody Diarrhoea (visible blood in the stools

observed by health worketr)

Is the patient has Severely Ill

Severely dehydration ?(see chart)OR

Altered consciousness ?OR

Has had a convulsion ?OR

In coma ?OR

Fever > 38.5 ?

YES

Treat dehydration and give supportive therapy (ORS)

Give Health Education Discharge Advise patient to return if

condition worsens

Treat Dehydration (Give ORS and/or IV fluids)

Start antibiotic therapy (nalidixic acid 2 x 400mg x 4 times daily in adults, 15mg/kg x 4 times daily in children)

Directly observed treatment by health worker or family member (record therapy on coupon provided)

Advise patients caretaker to provide fluids and food

Give health education Observe and assess patients

condition regularly Patients who are severely ill or

who do not respond to therapy should be referred to the district hospital

NO

Is the patient

less than 5 years ?OR

older than 50 years ?OR

Malnourished (visible wasting or bipedal oedema) ?

YES NO

Nalidixic acid treatment must be supervised !

Adults

Nalidixic Acid 2 x 500mg taken 4 times a day for 5 days

Children

Nalidixic Acid 15mg/kg taken 4 times a day for 5 days

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ANNEX 2: Patient Treatment Coupon

PATIENT TREATMENT COUPON

Health Facility:

Type: CHU ( ) Hospital ( ) Other ( ) Specify _______

Name of Patient: ________________________ Age ___

Village ___________________

Treatment____________________ Dose ____________

Date treatment commenced ___________

Prescribed by:______________ Supervised by:______________

Dose 1Morning

Dose 2Afternoon

Dose 3Evening

Dose 4Night

Day 1Day 2Day 3Day 4Day 5

-------------------------------------------------------------------------------------------------------

PATIENT TREATMENT COUPONHealth Facility:

Type: CHU ( ) Hospital ( ) Other ( ) Specify _______

Name of Patient: ________________________ Age ___

Village ___________________

Treatment____________________ Dose ____________

Date treatment commenced ___________

Prescribed by:______________ Supervised by:______________

Dose 1Morning

Dose 2Afternoon

Dose 3 Evening

Dose 4Night

Day 1Day 2Day 3Day 4Day 5

Place "X" in the appropriate box as tablet is given

Place "X" in the appropriate box as tablet is given

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ANNEX 3: Feeding during and after diarrhoea

General guidelines

Encourage the child to eat during the entire illness

During and after illness, feed the child as follows:

Up to age 4-6 months

Breastfeed as often as the child wants, day and night.

For children taking other milk, give appropriate milk as often as the child wants by cup. Increase the breastfeed while gradually reducing the other milk over several days. Give the additional milk by cup, not by bottle

If the child is fed on other milk alone, give this as often as the child wants by cup, not by bottle.

4-6 months up to 12 months

Breastfeed as often as the child wants.

Give foods three times a day if breastfed or five times a day if not breastfed

12 months up to 2 years

Breastfeed as often as the child wants

Give food five times a day

Above 2 years

Give family foods: three meals + two additional feeds.

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ANNEX 4

Public Health Action to Control Shigellosis in Sierra Leone by Level

LEVEL ACTION

Village Health Workers ("Blue Flag" Volunteers)

(and community leaders)

INFORM the community that - there is an outbreak of bloody diarrhoea - the disease is preventable and curable EDUCATE the community about the importance of personal hygiene especially the

washing of hands with soap and water (see health education material). DETECT cases of bloody diarrhoea in the community and give first aid (ORS or

sugar/salt solution) and refer cases to PHCC/PHCU/Hospital WARN local PHCU, and CHC about clusters of cases in villages Make sure that all cases treated with antibiotics complete their tablets

PHU without CHO, Nurse dispenser or SECHN

DIAGNOSE and REGISTER suspected cases of bloody diarrhoea GIVE cases supportive therapy (ORS) ADVISE case to drink adequate fluids and continue feeding EDUCATE suspected case and family about the importance of personal hygiene REFER patient to CHU who can further assess and treat with antibiotics if

necessary REPORT number of suspected cases treated to surveillance officer on a weekly

basis (see recording and reporting forms) REPORT IMMEDIATELY if number of cases is rising rapidly

PHU with CHO, Nurse dispenser or SECHN

OR

Hospital

DIAGNOSE and REGISTER suspected cases of bloody diarrhoea ASSESS patients according to standard protocol TREAT patients as indicated. ADVISE case to drink adequate fluids and continue feeding EDUCATE suspected case and family about the importance of personal hygiene ENSURE that treated patients complete their antibiotic course REPORT number of suspected cases treated to surveillance officer on a weekly

basis (see recording and reporting forms) REPORT IMMEDIATELY if number of cases is rising rapidly

District Medical teams and NGOs

TRAIN health care workers in diagnosis, treatment and reporting of bloody diarrhoea

STOCKPILE and DISTRIBUTE antibiotics, IV fluids and ORS for distribution to health facilities

COLLECT information from PHUs and hospitals on a weekly basis using provided form

ANALYSE information and data received from PHU/Hospital to monitor numbers and location of cases of bloody diarrhoea

CONFIRM disease in newly affected areas by site visits and take laboratory specimens as indicated in laboratory guideline

MoH Freetown and WHO

STOCKPILE and DISTRIBUTE antibiotics, IV fluids and ORS for distribution to health facilities

TRAIN District medical personnel in daignosis, case management and reporting COLLECT information from PHUs and hospitals on a weekly basis using provided

form (Use radios or available transport) ANALYSE situation in the country as a whole

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ANNEX 5 Laboratory Request Form

STOOL SPECIMEN DATA SHEETBACTERIOLOGIC SURVEILLANCE

Country __________________________

District _________________________

Team ________________________

Specimen No.

Date of Collection

Village/Town Age Sex Duration of illness (days)

Bloody Stool (Y/N)

Taken antiobiotic(YIN)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Date specimens received by laboratory _______

Temperature inside cool box on arrival _______

Condition of Specimens Good/Poor

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GOVERNMENT OF SIERRA LEONEMINISTRY OF HEALTH AND SANITATION

DAILY NUMBER OF CASES AND DEATHS FROM BLOODY DIARRHOEA

Clinic …………………………….. Reported by ……………………………. From ……………………………. To …………………………….

Case Definition of the disease: "Any patient with diarrhoea and visible blood in the stool (obersved by health worker)"

Date Day New cases seen Patients treated with antibiotic (Nalidixic acid)

Number of referrals Number of deaths

Dd/mm/yy< 5

years5 years

and overTotal < 5

years5 years

and overTotal < 5

years5 years

and overTotal < 5

years5 years

and overTotal

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Total

TO BE COMPLETED BY HEALTH WORKER IN PHU OR HOSPITAL

GOVERNMENT OF SIERRA LEONEMINISTRY OF HEALTH AND SANITATION

WEEKLY NUMBER OF CASES AND DEATHS FROM BLOODY DIARRHOEA

District ……………………….. Surveillance officer ……………………………. From ……………………………. To: …………………………….

Case Definition of the disease: "Any patient with diarrhoea and visible blood in the stool (obersved by health worker)"

Date New cases seenPatients treated with

antibiotic(severe or "high risk"

Number of referrals Number of deaths

Health facility < 5 years

5 years and over

Total < 5 years

5 years and over

Total < 5 years

5 years and over

Total < 5 years

5 years and over

Total

TO BE COMPLETED BY DISTRICT SURVEILLANCE OFFICER

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GOVERNMENT OF SIERRA LEONEMINISTRY OF HEALTH AND SANITATION

RECORD REVIEW for "Bloody Diarrhoea or Dysentery"

Monthly NUMBER OF CASES AND DEATHS FROM BLOODY DIARRHOEA

Health facility …………………………. Type PHU ( ) Hospital ( ) District ………………

New cases

Month < 5 years 5 years and over

Total

June 1999

July

August

September

October

November

December

January 2000

Total

TO BE COMPLETED BY FILLED INVESTIGATION TEAM OR DISTRICT SURVEILLANCE OFFICER

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ANNEX 9: Assessment for Dehydration

19

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ANNEX 10: Guidelines for Management of Dehydration

Rehydrate the patient, and monitor frequently.Then reassess hydration status

FOR SEVERE DEHYDRATION:

Give IV fluid immediately to replace fluid deficit. Use Ringer's lactate solution or, if not available, normal saline.

Start IV fluid immediately. If the patient can drink, begin giving oral rehydration salts (ORS) solution by mouth while the drip is being set up.

For patients aged 1 year and older, give 100 ml/kg IV in 3 hours, asfollows:

- 30 ml/kg as rapidly as possible (within 30 minutes); then- 70 ml/kg in the next 22 hours.

For patients less than 1 year, give 100 ml/kg IV in 6 hours, as follows:- 30 ml/kg in the first hour; then- 70 ml/kg in the next 5 hours.

Monitor the patient very frequently. After the initial 30 ml/kg have been given, the radial pulse should be strong (and blood pressure should be normal). If the pulse is not yet strong, continue to give IV fluid rapidly.

Give ORS solution (about 5 ml/kg/h) as soon as the patient can drink, in addition to IV fluid.

Reassess the patient after 3 hours (infants after 6 hours), using Table 1:- If there are still signs of severe dehydration (this is rare), repeat the IV therapy already given.- If there are signs of some dehydration, continue as indicated below for some dehydration.- If there are no signs of dehydration, go on to Step 3 to maintain hydration by replacing ongoing fluid losses.

FOR SOME DEHYDRATION:

Give ORS solution:- Administer ORS solution in the amount recommended on Table 2.- If the patient passes watery stools or wants more ORS solution than shown, give more.

1 Use the patient's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patient's weight (in kg) times 75.

Monitor the patient frequently to ensure that ORS solution is taken satisfactorily and to detect patients with profuse ongoing diarrhoea who will require closer monitoring.

Reassess the patient after 4 hours, using Table 1:

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- If signs of severe dehydration have appeared (this is rare), rehydrate for severe dehydration, as above.- If there is still some dehydration, repeat the procedures for some dehydration, and start to offer food and other fluids.- If there are no signs of dehydration, maintain hydration by replacing ongoing fluid losses.

FOR NO SIGNS OF DEHYDRATION:

Patients first seen with no signs of dehydration can be treated at home.

Give ORS packets to take home. Give enough packets for 2 days.Demonstrate how to prepare and give the solution. The caretaker should give the patient this amount of ORS solution:

Age Amount of solution ORS packets neededafter each loose stool

Less than 24 months 50 - 100 ml Enough for 500 ml/day2 - 9 years 100 - 200 ml Enough for 1000 ml/day10 years or more as much as wanted Enough for 2000 ml/day

Instruct the patient or the caretaker to return if any of the following signs develop:- Increased number of stools- Eating or drinking poorly- Marked thirst- Repeated vomiting

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