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DISEASE SURVEILLANCE BULLETIN
Volume 1 1 1st Quarter (January – March) 2015
Contents Page No
Surveillance of Diarrhea Etiologic Agents among children under 5 years
1 - 2
Surveillance of Multi Drug Resistance 2 – 3
Influenza Surveillance 4 - 7
Measles and Rubella Surveillance 7 - 8
Acute Encephalitis Syndrome Surveillance 8
Leptospirosis Surveillance 8
Scrub Typhus 8 - 9
HIV Confirmation 9
Surveillance on Urban Drinking Water 9 - 13
Summary of Disease Outbreaks Report 13
Summary of National Notifiable Diseases 14
Fourth Quarter 2015
Department of Public Health Ministry of Health www.phls.gov.bt
PUBLIC HEALTH LABORATORY
DISEASE SURVEILLANCE BULLETIN
Volume 4 1 4th Quarter (October-December) 2015
1. Surveillance of Diarrhea Etiologic
Agents among children under 5 years
A total of 237 samples were collected from children
below five years who presented with diarrhea from
JDWNRH. All the samples were subjected to different
Microbiological methods to identify the diarrheal
etiologic agents (Microscopy, Culture, Multiplex
Polymerase Chain Reaction, Antimicrobial
Susceptibility Test and ELISA).
1.1 Microscopy
Microscopic examination of stool specimens was able
to detect some parasites, most commonly Taenia
species and Entamoeba species.
1.2 Culture/Isolates
Six different types of organism were isolated from 237
samples, all of which were subjected to bio-typing,
sero-typing, geno-typing and antimicrobial
susceptibility test where necessary (Table 1).
1.3 Multiplex PCR.
A total of 116 isolates of both LF and NLF Escherichia
coli were subjected to multiplex PCR to confirm and
differentiate the strains of Diarrheagenic E-coli (Figure
1). The commonly genotyped Diarrheagenic E-coli are
Enteroagregative E-coli and Enteroinvasive E-coli.
1.4 Antimicrobial susceptibility test (AST)
Antimicrobial susceptibility testing showed that of all
Shigella species, 90% (n=10) were resistant to
Nalidixic acid, 90% to Ciprofloxacin and 70% to
Sulfamethoxazole but 100% susceptible to Ceftriaxone
and Gentamycin. Other bacterial isolates (Salmonella)
were found susceptible to Amoxycillin,
Sulfamethoxazole and Ceftriaxone. Diarrheagenic
E.coli showed resistance to Amoxycillin but were
susceptible to Ceftriaxone, Ciprofloxacin and
Tetracycline (Table 2).
1.5 ELISA
Test result for enteric viruses (rotavirus, norovirus and
adenovirus) are still pending due to shortages of test
kits.
Table 1: Common organism isolated
Organism isolated Total
Aeromonas spp 1
Campylobacter spp. 3
Shigella 10
Salmonella 5
LF E-coli 92
NLF E-coli 24
Figure 1: Multiplex PCR showing different Diarrheagenic E-coli
DISEASE SURVEILLANCE BULLETIN
Volume 4 2 4th Quarter (October-December) 2015
Table 2: Antibiotic Susceptibility pattern of bacterial isolates
S = Susceptible, I = Intermediate, R = Resistant
AMX: Amoxycillin, CIP: Ciprofloxacin, SXT: Sulfamethoxazole,
CRO: Ceftriaxone, NAL: Nalidixic acid, GEN: Gentamycin, CHL:
Choloramphenicol, TCY: Tetracycline.
2. Surveillance of Multi Drug Resistance
Tuberculosis
2.1 Culture & Drug Susceptibility Testing
A total of 136 patient sputum samples were received for
culture and Drug Susceptibility Testing (DST) at
National TB Reference Laboratory (NTRL), among
which 101 were culture positive, 14 culture negative, 6
contaminated and rest are under incubation. 152 extra-
pulmonary (EPTB) samples were also processed for
MTB culture among which 11 were culture positive, 46
negative 14 contaminated and rest are under incubation.
DST was completed for 16 samples (PTB) and 2
samples (EPTB). 4 confirmed MDR-TB cases from
PTB were reported for the given period.
Apart from routine sample processing for culture and
DST, NTRL has received and processed 125 patient
samples for MDR-TB culture follow-up and 7 patient
samples for ruling out TB by culture for the purpose of
medical certificate.
Table 3: Number of TB cases among different types of TB
Pulmonary TB Extra-
pulmonary
TB New
Smear
Positive
New
smear
Negative
Re-
treatment/
Failure/
Relapse
Unknown
Patient
Sample
received for
culture & DST
110 7 12 7 152
Culture
Positive
84 3 6 2 11
DST
completed
11 0 5 0 2
MDR-TB
detected
1 0 3 0 0
Figure 2: Pie chart showing different type of Tb cases (PTB) sent
for culture & DST
NSP81%
NSN5%
Retreatment9%
Unknown5%
DISEASE SURVEILLANCE BULLETIN
Volume 4 3 4th Quarter (October-December) 2015
Figure 3: Number of samples received for culture & DST for 4th Quarter
Figure 4: Different type of TB cases (EPT) sent for culture &
DST
2.2 Descriptive analysis of MDR-TB cases
Four MDR-TB cases were confirmed by NTRL in the
fourth quarter of 2015, among which one was new
smear positive, three retreatment/failure/relapse
cases. No MDR is detected among EPTB cases. The
MDR-TB cases were reported among the productive
age group (22 to 32 years) and the youngest one is 22
years old. 3 MDR among female and 1 MDR in male
was reported
Table 4: Number of MDR-TB case reported from hospitals
Name of the Hospital Numbers
JDWNRH 3
Samdrup Jongkhar 1
Total 4
Figure 5: Different type of MDR-TB confirmed
66
2
22
14
3
11
1 3 2 1 1 14 2 2
0
10
20
30
40
50
60
70
Hospitals
FNAC67%Urine
1%
Pus11%
Pleural Fluid10%
Ascitic Fluid5%
Biopsy4%
CSF1%
Gastric Aspirate
1%
NSP25%
Retreatment/Failure/
relapse75%
DISEASE SURVEILLANCE BULLETIN
Volume 4 4 4th Quarter (October-December) 2015
3. Influenza Surveillance
3.1 Influenza Like-Illness Surveillance (ILI) –
Epidemiological Component
Out of total 83539 OPD visits at seven sentinel sites a
cumulative of 2204 ILI visits had been recorded for
this quarter. Average ILI incidence was 38 cases per
1000 outpatient visits (Figure 6). The highest ILI
incidence among sentinel sites was observed in Paro
Hospital (1200 cases) followed by Trongsa Hospital
(418 cases). ILI cases were commonly observed in
age group of 15-29 years (28.45%), (Table 5).
Figure 6: Average number of ILI cases reported for the 4th Quarter (week 40 to 53)
Table 5: Distribution of ILI cases by age groups
Age (Years) ILI cases
Number Proportion (%)
0-1 148 6.72
2-4 286 12.98
5-14 616 27.95
15-29 627 28.45
30-64 460 20.87
65+ 67 3.04
3.2 Influenza Like-Illness Surveillance –
Virological Component
Out of 239 ILI samples received and tested by RT-
PCR, 11.29 % (27/239) were positive for Influenza
virus, which comprise of Influenza A pandemic 2009
(A/pdm H1) – 22% (6), A/H3 strain -29.6% (8) and
Flu B- 48.14% (13). Numbers of specimens positive
for various influenza subtypes by week are illustrated
in Figure 7.
Influenza B virus was the most predominantly
circulating influenza virus strain in Bhutanese
population followed by Influenza A/H3.
Geographical distribution of influenza virus strains
among sentinel sites is given in Figure 8.
A high positivity rate was detected among 30-64
years age group (25%) and was mostly influenza B
(Figure 9).
DISEASE SURVEILLANCE BULLETIN
Volume 4 5 4th Quarter (October-December) 2015
Figure 7: Influenza virus subtype by week. (Figure adopted from: FluNet ( www.who.int/flunet ), GISRS)
Figure 8: Influenza virus subtype distribution by site
DISEASE SURVEILLANCE BULLETIN
Volume 4 6 4th Quarter (October-December) 2015
Figure 9: Influenza virus subtype and positivity rate by age group
3.3 Severe Acute Respiratory Illness
Surveillance (SARI) - Epidemiological
Component
Sentinel sites that include hospitals of JDWNR,
Paro, Punakha, Samtse, CRRH, Trongsa, Tsirang,
MRRH, Trashigang, Phuntsholing and
Samdrupjongkhar hospitals recorded a total of 3349
admitted patients (only relevant wards included in
Regional and National Referral Hospital) during
this quarter of year. Of these, 195 were SARI cases.
Average SARI incidence was 6 SARI cases per 100
hospitalized patients (Figure 10). The highest
SARI incidence was observed in Paro (48 cases)
followed by Samdrupjongkhar Hospital (36 cases).
No death cases were reported from any of the sites.
SARI cases were commonly observed in children of
age group 2-4years of age (Table 6).
Table 6: SARI case distribution by age groups
Age Cases (Numbers) Proportion (%)
0-1 76 38.97
2-4 39 20
5-14 17 8.72
15-29 14 7.18
30-64 32 16.41
65+ 17 8.72
3.4 Severe Acute Respiratory Infection
Surveillance- Virological component
Total of 98 throat swab specimens were received
from SARI cases of 11 sentinels sites. Phuntsholing
Hospital collected the maximum number of
samples (26 samples) followed by Samtse Hospital
(18 samples). The samples were tested for influenza
and other respiratory viruses like Respiratory
syncytial virus (RSV) and human meta-pneumo
virus (hMPV). Out of 97 samples, 4.12% samples
tested positive for Influenza Virus, (A/pdm H1- 2
& Flu B-2), 5.15% positive for (hMPV) and 7.21%
positive for RSV.
(Figure 11).
DISEASE SURVEILLANCE BULLETIN
Volume 4 7 4th Quarter (October-December) 2015
Figure 10: No. of SARI cases reported weekly
Figure 11: Trend of influenza virus and other non-influenza virus
Table 7: Respiratory viruses detected according age groups
Age A/PdmH
1 (n*=2)
Flu B
(n*=2)
RSV
(n*=7)
hMPV
(n*=4) Total
0-1 2 0 6 3 11
2_4 0 1 1 0 2
5_14 0 1 0 1 2
15-29 0 0 0 0 0
30-64 0 0 0 0 0
65+ 0 0 0 0 0
n* = number of cases
4. Measles & Rubella Surveillance
National measles and rubella reference laboratory
has tested 57 serum samples in the last quarter and
no samples tested positive for anti-Rubella IgM. Of
the 57 serum specimens 9 tested positive for anti-
measles IgM and one of the samples obtained
during contact tracing from a positive case in
Phuntsholing tested to be equivocal on testing and
retesting from the same sample. However, awaiting
a repeat sample from the patient. Throat swab has
been collected simultaneously and referred to WHO
Regional Reference laboratory, NIH, Thailand for
0
20
40
60
80
100
120
0
0.5
1
1.5
2
2.5
3
3.5
40 41 42 43 44 45 46 47 48 49 50 51 52 53
Pe
rce
nta
ge P
osi
tive
No
. Po
siti
ve S
pe
cim
en
s
Week
PdmH1 Flu B hMPV RSV Positivity Rate(%)
DISEASE SURVEILLANCE BULLETIN
Volume 4 8 4th Quarter (October-December) 2015
confirmation. All the 9 samples testing positive has
been confirmed and tested positive.
Genotyping has been performed for the very first
time on the positive samples and have uploaded to
the measles nucleotide surveillance (MeaNS)
database. Currently we have two each of D8 and B3
genotypes obtained from sequencing the 450
nucleotide N gene of the measles virus.
Table 8: Measles and Rubella Testing Report
5. Acute Encephalitis Syndrome
(AES) Surveillance
ELISA for anti-JE antibody tests has been carried
out on a total of 31 CSF and serum samples,
received from JDWNRH and Gelephu. No sample
tested positive for anti-JE antibody. Most samples
received have been referrals from the pediatric
OPD and IPDs of JDWNRH. However no samples
have been received from other districts other than
just one CSF and 3 serum samples from Gelephu
CRRH.
Table 9: Number of samples tested for JE
Hospitals Samples
CS
F
Result Seru
m
Result
Pos Equi Neg Pos Equi Neg
JDWNRH 10 0 0 0 18 0 0 0
Gelephu 1 0 0 0 3 0 0 0
Total 11 0 0 0 21 0 0 0
Pos: Positive Equi: Equivocal Neg: Negative
6. Leptospirosis Surveillance
IDSL tested 31 samples in the 4th quarter of which
none tested positive. (Table 10).
Table 10: Number of samples tested for leptospirosis
Referring site Total
samples
Positive
1 JDWNRH 24 0
2 Samtse 5 0
3 S’Jongkhar 2 0
Total 31 0
Note: Laboratory uses Rapid chromatographic tests, ELISA
and MAT (Microscopic agglutination test) to detect and
confirm cases of leptospirosis.
7. Scrub typhus
Samples are tested using principles of ELISA and
rapid chromatographic assays. Figure 12 shows the
serum samples testing positive for Orientia
tsutsugamushi IgM (ELISA), IgG, IgM and IgA
DISEASE SURVEILLANCE BULLETIN
Volume 4 9 4th Quarter (October-December) 2015
(RDT). Sipsoo was showing an increased positivity
over the season. Literatures suggests the end of the
Scrub typhus season by October, probably the
reason for the declining number of samples coming
in from the districts year as well as positivity
Figure 12: Scrub typhus samples tested
8. HIV confirmation
IDSL has carried out 86 HIV confirmatory tests for
samples that has tested positive in their respective
referring centres (Figure 13) of which 21 were
confirmed positive by IDSL, using test kits other
than that used in the primary testing centres. Six of
the samples were collected from the people who
came for screening on the World AID’s day. Most
samples for HIV confirmation came in from
JDWNRH (n=23), followed by Chukha (n=14) and
Pemagatshel (n=10). This is probably due to the
sizable number of people living in those districts,
increased economic activities comprising social
networking, information flow, awareness and
understanding the need to get tested. The HIV
testing algorithm necessitates 2 out of 3 tests
positive/ reactive to interpret the final test a
positive. IDSL uses three testing principles namely
(i) ELISA (Genscreen), (ii) Gelatin particle
agglutination (Serodia) and (iii) rapid
chromatographic assay (Determine) for screening
the referred serum samples.
Figure 13: Total number of samples received and tested for
HIV confirmation
9. Drinking Water Quality
Monitoring 4th Quarterly Report 2015
9.1 Microbiological Report
A total of 670 samples were collected and tested for
fecal coliform from all the districts laboratories for
the 4th quarter of the year 2015(October-
December). The test results show that 284 samples
were safe water and the remaining 386 samples
were found unsafe. Among the 386 unsafe
samples, 258 samples are categorized as low health
risk, 123 as Intermediate to High health risk and 5
as grossly polluted sample.
DISEASE SURVEILLANCE BULLETIN
Volume 4 10 4th Quarter (October-December) 2015
Figure 14: Microbiological report of 20 districts water for 4th quarter.
Note: 0=Safe water; >1=Unsafe water
Figure 15: Categorization of bacteriological report VS health risk.
Note; 0 CFU=Safe water (SW); 1-10 CFU =Low Health Risk (LHR); 11-50 CFU=Intermediate to High Health Risk (IHHR);
>50 CFU=Grossly Polluted
0
10
20
30
40
50
60
70
80
90
Nu
mb
er
of
feca
l co
lifo
rm
Dzongkhag
Bacteriological report from 20 districts
GPW
IHHR
LHR
SW
DISEASE SURVEILLANCE BULLETIN
Volume 4 11 4th Quarter (October-December) 2015
9.2 Thimphu Thromde Physico-Chemical Test Report
The reports for physiochemical parameters viz. Residual Chlorine, pH, Turbidity, Total Dissolved Solids
& Conductivity, from Thimphu Thromdey at various sampling points are shown in Figure 16, 17, 18,
and 19.
Figure 16: Residual Chlorine.
Note: MTP-Motithang Treatment Plant;JTP- Jungshina Treatment Plant; BPT: Break Pressure Tank
Residual Chlorine was maintained in almost all the treatment plants and reservoir tanks. In reservoir tank
above JDWNRH residual chlorine was maintained only in November and it was not maintained in NPPF
colony reservoir tank and swimming pool tank during October month. Residual chlorine was found
beyond acceptable limit in Motithang treatment plant in the month of October.
0
1
2
3
4
5
6
7
Re
sid
ual
Ch
lori
ne
Acc
ep
tab
le v
alu
e (
0.2
-0.5
mg/
L)
Sampling station
October
November
December
DISEASE SURVEILLANCE BULLETIN
Volume 4 12 4th Quarter (October-December) 2015
Figure 17: pH
There was no much variation in pH for the 4th quarter, however there was slight change in pH during
October at Motithang treatment plant treated water, this may be due to higher residual chlorine in the
treated water.
Figure 18: Turbidity
The turbidity of the drinking water were within the acceptable limit for this quarter from all the sampling
stations.
0 2 4 6 8 10
JTP(Source)
JTP(Treated)
MTPlant (Source)
MTP (Treated)
BPT R1 Tank
Three Tank Lower Motithang
Tank above NPPF colony
Reservoir Tank near BCCI office
Tank above JDWNRH
Tank near Swimming pool
Changjiji Tank
Changjiji Pump House
pHAcceptable value(6.5-8.5)
Sam
plin
g St
atio
n
December
November
October
0
0.5
1
1.5
2
2.5
Turb
idit
y A
cce
pta
ble
val
ue
(<5
NTU
)
Sampling stations
October November December
DISEASE SURVEILLANCE BULLETIN
Volume 4 13 4th Quarter (October-December) 2015
Figure 19: Total Dissolve Solids (TDS and Conductivity (CND)
10. Summary of Disease Outbreaks Report
Figure 20: Disease Outbreak Notification Report from October to December 2015
0
50
100
150
200
250
300
350
400
450
TDS CND TDS CND TDS CND TDS CND TDS CND TDS CND
JTP (Source) JTP (Treated) MTP (Source) MTP (Treated) ChangjijiColony Tank
ChangjijiColony Pump
House
October
November
December
DISEASE SURVEILLANCE BULLETIN
Volume 4 14 4th Quarter (October-December) 2015
11. Summary of National Notifiable Diseases Surveillance
Table 13: National Notifiable Diseases Surveillance Summary during the 4th Quarter 2015
Notifiable Disease BUM CHU DAG GAS HAA LHU MON PAR PEM PUN SJK SAM SAR THI TRG TRY TRO TSI WNG ZHE Total
(1)Anthrax 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3
(2)Acute Bloody Diarrhea 32 42 3 3 0 53 35 81 46 19 101199 102 32 44 80 16 15 24 32 18 101876
(3)Acute Watery Diarrhea 137 460 99 57 1 184 166 461 212 259 1014355 592 478 362 488 131 151 213 383 194 1019383
(4)Acute Encephalitis Syndrome
0 0 0 0 0 0 0 0 0 0 1 1 2 0 0 0 0 0 0 0 4
(5)Acute Flaccid Paralysis 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 4
(6)Acute Haemorrhagic Fever Syndrome
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(7)Acute Jaundice Syndrome
0 26 0 0 2 0 0 25 10 5 0 2 0 14 29 7 0 1 7 0 128
(8)Acute Respiratory Infection
927 3866 491 163 479 726 1312 3223 2068 698 3393 4121 3667 3926 2307 770 1053 1391 1576 871 37028
(9)Bacterial Meningitis 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 3
(10)Dengue Fever 0 1 0 0 0 0 0 0 3 0 0 0 0 0 3 0 0 0 0 0 7
(11)Mumps 73 9 12 0 6 69 191 49 18 44 61 91 42 25 93 98 26 29 28 69 1033
(12)Diphtheria 0 0 1 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 9 13
(13)Fever with Rash 0 9 34 0 46 1 0 19 0 10 42 6 57 1 28 1 4 135 5 14 412
(14)Food Poisoning 2 0 0 0 0 0 4 2 1 5 1 36 2 0 4 13 2 1 0 16 89
(15)Malaria 0 0 0 0 0 0 0 0 0 0 0 0 19 0 0 0 0 0 1 0 20
(16)Pertussis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(17)Rabies (Human) 0 0 0 0 0 0 0 0 0 0 11 0 0 0 0 0 0 0 0 0 11
(18)Congenital Rubella Syndrome
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(19)Multi-drug Resistance TB
0 0 0 0 0 0 0 0 0 0 0 1 0 10 0 0 0 0 0 1 12
(20)Tetanus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(21)Typhoid / Paratyphoid Fever
0 46 0 0 1 2 4 4 18 2 100 10 19 0 47 4 0 0 1 10 268
(22)Unusual Disease(s), Death(s) OR Event(s)
0 36 0 3 0 0 0 0 0 1 0 0 25 0 0 0 0 0 0 0 65
(23)Severe Acute Respiratory Infection
4 25 0 0 0 0 1 9 39 22 16 82 15 15 8 22 12 12 4 61 347
(24)Rickettsioses 0 6 0 0 0 0 0 0 14 1 19 18 3 0 2 2 0 0 2 16 83