Manual of Procedures for the Philippine Integrated Disease Surveillance and Response (PIDSR), 3rd Edition

Manual of Procedures for the Philippine Integrated Disease Surveillance and Response 3rd Edition National Epidemiology Center Department of Health VOL 1

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Manual of Procedures for the Philippine Integrated Disease Surveillance and Response 3rd Edition April 2014

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Manual of Procedures for Philippine Integrated Disease Surveillance and Response (PIDSR) 3rd Edition April 2014 National Epidemiology Center, Department of Health, Philippines This document is not a formal publication of the National Epidemiology Center and all rights are reserved by the organization. This document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction for commercial purposes. The views expressed in documents by named authors are solely for the responsibility of those authors. The mention of specific companies does not imply that they are endorsed or recommended by the epidemiology bureau in preference to others of a similar nature that are not mentioned.

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By the Staff of the National Epidemiology Center the Department of Health, Philippines Editorial Board: Enrique Tayag, MD, PHSAE, FPSMID, CESO III Director IV, National Epidemiology Center Department of Health, Philippines Vito G. Roque, Jr. RMT, MD, PHSAE Chief, Public Health Surveillance and Informatics Division National Epidemiology Center Department of Health Dulce C. Elfa, RN, MPH Nurse IV National Manager, Vaccine Preventable Disease Surveillance, National Epidemiology Center Department of Health, Philippines Vidal E. Pantilano, Jr., RN Nurse III National Coordinator, Philippine Integrated Disease Surveillance and Response, National Epidemiology Center June Cantata B. Corpuz, RN Nurse II, National Coordinator, Philippine Integrated Disease Surveillance and Response, National Epidemiology Center Allan P. Ignacio Statistician II Philippine Integrated Disease Surveillance and Response, National Epidemiology Center Francis Raize Nicholas L. Bautista, RN Nurse II, Philippine Integrated Disease Surveillance and Response, National Epidemiology Center Joysa D. Lorico, RN Nurse I, Philippine Integrated Disease Surveillance and Response, National Epidemiology Center Diana Marie L. Sadiasa, RN Nurse I, Philippine Integrated Disease Surveillance and Response, National Epidemiology Center Van Farrah S. Ibea, RN Nurse I, Philippine Integrated Disease Surveillance and Response, National Epidemiology Center Ma. Romina P. Calalang , RN Nurse II, National Vaccine Preventable Disease Surveillance Officer – Acute Flaccid Paralysis Jezza Jonah T. Crucena, RN Nurse II, National Vaccine Preventable Disease Surveillance Officer – Adverse Events Following Immunization Jobelle M. Aquino, RN Nurse II, National Vaccine Preventable Disease Surveillance Officer – Measles Kris Pauline T. Martinez, RN Nurse II, National Vaccine Preventable Disease Surveillance Officer – New Vaccines Lee Anne Mappatao-Esguerra, RN Nurse II, National Vaccine Preventable Disease Surveillance Officer – Neonatal Tetanus Daisy Regine O. Pedron, RN Nurse I, Vaccine Preventable Disease, National Epidemiology Center

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Table of Contents v CONTRIBUTORS The contributions of the following consultants and staff to the final adaptation of this manual are gratefully acknowledged: RESEARCH INSTITUTE FOR TROPICAL MEDICINE Amado O. Tandoc III, MD, DPSP Anatomic and Clinical Pathologist Head-Department of Virology Research Institute for Tropical Medicine Rowena J. Capistrano, RN, PHSAE Head, Surveillance Unit Research Institute for Tropical Medicine RHO - RESU I Rosario P. Pamintuan, MD, MPH, PHSAE Maria Eloisa A. Sarmiento, RN Regional Epidemiologist RESU Nurse RHO - RESU II Lourdes R. Velasco, RN, PHSAE, MAN Berneve Ann G. Cambri, RN, MSN Regional Epidemiologist VPD Surveillance Officer RHO - RESU III Jessie F. Fantone, MD Marilou I. Pajarillaga, RN Regional Epidemiologist RESU Nurse Rosanna S. Rosell, RN Nurse Epidemiologist RHO - RESU IV-A Divina C. Antonio, MD, MPH, PHSAE Mark L. Mesina Regional Epidemiologist PIDSR Data Manager Ruth Tio, RN RESU Asst. Program Coordinator RHO - RESU IV-B Ma. Teresa G. Castillo, MD, MPH, PHSAE Noel T, Orosco, RN, PHSAE Regional Epidemiologist RESU Coordinator Ma. Teresa Du, RN, MAN Nilda Noceja RESU Epidemiology Nurse Epidemiology Assistant RHO - RESU V Aurora Teresa M. Daluro, MD, PHSAE Arnel L. Santiago Regional Epidemiologist Epidemiology Assistant

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RHO - RESU VI Jessie Glen L. Alonsabe, MD, MPH Flor D' Lyn Betita-Gallardo, RN, MAN Regional Epidemiologist Regional Epidemiology Nurse RHO - RESU VII Rennan C. Cimafranca, RN Chevroleta Deiparine, RN RESU Head VPD DSO RHO – RESU VIII Boyd Roderick S. Cerro, RN RESU Head RHO – RESU IX Norvie T. Jalani, MD, MPH, PHSAE Maxel G. Bermas, RN RESU Head RESU Nurse Edgardo S. Calunod Epidemiology Assistant RHO – RESU X David A. Mendoza, MD, PHSAE Jasper Kent Ola, RN RESDRU Coordinator RESDRU Asst. Coordinator RHO – RESU XI Cleo Fe S. Tabada, MD, MPH Maria Roselle C. Cueto, RN, MPH RESU Head Epidemiology Surveillance Nurse RHO – RESU XII Alah Baby C. Vingno, MD, PHSAE Myla P. Mapait Regional Epidemiologist VPD Surveillance Officer Kathleen R. Gecosala, RN PIDSR Data Manager DOH – RESU ARMM Pancho Cruz, MD Aisha Aloha S. Enampadan, RN RESU Head RESU Nurse Anisa A. Matuan Disease Surveillance Officer

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Table of Contents vii RHO – RESU CAR Elnoria G. Bugnosen, RN Victoria M. Cuyopan, RN RESU Head/HEMS RESU Coordinator Victoria L. Malicdan, RN Geeny Anne I. Austria, RN Disease Surveillance Officer VPD Surveillance Officer RHO – RESU CARAGA Gerna M. Manatad, MD, PHSAE Cheryl Mary L. Plaza, RN Regional Epidemiologist RESU Nurse RHO – RESU NCR Manuel C. Mapue II, RMT, MD, CFP, PHSAE Regional Epidemiologist Elizabeth M. Arriola RN, MAN Evangeline B. Empis, RM VPDS, PIDSR and Regional Officer PIDSR Surveillance Officer

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ix CONTENTS FOREWORD xiv ACRONYMS xv GLOSSARY xvii Section 1. Introduction to PIDSR…………………………………………………………………3 1.1 Purpose Of The Manual....................................................................................... 3 1.1.1 Who should use this manual? .................................................................. 3 1.2 Paradigm Shift: An Integrated Approach To Surveillance..................................... 4 1.2.1 Evolution Of Disease Surveillance System In The Philippines ........ 4 1.2.2 What is integrated disease surveillance?.................................................. 4 1.2.3 Framework of public health surveillance and action ................................. 5 1.3 The Philippine Integrated Disease Surveillance And Response (PIDSR)............. 6 1.3.1 Policies that support PIDSR ..................................................................... 6 1.3.2 Scope of PIDSR....................................................................................... 8 1.3.3 Goal and Objectives of PIDSR ................................................................. 8 1.3.4 Guiding Principles .................................................................................... 8 1.3.5 Basic Features of PIDSR ......................................................................... 9 1.3.5.1 PIDSR Conceptual Framework................................................. 10 1.3.6 Fundamental Surveillance Procedures................................................... 11 1.3.7 Priority Diseases, Syndromes and Conditions Targeted For Surveillance ........................................................................................... 11 Section 2: Roles and Responsibilities............................................................................. 14 2.1 Department of Health......................................................................................... 14 2.1.1 National Epidemiology Center................................................................ 14 2.1.2 Bureau of Quarantine............................................................................. 14 2.1.3 National Center for Disease Prevention and Control .............................. 15 2.1.4 Health Emergency Management Staff.................................................... 15 2.1.5 Center for Health Development.............................................................. 15 2.2 Local Government Units .................................................................................... 16 2.2.1 Provincial Health Office.......................................................................... 16 2.2.2 Municipal/City Health Office ................................................................... 16 2.3 Philippine Health Insurance Corporation (PHIC)................................................ 17 2.4 DOH Representative.......................................................................................... 17

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PIDSR Manual of Procedures Section 3. Identifying Cases............................................................................................. 19 3.1 Use Standard Case Definitions for Surveillance................................................. 20 3.2 Where do we expect to see cases? ................................................................... 20 3.2.1 Disease Reporting Units (DRUs)............................................................ 20 3.3 Who are our partners in detecting and reporting cases?.................................... 21 3.3.1 Disease Reporting Advocates (DRA)..................................................... 21 3.3.2 Disease Surveillance Coordinators (DSC).............................................. 22 3.3.3 Disease Surveillance Officers (DSO)...................................................... 22 3.4 Where will the patient’s information be recorded?.............................................. 23 3.4.1 PIDSR Case Investigation and Reporting Forms .................................... 23 3.4.2 How to fill up PIDSR Forms .................................................................... 24 3.5 How can we ensure quality data collection?....................................................... 25 3.6 Laboratory Diagnosis of Surveillance Diseases ................................................. 25 3.7 What specimen should be collected and where should these be submitted?......................................................................................................... 27 3.8 How should specimen be contained and transported?....................................... 29 Section 4: Notification and Reporting of Cases.............................................................. 31 4.1 Mandatory reporting of notifiable diseases, syndromes and events ................... 32 4.1.1 Requirement for PhilHealth accreditation and reimbursement of claims..................................................................................................... 32 4.1.2 Requirement for issuance of initial or renewal of hospital license to operate................................................................................................... 32 4.2 What is the flow of notification for immediately notifiable diseases, syndromes and events?..................................................................................... 32 4.3 What is the flow of weekly reporting notifiable diseases?................................... 33 4.3.1 Flow of Weekly Reporting for Component Cities: ................................... 33 4.3.2 Flow of Weekly Reporting for Chartered Cities:...................................... 34 4.4 What is zero reporting? Why is it needed?......................................................... 35 4.5 What is the mechanism of transmitting PIDSR Forms to the next higher level?................................................................................................................. 35 4.6 Receiving and Checking PIDSRS...................................................................... 37 4.6.1 Who shall be responsible for receiving and checking the PIDSRS? ....... 37 4.6.2 What items in the PIDSR shall be checked upon receipt?...................... 37 4.7 What is a “silent” DRU and how should we deal with them? .............................. 37 Section 5: Data Analysis and Interpretation.................................................................... 41 5.1 How should the PIDSR WNDR be consolidated and stored at the RHU/CHO level utilizing a paper-based system?............................................... 42

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xi 5.1.1 How to prepare a summary table of notifiable disease by barangay and morbidity week................................................................. 42 5.2 Computer-based data storage and analysis....................................................... 45 5.2.1 Computer hardware and software requirements..................................... 45 5.3 How should surveillance data be analyzed? ...................................................... 45 5.3.1 Analyze Data By Time............................................................................ 46 5.3.1.1 Techniques in Time Analysis.................................................... 47 5.3.2 Analyze Data by Place ........................................................................... 49 5.3.3 Analyze Data By Person ........................................................................ 51 5.3.4 Graphical Presentations of Surveillance Data ........................................ 53 5.3.4.1 Tables ...................................................................................... 53 5.3.4.2 Graphs ..................................................................................... 54 5.3.4.3 Charts ...................................................................................... 55 5.3.4.4 Maps ........................................................................................ 57 5.3.5 Interpretation of Surveillance Data ......................................................... 57 5.3.6 Using the Results of Analysis................................................................. 59 Section 6: Feedback ......................................................................................................... 61 6.1 What is feedback? ............................................................................................. 62 6.1.1 Verbal Feedback.................................................................................... 62 6.1.2 Written feedback .................................................................................... 63 6.1.2.1 Outbreak Response Report...................................................... 63 6.1.2.2 Information Summary Sheets ................................................... 63 6.1.2.3 Public Health Bulletin ............................................................... 63 6.1.2.4 Newsletter ................................................................................ 64 6.1.2.5 Fact sheets............................................................................... 64 6.1.3 Other methods of providing feedback..................................................... 64 6.2 What method of feedback is most appropriate at the level of the RHU/CHO, PHO, CHD and DOH-Central Office? .............................................. 64 6.3 How do I prepare a written disease surveillance report?.................................... 66 Section 7: Use of Information .......................................................................................... 69 7.1 What is the knowledge-driven model of decision-making?................................. 70 7.1.1 Converting information to knowledge ..................................................... 71 7.2 How can surveillance information be used?....................................................... 71 7.3 What are the ways to enhance the use of surveillance information in all levels of the health system?............................................................................... 73

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PIDSR Manual of Procedures Section 8: Epidemic Response ........................................................................................ 75 8.1 Epidemic Detection............................................................................................ 76 8.1.1 How are epidemics detected? ................................................................ 76 8.1.2 Who should verify reported epidemics?.................................................. 76 8.1.3 What is the role of the Bureau of Quarantine in detecting epidemics?............................................................................................. 76 8.2 Epidemic Investigation....................................................................................... 77 8.2.1 Deciding to Investigate an Epidemic....................................................... 77 8.2.2 What are the roles of LGUs during epidemic investigation and response? .............................................................................................. 78 8.2.3 What are the composition and core responsibilities of Epidemic Investigation and Control Team?............................................................ 78 8.2.4 What should the RHU or CHO do in instances when they do not have the capacity in conducting epidemic investigation?........................ 79 8.2.5 In what instances shall the NEC and CHD-RESU provide immediate on site technical assistance during epidemic investigation?......................................................................................... 80 8.2.6 What is the role of the National Epidemiology Center as the National IHR Focal Point?...................................................................... 80 8.3 Declaring an Epidemic....................................................................................... 80 8.3.1 What are the necessary information that should be used to support declaration of an epidemic? ................................................................... 80 8.3.2 What is the basic requirement for an LGU to declare an epidemic? ....... 81 8.3.3 In what instances does the Secretary of Health have the sole authority in declaring an epidemic? ........................................................ 81 8.4 Response .......................................................................................................... 82 8.4.1 Investigation........................................................................................... 82 8.4.2 Treatment of Cases................................................................................ 83 8.4.3 Establish Epidemic Disease Surveillance............................................... 83 8.4.4 Implement Public Health Measures........................................................ 84 8.4.5 Risk Communication .............................................................................. 84 8.5 Evaluation.......................................................................................................... 84 Section 9: Monitoring and Evaluation ............................................................................. 87 9.1 What is monitoring in the context of surveillance and response? ....................... 88 9.1.1 Surveillance Indicators ........................................................................... 89 9.1.2 Objectives of M & E................................................................................ 89 9.2 M&E activities will happen at three surveillance levels....................................... 90 9.2.1 Municipality and provincial level where the program is implemented .......................................................................................... 90 9.2.2 Regional level M&E................................................................................ 90

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xiii 9.2.3 National level M&E................................................................................. 90 9.3 What Is a Technical Assistance Visit (TAV)? ..................................................... 90 9.4 Performance Indicators...................................................................................... 90 9.4.1 AFP and Measles Specific Indicators ..................................................... 91

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PIDSR Manual of Procedures xiv FOREWORD The Philippine Integrated Disease Surveillance and Response (PIDSR) System was established to improve the current disease surveillance systems in the Philippines and to comply with the 2005 IHR call for an urgent need to adopt an integrated approach for strengthening the epidemiologic surveillance and response system of each member nation. PIDSR envisions the integration of all surveillance and response activities at all levels. This integration will provide a more rational basis for decision making and implementing public health interventions that effectively respond to priority diseases and events. The focus of PIDSR is to strengthen the capacity of local government units for early detection and response to epidemics. It emphasizes a standardized proactive nationwide approach to outbreak detection, prevention and control from the community up to the national level. It harmonizes existing systems and synchronizes training, manpower deployment, laboratory and financial support from all levels. This Manual of Procedures describes in detail the integrated approach of disease surveillance and response and will serve as a practical guide to all who will implement, monitor and support the PIDSR. All disease surveillance coordinators in disease reporting units from hospitals, clinics, rural health units, city health offices, and staff in epidemiology and surveillance units at the provincial, regional, and national levels should be guided by this manual in the management and implementation of their surveillance systems. Likewise, communicable disease program managers and managers of the Expanded Program on Immunization at the national and local levels, members of the epidemic investigation and control team, epidemic management committee at the provincial and regional levels, health emergency management staff, medical doctors and nursing personnel, and community health volunteers will find this manual as a useful reference. We would like to acknowledge and appreciate the frontline health workers who have in their own way dedicated their work and lives in the field of disease detection, control and prevention in the Philippines. We also extend our heartfelt gratitude to all our partners in health especially the Local Government Units, Non-Government Organization and other Government and Civil Societies who are always supporting the works of the Department of Health. Lastly, we also express our sincerest gratitude to all the staff at the regional, provincial, city and municipal health offices, whose dedication and commitment have contributed to the realization of this manual of procedures. ENRIQUE A. TAYAG, MD, FPSMID, PHSAE, CESO III Assistant Secretary Department of Health

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xv ACRONYMS AFP Acute Flaccid Paralysis AEFI Adverse Events Following Immunization AFRIMS Armed Forces Research Institute of Medical Sciences AI Avian Influenza AIDS Acquired Immune Deficiency Syndrome BFAD Bureau of Food and Drugs BFAR Bureau of Fisheries and Aquatic Resources BHS Barangay Health Station CESU City Epidemiology and Surveillance Unit CFR Case Fatality Rate CHD Center for Health Development CHO City Health Office / City Health Officer CSF Cerebrospinal Fluid DA-BAI Department of Agriculture-Bureau of Animal Industry DA-RADDL Department of Agriculture-Regional Animal Disease Diagnostic Laboratories DOH Department of Health DOH-PCREID Department of Health Management Committee on Prevention and Control of Emerging and Re-emerging Infectious Diseases DOST Department of Science and Technology DRA Disease Reporting Advocate DRU Disease Reporting Unit DSC Disease Surveillance Coordinator DSO Disease Surveillance Officer EID Emerging Infectious Disease EPI Expanded Program on Immunization EREID Emerging And Re-Emerging Infectious Disease ESR Epidemiological Surveillance and Response ESSC Epidemiology and Surveillance Sub-Committee ESU Epidemiology and Surveillance Unit F1 FOURmula ONE for Health FETP Field Epidemiology Training Program FHSIS Field Health Service and Information System GIS Geographical Information System HEMS Health Emergency Management Staff

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PIDSR Manual of Procedures xvi HIS Health Information System HIV Human Immunodeficiency Virus HMN Health Metrics Network IDSR Infectious Disease Surveillance and Response IEC Information Education Communication IHR International Health Regulations ILI Influenza-like Illness ITR Individual Treatment Record LCE Local Chief Executives LGU Local Government Unit MHO Municipal Health Office / Municipal Health Officer NDRS Notifiable Disease Reporting System NEC National Epidemiology Center NESSS National Epidemic Sentinel Surveillance System NT Neonatal Tetanus PHEIC Public Health Emergency of International Concern PhilHealth Philippine Health Insurance Corporation PHO Provincial Health Office / Provincial Health Officer PHSID Public Health Surveillance and Informatics Division PIDSR Philippine Integrated Disease Surveillance and Response PRIMEX Pacific Rim Innovation and Management Exponents, Inc. RIG Rabies Immunoglobulin RESU Regional Epidemiology and Surveillance Unit RHU Rural Health Unit RITM Research Institute for Tropical Medicine SACCL STD/AIDS Cooperative Central Laboratory SARS Severe Acute Respiratory Syndrome SMS Short Message Service STI Sexually Transmitted Infection TCL Target Client List UP- NPMCC University of the Philippines National Poison Management and Control Center VPD Vaccine Preventable Disease VPDISS Vaccine Preventable Diseases and Immunization Safety Surveillance WHO World Health Organization WNDR Weekly Notifiable Disease Report

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xvii GLOSSARY Active Surveillance – refers to public health officers either collect the data themselves or seek reports from participants in the surveillance system on a regular basis, rather than waiting for the reports. Alert Threshold – refers to the level of occurrence of disease that serves as an early warning for epidemics. An increase in the number of cases above the threshold level should trigger an investigation, check epidemic preparedness and implement appropriate prevention and control measures. Case-based Surveillance - refers to the collection of specific data on each case (e.g. collecting details on each case of acute flaccid paralysis [AFP]) as determined by the national coordinating body. Cluster - refers to the aggregation of relatively uncommon events or diseases in space and/or time in magnitude that is believed or perceived to be greater than could be expected by chance. Disease – refers to a specific illness or medical condition, irrespective of origin or source that directly presents or has the potential to present significant harm to humans. Disease Reporting Unit (DRU) - refers to any health facility where cases of notifiable diseases are identified and reported (e.g., hospitals, clinics, Municipal Health Offices [MHO], City Health Offices [CHO], Barangay Health Stations [BHS], community, Quarantine Stations). Disease Reporting Advocates (DRA) – refers to health workers and other individuals (e.g. community leaders, private practitioners) who have attended orientation on PIDSR and are committed to actively participate in reporting cases. Disease Surveillance Coordinator (DSC) - refers to staff of government and non- government health facilities (e.g. hospitals, clinics, RHUs) who have received training on PIDSR with an official designation as disease surveillance coordinator by the head of the facility. Disease Surveillance Officer (DSO) - refers to a fulltime staff of the Epidemiology and Surveillance Unit (ESU) of the CHOs (chartered cities), PHOs and CHDs who has received training on basic epidemiology, public health surveillance and PIDSR with an official designation as disease surveillance officer by the head of office. Ideally, a DSO should either be a physician or a nurse. Epidemic - refers to the occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess of normal expectancy. The community or region and the period in which the cases occur are specified precisely. The number of cases indicating the presence of an epidemic varies according to the agent, size, and type of population exposed; previous experience or lack of exposure to the disease; and time and place of occurrence. (Adapted from Last JM, Ed. A Dictionary of Epidemiology, 1997). A community may refer to specific groups of people (e.g., those attending a social function and got ill from food poisoning). Epidemic threshold - refers to the level of occurrence of disease above which an urgent response is required. The threshold is specific to each disease and depends on the

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PIDSR Manual of Procedures xviii infectiousness, other determinants of transmission and local endemicity levels. For some diseases, such as poliomyelitis or SARS, one case is sufficient to initiate a response. Epidemiology - refers to the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems. Epidemiology and Surveillance Unit - refers to the unit established in the Centers for Health Development (CHD), Provincial Health Offices (PHO), City Health Offices (CHO) and Rural Health Units (RHU) that provide services on public health surveillance and epidemiology. HIV/AIDS Registry - refers to the registry of all HIV-AIDS cases in the Philippines that are reported from both public and private hospitals, laboratories, and other agencies. Integrated Disease Surveillance and Response - refers to the process of coordinating, prioritizing, and streamlining of core surveillance activities (e.g., data collection, reporting, laboratory and epidemiological confirmation, analysis, feedback), support functions (e.g., training, monitoring, financial and logistics) and response (e.g., epidemic investigation) with the aim of making the system more efficient and effective in providing timely, accurate and relevant information for action. International Health Regulations (IHR) of 2005 - refers to the international legal instrument that binds all WHO Member States to implement a set of international standards with the aim to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade. Isolation – refers to the separation of ill or contaminated persons or affected baggage, containers, conveyances, goods or postal parcels from others in such a manner as to prevent the spread of infection or contamination. National Epidemic Sentinel Surveillance System (NESSS) - refers to the hospital-based surveillance system that monitors 15 diseases with outbreak potential that are either laboratory-confirmed (e.g. cholera, hepatitis A, hepatitis B, malaria, measles, typhoid fever) or clinically-diagnosed (e.g., dengue, diphtheria, leptospirosis, meningococcal disease, non- neonatal tetanus, neonatal tetanus, pertussis, rabies). National IHR Focal Point- refers to the national center, designated by each State Party, which shall be accessible at all times for communications with WHO IHR Contact Points under the 2005 IHR. Notifiable Disease Reporting System (NDRS) - refers to the component of the Field Health Service Information System (FHSIS) that provides the Department of Health (DOH) with field-based surveillance and program management information on the different public health programs. It monitors 17 diseases and 7 syndromes. Data are generated from the barangay health stations, rural health units and municipal or city health centers. Notifiable Disease - refers to the disease that, by legal requirements, must be reported to the public health or other authority in the pertinent jurisdiction when the diagnosis is made. Outbreak – synonymous with epidemic; when used in a sentence, refers to an epidemic limited to localized increase in the incidence of a disease, e.g., in a village, town, or closed institution. (Adapted from Last JM, Ed. A Dictionary of Epidemiology, 1997).

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xix Passive surveillance – refers to a surveillance system in which reports are awaited and no attempt is made to seek reports actively from the participants in the system. Point of Entry – refers to a passage for international entry or exit of travelers, baggage, cargo, containers, conveyances, goods and postal parcels as well as agencies and areas providing services to them on entry or exit. Public Health Surveillance - refers to the ongoing, systematic collection, analysis, interpretation and timely dissemination of health data for the planning, implementation and evaluation of public health program. The use of information based from these data to disease prevention and health promotion program completes the surveillance cycle in public health. Public Health Emergency of International Concern – refers to an extraordinary event which is determined, as provided in the 2005 IHR: 1) to constitute a public health risk to other states through the international spread of disease and 2) to potentially require a coordinated international response. Quarantine – refers to the restriction of activities and/or separation from others of suspect persons who are not ill or of suspect baggage, containers, conveyances, or goods in such a manner as to prevent the possible spread of infection or contamination. Surveillance Report - refers to the regular publication with specific information on the disease under surveillance. It contains updates of standard tables and graphs as well as information on epidemics. In addition it may contain information on the performance of participants using agreed performance indicators. Syndrome - refers to a symptom complex in which the symptoms and/or signs coexist more frequently than would be expected by chance on the assumption of independence. Syndromic report – refers to the notification of a health event under surveillance for which the case definition is based on a syndrome not on a definite disease (e.g. acute hemorrhagic fever syndrome, acute respiratory syndrome). Vaccine Preventable Diseases and Immunization Safety Surveillance - refers to the intensive case-based, hospital-based surveillance for diseases targeted for eradication and elimination. This includes acute flaccid paralysis or suspected polio, measles and neonatal tetanus and adverse events following immunization (previously known as Expanded Program on Immunization (EPI) Surveillance). Zero Case Reporting – refers to the reporting of “zero case” when no cases have been detected by the reporting unit.

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1 Section 1: Introduction to PIDSR This section discusses the:  Purpose of the manual of procedures  Integrated approach to disease surveillance and response  Philippine Integrated Disease Surveillance and Response (PIDSR) system  Policies that support PIDSR  Scope, goal and objectives of PIDSR  Basic features and the conceptual framework of PIDSR  Priority diseases, syndromes and conditions targeted for surveillance

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Section 1: Introduction 3 1.0 Introduction Disease surveillance is recognized as the cornerstone of public health decision-making and practice. Surveillance data provide information which can be used for priority setting, policy decisions, planning, implementation, resource mobilization and allocation, prediction and early detection of epidemics. A surveillance system can also be used for monitoring, evaluation and improvement of disease prevention and control programs. Also, the surveillance system generates data that is helpful to the Public Health Officials in understanding the existing and emerging infectious and non-infectious diseases. Without these quality data, interventions may become misguided and wasteful. With the functional surveillance and proper understanding of health problem it will not be difficult to ameliorate the health issue. The six core functions of public health surveillance must be implemented regularly to all Epidemiology Surveillance Unit for us to monitor and detect new disease that threatens global health security and to our community. There is a need to strengthen disease surveillance and response system in the Philippines. The revised International Health Regulations (IHR), adopted by the World Health Assembly in May 2005, gives further impetus to this issue. Strengthening surveillance and response systems starts with developing policies and strategies that would make the system more efficient and effective. In order to achieve this, the Philippine Department of Health has adopted an integrated approach to surveillance of priority communicable diseases and conditions. This approach aims at coordinating and streamlining all surveillance activities and ensuring timely provision of surveillance information for action. The PIDSR manual defines and discusses the various steps of an integrated disease surveillance and response process, from collecting data that will help to identify problems, through data analysis that leads to an appropriate response, to evaluating and improving the response and the system as a whole. 1.1 Purpose Of The Manual The manual provides general guidance on surveillance and response. It is intended for use as:  a general reference for surveillance activities across all levels  a resource for developing training, supervision and evaluation of surveillance activities  a guide for improving early detection and preparedness activities for improved and timely response 1.1.1 Who should use this manual? This manual is intended for use primarily of the DSO and DSC in disease reporting units and staff in epidemiology and surveillance units at the municipal, city, provincial, regional, and national levels. Other users of this manual may include but is not limited to:  Managers of the communicable disease program, Expanded Program on Immunization, and Environmental Health and Sanitation Program  Members of the epidemic investigation and control team  Members of the epidemic management committee at all levels  Health emergency management staff

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PIDSR Manual of Procedures 4  Medical doctors, nurses and other allied health professionals  Community health volunteers 1.2 Paradigm Shift: An Integrated Approach To Surveillance 1.2.1 Evolution Of Disease Surveillance System In The Philippines Prior to the establishment of PIDSR, there were four major disease surveillance systems that exist in the country. These are the following: 1) The Notifiable Disease Reporting System (NDRS) that generates information on 17 diseases and 7 syndromes. The data in this system are used to estimate morbidity rates; 2) The National Epidemic Sentinel Surveillance System (NESSS), a hospital-based surveillance system that yields information on admitted cases of diseases with outbreak potential in sentinel hospitals and which can serve as an early warning system for epidemics in the community; 3) The VPD Surveillance focuses on the monitoring of priority vaccine-preventable diseases targeted for eradication and elimination, namely: poliomyelitis, measles and neonatal tetanus; 4) The HIV-AIDS Registry keeps track of the number of HIV-AIDS cases through a voluntary testing program. These disease surveillance systems with their own data collection and reporting flows, hardware and software requirements, and procedures for processing and analysis at different levels produce a lot of inefficiencies, redundancies and duplication of efforts. This entails extra costs and training requirements, and often results in health workers becoming overloaded and unmotivated. The inadequacy of the current disease surveillance systems in the Philippines and the need to comply with the 2005 IHR calls for an urgent need to adopt an integrated approach for strengthening the Philippine epidemiologic surveillance and response system. 1.2.2 What is integrated disease surveillance? It is a process of coordinating, prioritizing, and streamlining of multiple disease surveillance systems into a unified national disease surveillance system that combines core surveillance activities and support functions into a single integrated activity for the purpose of making the system more efficient and effective in providing timely, accurate and relevant information for action. In an integrated system:  All surveillance activities are coordinated and streamlined. Rather than using scarce resources to maintain separate surveillance activities, resources are combined to collect information from a single focal point at each level.  Several activities are combined into a single integrated activity and take advantage of similar surveillance functions, skills, resources and target populations. For example, surveillance activities for acute flaccid paralysis (AFP) can address surveillance needs for other diseases (e.g., encephalitis and meningitis). Thus, health staff who routinely monitors AFP cases can also review health facility records for information about other priority diseases.

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Section 1: Introduction 5  Surveillance focal points at the local and national levels collaborate with epidemic response committees at each level to plan relevant public health response actions and actively seek opportunities for combining resources.  It emphasizes standardized nationwide preparation rather than ad hoc reactions to outbreaks; that is, it secures human and financial resources needed to operate an ongoing, effective system; monitors disease outbreaks particularly at the local level; confirms diagnoses if necessary through laboratory tests; reports outbreaks in a timely manner; responds with the most effective public health intervention based on hard evidence; takes action to prevent future outbreaks; and evaluates the performance of both the intervention and the surveillance system itself. 1.2.3 Framework of public health surveillance and action The conceptual framework presented in Figure 1 at page 6 serves as a guide for strengthening the diseases surveillance system in the Philippines. The framework emphasizes the six surveillance core activities (detection, registration, reporting, confirmation, analysis and feedback) that should be maintained in any public health surveillance system. However, in order for the system to run effectively, it needs the support of four activities which are training, communication, supervision and resource- provision. The four support activities promote or improve the core activities by enhancing their performance through more efficient and effective functioning. Core activities can and do occur with or without support activities. Generally, the more support, the better the performance. Two core public health actions of acute (epidemic-type) and planned (management- type) responses rely upon messages derived from surveillance. Acute (epidemic-type) responses occur directly, reactively, and generally include immediate public health actions (e.g. epidemic investigation, contact follow-up or targeted interventions to stop the ongoing transmission of disease). Planned (management-type) responses occur with periodicity over time and require a vision of future needs. Examples of such responses include community public health education, purchasing next year's immunization supplies, ordering tuberculosis medication in anticipation of future needs, or reallocating public health personnel and resources in response to changing trends of disease. Public health actions, in turn, must be monitored and evaluated. The results of these will be used to measure and modify the control and prevention measures taken, and to guide future modifications in public health surveillance.

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PIDSR Manual of Procedures 6 1.3 The Philippine Integrated Disease Surveillance and Response (PIDSR)  Administrative Order No. 2007-0036 “Guidelines on the Philippine Integrated Disease Surveillance and Response (PIDSR) Framework” is shown in Annex 1. 1.3.1 Policies that support PIDSR The PIDSR is supported by the following legal mandates and policies:

1. Republic Act 3573 (Law of Reporting of Communicable Diseases – An Act providing for the prevention and suppression of dangerous communicable diseases…) [November 26, 1929]; requires all individuals and health facilities to report notifiable diseases to local and national health authorities.
2. Resolution WHA48.13 (1995) urges Member States to strengthen national and local programs of active surveillance for infectious diseases, ensuring that efforts were directed towards early detection of epidemics and prompt identification of new, emerging and re-emerging infectious diseases.
3. Administrative Order No. 95 s. 2003 (Guidelines for Acute Flaccid Paralysis, Measles and Neonatal Tetanus Disease Surveillance System) refers to the strengthening of the integration of surveillance of the EPI diseases targeted for elimination and eradication. It includes the case definitions, differential diagnosis, specimen collection, storage and transport procedures, and specific roles and functions of hospitals and LGUs in EPI surveillance. Figure 1: Framework of Public Health Surveillance and Action

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Section 1: Introduction 7 4. International Health Regulations of 2005, Article 5-1 Surveillance, urges Member States to develop, strengthen and maintain, as soon as possible but no later than five years from the entry into force of these Regulations, the capacity to detect, assess, notify and report events in accordance with these Regulations. 5. Administrative Order No. 2005-0023 (Implementing Guidelines for Fourmula One for Health as Framework for Health Reforms), Section C2.c.iii, states that, “Disease surveillance shall be intensified to ensure that the targets for disease elimination, prevention and control are attained”. 6. Department Personnel Order No. 2005-1585 (Creation of a Management Committee on Prevention and Control of Emerging and Re-emerging Infectious Diseases or DOHMC-PCREID) creates the Epidemiology and Surveillance Sub- Committee (ESSC) in which one of its major functions is to “…formulate and recommend policies, standards, procedures, guidelines and systems on the early detection, contact tracing, surveillance, investigation and follow-up of emerging and re-emerging infectious disease (EREID) suspects and the timely and accurate recording, reporting and collation of epidemiological data on EREID.” 7. Administrative Order No. 2007-0036 (Guidelines on the Philippine Integrated Disease Surveillance and Response (PIDSR) Framework”), This Administrative Order provides the framework for PIDSR to guide its implementation at all levels of the health care delivery system as well as both the public and private sectors. 8. Administrative Order No. 2010-0017 (Guidelines in Surveillance and Response to Adverse Events Following Immunization) urges all levels of the health system to strengthen the surveillance and management of AEFIs that will contribute to the credibility of the immunization program. This guideline covers provisions on investigation, legal assistance to AEFI cases and health workers, risk communication, including the roles and responsibilities of concerned agencies and stakeholders. 9. Administrative Order No. 2010-0017-A “Guidelines in Surveillance and Response to Adverse Events Following Immunization” was amended to include the need to organize an AEFI committee at the regional and provincial levels whose function is to conduct immediate preliminary causality assessment of reported serious AEFIs. 10. Administrative Order No. 2011-0016 (Guidelines on the National Preparedness and Response to Wild Poliovirus), since the country remains at risk for WPV importation from endemic countries and areas with WPV transmission, this guideline was made to established preparedness and response mechanism in case a WPV importation is confirmed and also to prevent WPV secondary or re- established transmission. 11. Administrative Order No. 2012-0003 (Guidelines on Strengthening Laboratory Confirmation of Suspected Measles Cases), in support to the country’s goal of measles elimination, any person that fits the suspect case definition of measles shall be immediately reported, investigated and a blood specimen must be collected to confirm whether the suspected case is indeed a case of measles. Other means of confirmation for presence of anti-measles IgM antibodies is the DBS procedure. In addition, viral isolation through collection of NPS/OPS specimen provides evidence of elimination of indigenous measles virus, including outbreak source and transmission pathways. Adequate laboratory support for confirmation of diagnosis plays a vital role in measles surveillance.

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PIDSR Manual of Procedures 8 1.3.2 Scope of PIDSR The scope in the implementation of PIDSR applies to the following:  Entire health sector, to include public and private, national agencies and local government units, external development agencies, and the community involved in disease surveillance and response activities;  Routine surveillance of priority diseases and events identified by the Department of Health;  Routine surveillance complements the Event-based surveillance of priority diseases and events. 1.3.3 Goal and Objectives of PIDSR Goal To support the health sector in reducing morbidity and mortality from diseases of public health importance through an institutionalized, functional integrated disease surveillance and response system. Objectives

1. To continually improve capacities at the national and regional levels to efficiently and effectively manage national and sub-national surveillance and response system.
2. To mobilize and empower LGUs in the establishment and institutionalization of disease surveillance and response system.
3. To support health sector capacity development for sustainable disease surveillance and response system.
4. To enhance utilization of disease surveillance data for decision making, policy development, program management, planning, monitoring and evaluation at all levels. 1.3.4 Guiding Principles The PIDSR is guided by the following principles:
5. The PIDSR shall be consistent with the technical leadership role of the DOH in health and shall contribute to the achievement of the National Health Objectives and the country’s commitment to the Millennium Development Goals.
6. The PIDSR shall be faithful to the spirit of decentralization and recognize the vital role of local government units on all matters related to health.
7. The PIDSR shall be compliant with the 2005 IHR surveillance and response standards and be guided by the country’s commitments and obligations.
8. The PIDSR shall build on the strengths and learn from the weaknesses of existing disease surveillance systems.
9. The PIDSR shall comply with the overall guiding principles of usefulness, simplicity and flexibility of the system, orientation to a specific action, and integration.
10. The PIDSR shall recognize and adopt the principles of partnership and shared responsibility. A partnership is a voluntary agreement between two or more parties to work cooperatively toward a set of shared outcomes in disease surveillance. Partnership includes the public and private sectors, national agencies and local government units, external development agencies, and the

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Section 1: Introduction 9 community involved in disease surveillance and response activities. The principle of shared responsibility recognizes that disease surveillance and response is the responsibility of all sectors and governments at all levels. 7. The privacy and confidentiality of patient’s information be maintained. Privacy is the right of patients to choose what information they will release about themselves and to whom. Confidentiality is the obligation of public health workers to keep information about individuals restricted only to those persons who absolutely need it for the health of the community. Patients have the right to know why they are providing information, to refuse to provide information, and to expect that information will be handled as confidential. 1.3.5 Basic Features of PIDSR The basic features of PIDSR are the following:

1. Integrated in terms of the use of standard case definitions, surveillance core activities (detection, registration, reporting, confirmation, analysis, feedback) and resources.
2. Capacity for early detection of epidemics.
3. Integrated response to epidemics and other public health threats.
4. Utilizes case-based, laboratory-based and event-based surveillance approaches to enhance sensitivity and specificity of the system.
5. Strengthens local capacity for surveillance and response. This includes involvement of the community in disease surveillance activities. The primary role of the LGU is to provide appropriate intervention to emerging diseases, epidemics and other public health threats.
6. Established capacity of laboratories and strengthened involvement in disease surveillance system.
7. Efficient and effective management of surveillance data (e.g., collection, analysis, interpretation and dissemination) and use of information for decision-making, including monitoring and evaluation of intervention programs at all levels.
8. Open lines of communication with established feedback loop at all levels.

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PIDSR Manual of Procedures 10 Figure 2: Conceptual Framework for the Philippine Integrated Disease Surveillance and Response (PIDSR) 1.3.5.1 PIDSR Conceptual Framework

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Section 1: Introduction 11 1.3.6 Fundamental Surveillance Procedures In order to enhance the coverage of reporting, a facility and community- based surveillance approach shall be utilized. This means, cases or events seen or detected from the health facilities and communities should be reported. In this approach, the sources of reports shall be coming from the Disease Reporting Units (DRU) that includes the following:

1. Community
2. Barangay Health Stations (BHS)
3. Rural Health Units (RHU)
4. City Health Offices (CHO)
5. Government and private hospitals or clinics
6. Government and private laboratories
7. Ports and airports Case-based data collection shall be utilized. This means that, a set of data is collected for every case of notifiable disease/syndrome seen or detected. Two types of case-based surveillance shall be used:
8. Intensive Case-based This type of surveillance shall apply to diseases targeted for elimination (e.g. measles, neonatal tetanus), eradication (e.g. AFP/poliomyelitis) and other priority diseases as determined by the DOHMC-PCREID. This means that, a comprehensive set of data is collected for every case of diseases/syndromes detected using a standard case-investigation form.
9. Line list Case-based For other notifiable diseases/syndromes, a minimum set of data is collected using a line list. The system shall adopt a combination of active and passive type of surveillance. Active surveillance shall be required in health-care facilities and other DRUs considered as “silent”. Silent DRUs are those that have not submitted weekly notifiable disease report for 3 or more morbidity weeks. 1.3.7 Priority Diseases, Syndromes and Conditions Targeted For Surveillance The priority diseases/syndromes/conditions targeted for surveillance (Table 1) were selected based on one or more of the following categories:
10. Epidemic-prone diseases
11. Diseases targeted for eradication and elimination
12. Other diseases of public health importance as determined by the DOHMC- PCREID or those required by the IHR

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PIDSR Manual of Procedures 12 Table 1. Priority Diseases/Syndromes And Conditions Targeted For Surveillance Epidemic-Prone Diseases Diseases Targeted For Eradication Or Elimination Other Diseases Or Conditions Of Public Health Importance

1. Acute Viral Hepatitis
2. Anthrax
3. Bacterial Meningitis
4. Cholera
5. Dengue
6. Human Avian Influenza
7. Influenza-like Illness
8. Leptospirosis
9. Meningococcal Disease
10. Paralytic Shellfish Poisoning
11. Severe Acute Respiratory Syndrome (SARS)
12. Typhoid And Paratyphoid Fever 1.Poliomyelitis (Acute Flaccid Paralysis) 2.Measles 3.Neonatal Tetanus 4.Rabies 5.Malaria 1.Acute Bloody Diarrhea 2.Acute Hemorrhagic Fever 3.Acute Encephalitis Syndrome/ Japanese Encephalitis 4.Adverse Event Following Immunization (AEFI) 5.Diphtheria 6.Hand Foot and Mouth Disease 7.Non-Neonatal Tetanus 8.Pertussis 

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13 This section describes the roles and responsibilities of the following agencies:  Department of Health  National Epidemiology Center  Bureau of Quarantine  National Center for Disease Prevention and Control  Health Emergency Management Staff  Center for Health Development  Local Government Units  Provincial Health Office  Municipal/City Health Office  Philippine Health Insurance Corporation (PhilHealth or PHIC)  DOH Representative Section 2: Roles and Responsibilities

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PIDSR Manual of Procedures 14 2.0 Roles and Responsibilities The local, provincial, regional, and national levels shall have the following basic roles and responsibilities for surveillance and response: 2.1 Department of Health 2.1.1 National Epidemiology Center a. Assess all reported epidemics within 48 hours. b. Notify WHO when the assessment indicates that the event is a public health emergency of international concern (PHEIC). c. Determine rapidly the control measures required to prevent domestic and international spread of disease. d. Provide support through specialized staff and logistical assistance during epidemic investigation and response. e. Establish effective networking with other relevant government agencies at the national level and local level, including the National Philhealth office. f. Provide direct operational link with health officials at the national and local levels for immediate approval and implementation of containment measures. g. Facilitate the dissemination of information and recommendations from DOH Central office and WHO regarding local and international public health events to the concerned agencies and institutions. h. Initiate the development and implementation of the integrated national epidemic preparedness and response plan. i. Facilitate or expedite the budget allocation for surveillance and response at the regional health offices. j. Oversee the design and implementation of PIDSR. k. Provide surveillance feedback to regional level. l. Maintain the National PIDSR database. 2.1.2 Bureau of Quarantine a. Develops and ensures compliance to protocols and field operation guidelines on entry/exit management of persons, conveyances and goods in coordination with airport and port authorities. b. Conducts surveillance in ports and airports of entry and sub-ports as well as the airports and ports of origin of international flights and vessels. c. Monitors public health threats in other countries. d. Provides effective networking and collaboration among the Bureau of Quarantine stakeholders. e. Assist in the development and implementation of the integrated national epidemic preparedness and response plan.

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Section 2: Roles and Responsibilities 15 2.1.3 National Center for Disease Prevention and Control a. Provides updates, technical advice and recommendations on the recognition, prevention and control of diseases. b. Assist in the development and implementation of the integrated national epidemic preparedness and response plan. c. Organize the DOH Management Committee for the Prevention and Control of Emerging and Re-emerging Infectious Diseases. 2.1.4 Health Emergency Management Staff a. Acts as the DOH coordinating unit and operations center for all health emergencies, disasters and incidents with potential of becoming an emergency. b. Assist in the development and implementation of the integrated national epidemic preparedness and response plan. 2.1.5 Center for Health Development a. Provide on-site assistance (e.g., technical, logistics, and laboratory analysis of samples) as requested to supplement local epidemic investigations and control. b. Establish, operate and maintain a regional epidemic preparedness and response plan, including the creation of multidisciplinary/multisectoral teams to respond to events that may constitute a public health emergency of local and international concern. c. Assess reported epidemics immediately and report all essential information to DOH central office. d. Provide direct liaison with other regional government agencies. e. Provide a direct operational link with senior health and other officials at the regional level. f. Facilitate submission of weekly notifiable disease surveillance reports from public and private hospitals. g. Provide technical and logistical assistance in the establishment of ESUs at the provincial/city/municipal health offices. (See Annex 2: Guide in the Establishment and/or Strengthening Of Epidemiology And Surveillance Units) h. Ensure the functionality of the regional disease surveillance and response system. i. The Hospital Licensing Team at the CHDs shall track and monitor the compliance of public and private hospitals in the implementation of PIDSR as part of the requirements for renewals of license to operate. The team will inform the CHDs/PHOs/LGUs of activities taken against non-complying hospital institutions. Likewise, CHOs/MHOs/PHOs shall report to the CHDs hospitals and related facilities that fail to comply with the PIDSR reporting requirements. The regional director shall issue a regional order to enforce compliance. j. Create Epidemic Management Committee (EMC) at the regional level.

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PIDSR Manual of Procedures 16 2.2 Local Government Units 2.2.1 Provincial Health Office a. Set up and maintain a functional provincial disease surveillance system equipped with the necessary resources and adequate local financial support. Financial support may come from the disaster, calamity or other appropriate funding sources as determined by the provincial government officials. (See Annex 2: Guide In The Establishment and/or Strengthening Of Epidemiology And Surveillance Units) b. Collect, organize, analyze and interpret surveillance data in their respective areas. c. Report all available essential information (e.g., clinical description, laboratory results, numbers of human cases and deaths, sources and type of risk) immediately to the next higher level. d. Assess reported epidemics immediately and report all essential information to CHD and DOH central office. e. Provide on-site assistance (e.g., technical, logistics, and laboratory analysis of samples) as requested to supplement local epidemic investigations and control. f. Facilitate submission of weekly notifiable disease surveillance reports from public and private hospitals. g. Establish, operate and maintain a provincial epidemic preparedness and response plan, including the creation of multidisciplinary/multisectoral teams to respond to events that may constitute a public health emergency of local and international concern. h. Create Epidemic Management Committee (EMC) at the provincial level. 2.2.2 Municipal/City Health Office a. Set up and maintain a functional municipal/city/community disease surveillance system equipped with the necessary resources and adequate local financial support. Financial support may come from the disaster, calamity or other appropriate funding sources as determined by the municipal/city government officials. (See Annex 2: Guide In The Establishment and/or Strengthening Of Epidemiology And Surveillance Units) b. Collect, organize, analyze and interpret surveillance data in their respective areas. c. Report all available essential information (e.g., clinical description, laboratory results, numbers of human cases and deaths, sources and type of risk) immediately to the next higher level. d. Implement appropriate epidemic control measures immediately. e. Establish, operate and maintain a municipal/city epidemic preparedness and response plan, including the creation of multidisciplinary/multisectoral teams to respond to events that may constitute a public health emergency.

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Section 2: Roles and Responsibilities 17 f. Facilitate submission of weekly notifiable disease surveillance reports from public and private hospitals. 2.3 Philippine Health Insurance Corporation (PHIC) a. The Philippine Health Insurance Corporation shall support the implementation of PIDSR in hospitals and private practitioners by using its accreditation authority and reimbursement of claims as a leverage to encourage compliance. 2.4 DOH Representative A DOH representative ensures that the roles and functions of the CHD are being implemented in his/her assigned municipality/city, as follows:

1. Planner
2. Advocate  Advocate the implementation of functional ESU to the Local Health Board through the DOH Representative assigned in the area.

Technical assistance provider  Hospital development  Formation of functional unit of surveillance, outbreak, emergency and disaster response  DOH rep shall provide regular feedback to CHD the status of ESU functionality  Regulatory issues 4. Resource mobilize 5. Evaluation 6. Inter-agency and inter-sectoral collaborator 

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19 This section describes the following:  Using Standard Case Definitions for diseases, syndromes and events under surveillance  Partners in detecting and reporting cases  PIDSR Case Investigation and Reporting Forms  Ensuring quality data collection  Laboratory Diagnosis of Surveillance Diseases  Specimen collection, storage and transport Section 3: Identifying Cases

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PIDSR Manual of Procedures 20 3.0 Identifying Cases 3.1 Use Standard Case Definitions for Surveillance  A standard case definition for surveillance is a set of criteria that is used to determine if a person has a particular disease, syndrome or condition and if the case should be included in reporting and investigation.  Using the same case definition throughout the entire surveillance system allows data from all reporting units to be compared consistently and ensures accurate tracking of particular diseases, syndromes or conditions.  The DRUs should strictly use the standard case definitions for each of the notifiable diseases, syndromes or conditions. This is to ensure a consistent and accurate identification of cases throughout the system.  Cases are further classified to indicate whether cases are suspect, probable or confirmed. These definitions were designed for surveillance purposes only and are not intended for use in managing cases nor to indicate intention to treat.  Note that Case definitions are not sufficient for establishing a medical diagnosis and should not be relied upon to initiate therapy.  A 3-tiered system with the following levels is used:

Suspected case: indicative clinical picture without being a confirmed or probable case

Probable case: clear clinical picture, or linked epidemiologically to a confirmed case; Note: A "case with an epidemiological link" is a case that has either been exposed to a confirmed case, or has had the same exposure as a confirmed case (e.g. eaten the same food, stayed in the same hotel, etc).

Confirmed case: verified by laboratory analysis. Note: The classification on these different levels might vary according to the epidemiology of the individual diseases.  Unless specifically stated, only symptomatic cases are to be reported. Asymptomatic infections are to be regarded as cases, however, if the infection has therapeutic or public health implications. 3.2 Where do we expect to see cases? 3.3.1 Disease Reporting Units (DRUs) Case detection will be done by the Disease Reporting Units (DRUs) which are the following:

• Barangay Health Stations
• Rural Health Units
• MHO/CHO
• Local hospitals (district hospitals, provincial hospitals, regional hospitals)
• Private Clinics

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Section 3: Identifying Cases 21

• Sea Ports (Human Quarantine Stations)
• Airports (Human Quarantine Stations) The DRUs are expected to:
• Use standard case definitions to identify notifiable and immediately notifiable diseases or syndromes in inpatient and outpatient services, and community reports.
• Record Information about suspected cases in clinic registers.
• Use local laboratory capacity to diagnose suspected cases.
• Use standard protocols to process laboratory specimens.
• Collect and transport clinical specimens for laboratory investigation.
• Update list of DRUs in the area. List of DRUs should be updated annually to determine status of report submission at every level of health facility. This will further validate increase or decrease in the number of cases reported. 3.3 Who are our partners in detecting and reporting cases? 3.3.1 Disease Reporting Advocates (DRA) Disease Reporting Advocates are health workers and other individuals who have attended orientation on the PIDSR and committed to actively participate in reporting. They can be any of the following:
• Community leaders – e.g. Barangay Captain, Tribal Leader
• Barangay Health Worker
• Faith Healer/Traditional Healer
• Private Practitioners DRAs will report cases of notifiable diseases detected in their areas to the DRU. Referral to report these cases is possible when:
• A member of the community reports a single suspect case, a cluster of deaths and or an unusual health event in the community.
• A school has increasing number of absentees due to similar signs and symptoms.
• Attendees of a festival or any gathering become ill with similar signs and symptoms.
• A member of the community reports on information obtained from the radio, television and newspaper of a rare or unexplained health event in the area.

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PIDSR Manual of Procedures 22 3.3.2 Disease Surveillance Coordinators (DSC) Disease Surveillance Coordinators are staff of government and non-government health facilities (hospitals, private clinics, RHUs) officially designated as disease surveillance coordinator by the head of the facility and are trained on PIDSR. The roles of DSCs are the following:

• Notify the next higher level case/s of disease/syndrome/event classified as “immediate notification” within 24 hours of detection.
• Notify the next higher level of suspect epidemics within 24 hours of detection and perform preliminary investigation.
• Conduct preliminary investigation of suspect epidemics in their respective areas.
• Assist in epidemic investigation conducted by PESUs, RESUs or NEC.
• Record in the Weekly Notifiable Disease Report (WNDR) all cases of notifiable diseases admitted in the hospital/clinic or seen in the community/ RHU/CHO.
• Submit PIDSR report forms to the next higher level. Retain a copy of PIDSR forms and perform regular basic data analysis (time, place, and person).
• Prepare and disseminate weekly/monthly disease surveillance reports.
• Participate in workshops, seminars, training, scientific meetings and other surveillance-related activities. 3.3.3 Disease Surveillance Officers (DSO) Disease Surveillance Officers are fulltime staff of the Epidemiology and Surveillance Unit (ESU) of the CHOs (chartered cities), PHOs and CHDs who has received training on basic epidemiology, public health surveillance and PIDSR; and, are officially designated as Disease Surveillance Officer by the head of office. Ideally a DSO should either be a physician or a nurse. The roles of DSOs are the following:
• The DSO shall be responsible in the collection of PIDSR forms from the hospitals at their level (levels: 1 –clinics or infirmaries; 2 –primary hospitals; 3 – secondary hospitals and 4 –tertiary hospitals). However, hospital DSC and provincial DSO may agree on other means of submission or collection of PIDSR appropriate to their local condition.
• Encode data into the computer and maintain a file of the case investigation forms.
• Consolidate data from the different DRUs for weekly submission to the next higher level.
• Analyze and Interpret data to provide weekly and/or monthly disease surveillance report to the next higher level.
• Provide technical assistance in outbreak investigations and response to their respective DRUs when necessary.
• Disease Surveillance Officers (DSO) at the Provincial or Regional Epidemiology and Surveillance Units shall provide technical assistance to DSCs on safe collection, storage and transport of laboratory specimens for confirmatory testing. Laboratory results should be provided to the clinical staff and the patient.

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Section 3: Identifying Cases 23

• Conduct regular monitoring and assessment of DRUs to determine AND verify “silent” DRUs.
• Conduct regular technical assistance visits of DRUs with the epidemiologist.
• Manage logistics needed in the surveillance operations at their level. 3.4 Where will the patient’s information be recorded? 3.4.1 PIDSR Case Investigation and Reporting Forms After receiving the initial verbal report from the DRA, the DSC should proceed with the case investigation by completing the different PIDSR forms composed of the Weekly Notifiable Diseases Summary Page, the PIDSR Case Investigation Forms for Category I diseases/syndromes, and the PIDSR Case Report Forms for the Category II diseases/syndromes. Important initial information about the case the DRA should report to facilitate the investigation of the DSC should include:
• Complete name, address and type of the DRU where the patient was seen or admitted
• Patient’s name. If neonatal tetanus is reported, also record the name of the mother
• Patient’s age and/ or date of birth
• Patient’s gender
• Patient’s current complete address (if possible get landmarks or sketch)
• How to contact the patient
• Date patient sought consult to the DRU or date of admission
• Date of the onset of illness
• Patient’s diagnosis/ condition
• Name of the DRA who made the report
• How to contact the reporting DRA
• Date the report was received Obtain information from the patient, guardian, watcher, attending physician and/or nurse and from available records at the DRU. Since most patients may be too young to answer, ask family members or guardian to provide needed information, particularly about the patient’s symptoms, immunization and travel history. The health worker who conducted the investigation and completed the PIDSR forms should record his or her name and the date the form was completed and sent to the next higher level. Make several copies of the completed PIDSR forms so that one copy is left with the DRU, send one copy for the laboratory (e.g. if laboratory confirmation is required) along with the required specimen, and one for submission to the next higher level.

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PIDSR Manual of Procedures 24 The DSC and the DSO should ensure that only true cases are investigated and the process of case investigation is complete and conforms to the standard procedures as stated in the manual of operation. There are 3 types of PIDSR forms:

1. Weekly Notifiable Diseases Report Summary Page – It serves as the summary table for the weekly reporting of notifiable diseases. It also shows the category and frequency of reporting of all the notifiable disease included in the PIDSR. (See Annex 3)
2. Case Investigation Forms – It is a disease specific investigation form that should be filled up by the DSC during case investigation diseases/syndromes under Category I. (See Annex 4)
3. Case Report forms – It is a disease specific report form that should be filled up by the DSC for diseases/syndromes under Category II. (See Annex 5) 3.4.2 How to fill up PIDSR Forms Information gathered during the investigation process will lose its value if not recorded in the standard PIDSR forms. A specific notifiable disease has a corresponding investigation/reporting form that will be used for the case-based investigation. Each form contains questions that are disease specific; hence, it is important for the investigator to check if he or she has the correct form before proceeding with the investigation. All the PIDSR forms are self-explanatory, easy to understand and simple to follow. In filling up the forms, it is essential to do the following:  Write legibly  Ask all the questions written in the case investigation form or case report form  Ask the question clearly and understandable  Don’t leave blanks  Read and review the forms before leaving the DRU to avoid any inconveniences in the future Reminders: The DSC or the DSO must obtain information from the patient, guardian, watcher, attending physician and/or nurse and from available records at the DRU. Since most patients may be too young to answer, ask family members or guardian to provide needed information, particularly about the patient’s symptoms, immunization and travel history. The health worker (DSC, DSO and DRA) who conducted the investigation and completed the PIDSR forms should record his or her name and the date the form was completed and sent to the next higher level. The DSC will make several copies of the completed PIDSR forms so that one copy is left with the DRU, send one copy for the laboratory and the laboratory request form (e.g. if laboratory confirmation is required) along with the required specimen, and one for submission to the next higher level. The DSC and the DSO should ensure that only true cases are investigated and the process of case investigation is complete and conforms to the standard procedures as stated in the manual of operation.

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Section 3: Identifying Cases 25 3.5 How can we ensure quality data collection?  Efforts to ensure the quality of the data collected should be a concern at all levels. The following are some measures that can be adopted to assure data quality:

• All staff (midwives, nurses, med-techs, etc.) involved in data collection shall be trained in completing the forms using the standardized clinical case definitions.
• All staff (DSC and DSO) involved in collecting the PIDSR forms from the barangay and municipal levels and other data reporting units shall be primarily responsible for the conduct of quality assurance checks of reports coming from lower levels. Facilities and staff submitting faulty reports shall be followed up and remedial measures introduced as appropriate.
• Health managers at all levels shall use regular meetings, monitoring visits, purposive consultative meetings and conferences as opportunities to emphasize the importance of data quality.
• Random sampling of CIF/CRFs should be done to check for accuracy and completeness of data. 3.6 Laboratory Diagnosis of Surveillance Diseases  Ideally, confirmatory determination of the diagnosis of cases during routine surveillance should be performed using standardized laboratory methods. As much as possible, specimen should be properly collected and brought to qualified laboratories even if the case consulted only at rural health units and is not seen at hospital facilities.  During an outbreak, specimen collection for laboratory diagnosis should be a mandatory activity for the investigating team. DSOs must ensure that specimens are brought to diagnostic laboratories.  Specimen need not be collected from every suspect case during an outbreak. Only a few positive samples may be needed to diagnose an outbreak. Epidemiologic linkage may then be used confirm the other cases.  Where no diagnostic procedure was conducted on specimen from cases that are in accordance with surveillance case definition standards, these cases shall remain classified as suspect cases.  The specimen collection kits of certain priority diseases (e.g. AFP, measles, and cholera) must be readily available at the regional and provincial levels. Whether during routine surveillance or outbreak investigations, the DSCs should facilitate the collection and transport of specimen, with technical assistance provided by the DSOs. The laboratory results should be given to the DSOs and DSCs.  The DSOs should have a list of laboratories in their respective regions or provinces that perform certain laboratory procedures for guidance.  Specimens may be brought to tertiary laboratories that perform the following tests:

1. Bacteriology culture and typing a. Cholera b. Diphtheria c. Meningococcal disease d. Pertussis

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PIDSR Manual of Procedures 26 e. Typhoid and paratyphoid fever 2. Serological tests a.Hepatitis A b.Hepatitis B 3. Clinical microscopy a.Malaria b.Amebic dysentery  Specialized laboratories are reference diagnostic laboratories for the following diseases/syndromes or conditions:

1. RITM a. Measles b. Dengue c. AFP / Poliomyelitis d. ILl / Human Avian Influenza e. SARS f. Rota Virus g. Japanese Encephalitis h. HFMD i. Chikungunya
2. SACCL a.STI / HIV / AIDS
3. UP-NPMCC a.Chemical Poisoning
4. BFAD, BFAR, DOST a.Food samples for Food-borne diseases  Laboratories are encouraged to perform diagnostic procedures on other surveillance diseases such as rabies, tetanus, leptospirosis, PSP, etc.  Microscopy for malarial smears and stool analysis may be done at the rural health units with trained microscopists.  Serological tests for typhoid fever (e.g. Widal test and Typhidot) may be used only for presumptive diagnosis. It should not be used as a confirmatory diagnostic tool for typhoid. Hence, cases diagnosed using such method will remain classified as suspect cases.  Human rabies cases are basically diagnosed clinically on persons with a history of animal bites. The biting animal may be sacrificed with its head decapitated and brought to any laboratory (e.g. RITM, DA-BAI, DA-RADDL) that tests for the presence of negri bodies in the animal brain.  For food poisoning outbreaks, food samples should also be collected in separate containers and brought to a laboratory that performs specific analytic tests of the samples.

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Section 3: Identifying Cases 27  Bacteriological tests for water, especially during suspected water-borne outbreaks, should be conducted in reference water laboratories located in respective regional or local levels. However, water tests for coliforms using commercially-available kits may also be utilized by the DRU. 3.7 What specimen should be collected and where should these be submitted?  Table 2 at page 28 lists the recommended laboratory tests for confirming priority diseases and conditions. The table contains information about:

• The disease or condition.
• The diagnostic test for confirming the disease or condition.
• Where the test can be performed.
• What specimen to collect.  The table is intended to be used as a rapid reference tool. Use the information when suspected notifiable diseases/conditions or outbreaks are reported.

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PIDSR Manual of Procedures 28 Table 2. Recommended Laboratory Tests for Notifiable Diseases Disease / Syndrome Diagnostic Classification Where Test Can Be Done Specimen Required USING HUMAN SPECIMEN Acute Bloody Diarrhea Bacteriology culture; Clinical microscopy Any Tertiary laboratory Stool Acute Hemorrhagic Fever Virology culture; Serology; Clinical microscopy RITM; Any capable laboratory Blood, serum, post-mortem tissue specimen Acute Viral Hepatitis Serological Any capable laboratory Serum AFP / Poliomyelitis Virological culture RITM Stool Anthrax Bacteriology culture; Serology Any Tertiary laboratory Stools ; Sputum Skin lesion ; Blood Chemical Poisoning Toxicology UP - NPMCC Body fluids Cholera Bacteriology culture Any Tertiary laboratory Stool / rectal swab Dengue/Chikungunya Serological RITM, AFRIMS Serum Diphtheria Bacteriology culture Any Tertiary laboratory Throat swab HIV / AIDS Serological SLH-SACCL Serum Influenza Virological culture RITM Throat / nasal swab Leptospirosis Bacteriology culture &Serology SLH, RITM Serum Malaria Clinical microscopy Any laboratory or RHU w/ trained microscopist Thick & thin blood smear Measles Serological RITM Serum Meningococcal disease Bacteriology culture Any Tertiary laboratory Blood, CSF, skin scraping Paralytic Shellfish Poisoning Toxicology UP - NPMCC Serum, urine Pertussis Bacteriology culture Any Tertiary laboratory Throat swab / sputum SARS, MERS-CoV, A(H7N9), Novel Respiratory Pathogens Virological culture RITM Respiratory discharges Typhoid / Paratyphoid fever Bacteriology culture Any Tertiary laboratory Blood – 1st week Urine / stool – 2nd-3rd week USING OTHER SPECIMEN Chemical poisoning Toxicology UP-NPMCC Water, air, soil Food-borne outbreak Bacteriology culture BFAD Food samples Paralytic Shellfish Poisoning & other marine poisons Toxicology UP-NPMCC; BFAR Seafood, shellfish Rabies Clinical microscopy RITM Dog brain Water-borne outbreak Bacteriology culture Water reference laboratory Water

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Section 3: Identifying Cases 29 3.8 How should specimen be contained and transported?  During outbreak investigations, the most common specimen collected are stool, blood, water and food samples. The following is an overview of how these specimens should be collected for certain classified diagnostic procedures.

1. Stool

• When stool analysis can be done within a few hours, fresh stool must be collected and placed in clean, spill-proof containers and brought to the laboratory immediately. If stool cannot be processed immediately:
• For bacteriologic analysis, if inoculation will be done after six hours, rectal swabbing must be done and placed in appropriate transport media (e.g. Cary and Blair media) and transported to laboratory at room temperature.
• For parasitological analysis, mix stool in 10% formalin solution and transport to laboratory at room temperature.
• For virological analysis, place stool in clean, leak-proof containers, wrap with leak- proof plastic bag and transport to laboratory at refrigerator temperature.

2. Blood

• For bacteriology, collect 3-5 ml of whole blood and place in appropriate transport media (e.g. Brain heart infusion, Oxgall, Bile citrate broth) prior to transport to laboratory at room temperature.
• For immunology, collect blood serum and place in cryotube and transport to laboratory in frozen condition.
• For toxicology, collect 5-10 ml whole blood and place in heparinized test tube (green top) and transport to laboratory at refrigerator temperature.
• For parasitology, collect blood and place in tube with anticoagulant (e.g. EDTA, Na citrate).

3. Food samples

• In food-borne outbreaks, samples of food items must be collected even if a particular is not implicated as the cause of the outbreak. The samples must be placed in individual containers and sent to the laboratory under refrigerator or frozen temperature, depending on the type of analysis to be done.

4. Water

• Water samples must be collected in sterile bottles and immediately sent to the laboratory within 6 hours. If not, store the samples at refrigerator temperature but ensure that specimen will be at the laboratory within 24 hours.

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31 Section 4: Notification and Reporting of Cases This section describes the:  Mandatory reporting of notifiable diseases, syndromes and event.  Requirement for PhilHealth accreditation, reimbursement of claims, issuance of initial or renewal of hospital license to operate, and Sentrong Sigla Certification.  Flow of notification for immediately notifiable diseases, syndromes and events and of the weekly reporting notifiable diseases.  Importance of zero reporting.  Process of receiving and checking the PIDSR forms.

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PIDSR Manual of Procedures 32 4.0 Notification and Reporting of Cases 4.1 Mandatory reporting of notifiable diseases, syndromes and events 4.1.1 Requirement for PhilHealth accreditation and reimbursement of claims Hospitals, lying-in clinics, and facilities providing ambulatory services that have been determined to be non-compliant to the PIDSR reporting requirements shall be reported to the provincial or regional PhilHealth office for appropriate action. After a reasonable period of time has elapsed, the PHO or the CHD shall follow-up with the PHIC office for feedback on actions taken. 4.1.2 Requirement for issuance of initial or renewal of hospital license to operate  All hospitals/clinics shall be required to fill up a Notifiable Disease Report Register (NDRR). The NDRR is a record of all PIDSR Weekly Notifiable Disease Reports prepared or submitted to the health office. The NDRR serves as the monitoring and tracking tool for both the health facility and the evaluators of the CHD hospital licensing and surveillance staff on the PIDSR implementation.  The designated Disease Surveillance Coordinator (DSC) in the hospital/clinic shall be responsible in filling up and safekeeping of the NDRR.  The CHD staff tasked to assess hospitals for issuance of initial or renewal of license to operate shall make sure that the items on submission of PIDSRS is observed by the hospital or facility.  The CHD surveillance unit or the PHO shall notify the CHD hospital licensing unit of those hospitals and facilities that are not submitting the reports as confirmed by the Data Processing Registry. The referring PHO or CHD surveillance unit shall be informed of any action taken by the CHD licensing team. 4.2 What is the flow of notification for immediately notifiable diseases, syndromes and events?  The flow of notification for Category I or immediately notifiable diseases, syndromes or events is shown in Figure 3 below.  Cases are identified as immediately notifiable diseases at DRUs.  Cases are reported simultaneously to the PHO/ PESU, CHD/RESU and NEC within 24 hours of detection by the fastest means possible.  Initial report can be verbal using the telephone or radiophone, or written via facsimile or email.  It will be followed by case-based reporting form using the standard PIDSR case investigation form.

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Section 4: Notification and Reporting of Cases 33  Reports received by the NEC will be reported to World Health Organization possibly within 24 hours also.  The diseases/syndromes or events under this category includes:

• Acute Flaccid Paralysis
• Adverse Events Following Immunization (AEFI)
• Anthrax
• Human Avian Influenza
• Measles
• Meningococcal Disease
• Neonatal Tetanus
• Paralytic Shellfish Poisoning
• Rabies
• Severe Acute Respiratory Syndrome (SARS) 4.3 What is the flow of weekly reporting notifiable diseases?  The flow of weekly reporting of notifiable diseases (PIDSR) is shown in Figure 4 below. 4.3.1 Flow of Weekly Reporting for Component Cities:  Cases identified as notifiable diseases in the community are reported to their respective DRUs (BHS, hospitals, clinics, ports and airports).  The DSC records in the PIDSR Case Report Forms all cases of weekly notifiable diseases from the different DRUs.  The DSC at the BHS will submit the PIDSR case report forms (including the WNDR Summary Page and Case Investigation Forms) to the DSC of the next higher DRU (RHU/Main Health Center or the CESU for chartered cities) every Friday of the week.  The DSC will consolidate, analyze and interpret data from the different DRUs (including the hospitals) of their municipality/city. The DSC will maintain a file of all the PIDSR forms. DSC from the hospitals will do their own analysis and interpretation of data and will submit their report and dataset to the DSC in the RHU/Main Health Center or CHO.  The DSC will prepare and disseminate a weekly Municipality/City Disease Surveillance Report.  The DSC (including the hospitals) will submit the report and copies of PIDSR forms, and electronic file if available to the DSO of the next higher level (PESU) every Friday of the week. If the dataset was submitted as a paper file, the DSO will encode data into the computer and maintain a file of the PIDSR forms.  The DSO will prepare and disseminate a weekly Provincial Surveillance Report.

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PIDSR Manual of Procedures 34  The Provincial DSO will consolidate, analyze and interpret data from the different DRUs of their province and submit the dataset to the DSO of the next higher level (RESU) every Friday of the week.  The Regional DSO will consolidate, analyze and interpret data from the different DRUs of their region and submit the dataset to the PHSID of the NEC every Friday of the week.  The PHSID of NEC will consolidate, analyze and interpret data from the RESUs to prepare and disseminate a weekly National Surveillance Report. 4.3.2 Flow of Weekly Reporting for Chartered Cities:  Cases identified as notifiable diseases in the community are reported to their respective DRUs (barangay health stations, hospitals, clinics, ports and airports).  The DSC records in the PIDSR Case Report Forms all cases of weekly notifiable diseases from the different DRUs.  The DSC at the BHS will submit the PIDSR case report forms (including the WNDR Summary Page and Case Investigation Forms) to the DSO of the next higher DRU (CESU) every Friday of the week.  The DSO will encode, consolidate, analyze and interpret data from the different DRUs (including the hospitals*) of their city. However, the DSO will maintain a file of the PIDSR forms.  DSC from the hospitals will do their own analysis and interpretation of data and will submit their report and dataset to the DSC in the RHU/Main Health Center or CHO.  The DSO will prepare and disseminate a weekly City Disease Surveillance Report.  The DSO will submit the report and the dataset (electronic file) to the DSO of the next higher level (RESU) every Friday of the week.  The DSO will consolidate, analyze and interpret data from the different DRUs of their region and submit the dataset to the PHSID of the NEC every Friday of the week.  The PHSID of NEC will consolidate, analyze and interpret data from the RESUs to prepare and disseminate a weekly National Surveillance Report.

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Section 4: Notification and Reporting of Cases 35 4.4 What is zero reporting? Why is it needed?  Zero reporting is the report made by the DSCs to the next higher level even if no cases have been found in their respective DRUs. It is informing the next higher level that no cases were detected.  However, zero reporting may not always indicate that there are no cases in the area but it could also mean that there may be problems encountered in the surveillance system.  Possible reasons for consistently submitting zero report may include:

• lack of admission of cases that is notifiable
• presence of “missed” cases that are not reported to the respective DSC or
• absence of DSC, who is in-charge of monitoring reports from DSAs and admissions of notifiable disease  Why is “zero” reporting important?
• Serve as basis for assessing sensitivity of the disease surveillance system
• Allows the ESU to monitor DRUs that comply with regular weekly reporting and those that do not
• Enable the ESU to determine which DRUs frequently submit “zero” reports
• Serve as a basis for prioritizing the sites requiring close monitoring
• Prompts the DSO to evaluate implementation of surveillance activities and to determine reason(s) for consistently sending “zero” report
• Zero reporting may be done through phone calls, SMS, fax, email, or whatever mode of communication is available. Failure to submit timely reports will be given appropriate action by the next higher level. 4.5 What is the mechanism of transmitting PIDSR Forms to the next higher level?  The DSC shall be responsible for submitting the PIDSRS forms from the city or municipality to the provincial health office either in electronic form or paper copy of the PIDSR forms. The DSO may send the electronic file by email simultaneously to the PHO, CHD and DOH-NEC.  The DSO shall be responsible for submitting an electronic copy of the PIDSR forms from all the reporting units of the province to the CHD. The DSC may also email the electronic files to the CHD and the DOH-NEC.

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PIDSR Manual of Procedures 36  The RESU shall be responsible for submitting an electronic copy of the PIDSR forms from all the reporting units in the region to the DOH-NEC

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Section 4: Notification and Reporting of Cases 37 4.6 Receiving and Checking PIDSRS 4.6.1 Who shall be responsible for receiving and checking the PIDSRS?  The following shall be responsible for receiving and checking the PIDSRS

• RHU: DSC
• PHO: DSO
• CHD: Regional Surveillance Officer
• NEC: DOH-NEC Public Health Surveillance Unit 4.6.2 What items in the PIDSR shall be checked upon receipt?  The following items in the PIDSR shall be checked upon receipt:
• Completeness of the data entries in the required forms
• Consistency of data in the summary sheets, case investigation forms and case report forms 4.7 What is a “silent” DRU and how should we deal with them?  A “silent” DRU is a health facility that has not submitted PIDSR, including failure to maintain zero reporting, for two or more weeks.  When a silent DRU is identified, the DSO should conduct active surveillance in that health facility to determine reason for “silence”. This would include the following activities: For Hospitals:  Scrutiny of hospital records and logbooks (including admission logbooks, residents and nursing endorsement logbooks, Emergency Room and Out-Patient Department logbooks, and other relevant records) which may include clues and information on recent admissions of cases.  Retrospective records review.  Find out the reasons why they failed to submit the PIDSR  Persuade the hospital management to participate in the surveillance activities. For Rural Health Units/ Health Centers / Clinics / BHS:  Scrutiny of health facility records and logbooks (including TCL, ITR, FHSIS Summary Table)  Retrospective records review.  Find out the reasons why they failed to submit the PIDSR  Persuade the health facility management to participate in the surveillance activities.

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PIDSR Manual of Procedures 38 Figure 3: Flow of Notification for Immediately Notifiable Diseases, Syndromes and Events

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Section 4: Notification and Reporting of Cases 39 Figure 4: Flow of Weekly Reporting of Notifiable Diseases

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41 Section 5: Data Analysis and Interpretation This section describes about:  Preparing a summary table by disease, barangay and morbidity week  Computer-based data storage and analysis  Computer hardware and software requirement  Showing disease trends through the use of graphs  Analyzing data by time, place and person

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PIDSR Manual of Procedures 42 5.0 Data Analysis and Interpretation 5.1 How should the PIDSR WNDR be consolidated and stored at the RHU/CHO level utilizing a paper-based system?  Each reporting unit is required to analyze data on a weekly basis to guide appropriate actions needed for unusual occurrences and patterns.  The RHUs are expected to fill up the PIDSR case investigation and case report forms by disease. One copy of the forms will be given to the PHO and one copy is retained at the RHU for encoding.  RHUs are required to make a summary notifiable disease table by disease, barangay and morbidity week. Figure 5 is a partial summary notifiable disease table and instruction for completion is discussed in section 5.2.1 below.  For each fiscal year, the 52 weekly summary tables for the morbidity reports can be consolidated to prepare the Annual summary table of notifiable disease.  The “notifiable disease” component of the FHSIS shall be covered and/or integrated with the disease monitored under the PIDSR. As such, a common reporting form (i.e. PIDSR forms) will be used. 5.1.1 How to prepare a summary table of notifiable disease by barangay and morbidity week This table gives a picture of the occurrence of specific diseases in a barangay of the municipality in a specific period of time. The period of occurrence is guided by the morbidity calendar prepared by the NEC. Cases will be logged in on the table according to the morbidity week that it occurred. The table is shown in Figure 5 below.

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Section 5: Data Analysis and Interpretation 43 Figure 5: Summary Table of Notifiable Disease Occurrence by Barangay and Morbidity Week Year: _______ Notifiable Disease: e.g., Measles Municipality: Province: Region: Reporting Unit: Name and Signature of Reporting Staff: Contact Numbers: Names of Barangays Category of Cases Morbidity Weeks Total cases for the year MW 1 MW 2 MW 3 MW 4 MW 5 MW 6… MW ….. MW ….. MW ...52 Barangay 1 Survived Died Barangay 2 Survived Died …. Last Barangay Survived Died Total number of all cases (Survived and Died) per morbidity week (Grand total for the municipality or city for the year) Total number of Deaths per morbidity week (Grand total for the municipality or city for the year) Here’s how to fill out the summary table:  Remember the table must provide data on the occurrence of only one disease. Write the particular name of the disease you would like to report in this particular sheet at the title space (in this example, Measles). This means that you will submit separate sheets for each disease you are reporting.  Diseases occur and spread regardless of political or governance divisions. Write the complete name of your municipality or city, the province, and the region. These must be filled out even by chartered cities as we need to geographically locate your area in

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PIDSR Manual of Procedures 44 relation to other reporting units. This will give information on the activity of the disease in a municipality/city in relation to its neighbors.  Write the complete name of your reporting unit, be it an RHU or a City Health office.  Write the name of the reporting staff in print and ask him to sign above it. This will render the report official. Indicate the contact number, landline or cellular phone. If landline is used, indicate the area codes. These data will provide ease if data verification is needed. The telephone provides efficient access in times of urgency.  On the first column of the body of the table, write the names of all barangays included in your municipality or city.  The second column is the classification or category of cases as to whether they survived or died. “Survived” signify those who got sick but survived with or without complications and “Deaths” are those who got sick and died. Do not add them. Fill out the appropriate cell with the correct figure.  The third column onwards pertains to the time period of report. The time period progresses to the right of the table from the first morbidity week which is the first week of the calendar year until the 52nd week which corresponds to the last week of the calendar year. For each barangay, write down the number of cases for the particular disease being reported. Write “0” if there is none for the week in a barangay. Zero (0) means that your unit looked for the cases or did not see any case during the particular week. Do not leave blanks. A blank does not mean anything at all except that your report is incomplete. This will prompt the upper level data manager to contact you and verify the meaning of the blank cells.  The cases that must be encoded here include both those who survived and those who died. For each barangay, write the number of cases who survived in the upper row and the number of cases who died in the lower row. Make sure to separate them by categories so that the total number of cases for the barangay will not artificially increase.  On the last column on the right, write the total number of cases seen during the particular morbidity weeks. Each will give the picture for the barangay for the year, distributed by morbidity weeks.  On the last/bottom row of the table, write the vertical totals for a particular morbidity week. This will give the total for the municipality or city for the particular morbidity week distributed by barangay. The right-most bottom cell simply gives the grand total number of cases of a particular disease in the municipality or city for the year.  The high value of this summary table lies on the information it gives us on disease activity. It graphically shows where cases occur, where they are spreading, when they occur, where cases are increasing, and also where cases do not occur. It also shows where deaths occur and provides us the basis for determining case fatality rates for each barangay and for the municipality/city. As a guide, Case Fatality Rate is computed by using the formula shown below: Total number of deaths in a barangay Case Fatality Rate = x 100 Total number of cases (survived and died) in a barangay

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Section 5: Data Analysis and Interpretation 45  Data through morbidity weeks in particular barangays will also give us the trend and prompt us to take action especially when cases are increasing. From the table, we can prioritize barangays easily and monitor as well as evaluate very simply the results of our public health efforts. This table will become basis for other graphical presentations regarding a particular disease. 5.2 Computer-based data storage and analysis  The use of computer-based data storage and analysis is highly recommended in all reporting units (RHU/CHO/PHO/CHD). However, for the time being while some LGUs are still acquiring the means for computerization, a paper-based system for reporting may be undertaken.  The PIDSR data entry and analysis software has been developed and it will be provided with a separate Users Manual. The different variables obtained for each case reported are included in the program. This will provide the summary of data on all cases reported at all levels. Automatic generation of graphs, tables and charts provided by the program will greatly ease management of voluminous data and their analyses.  A special training for data encoders to build capability at the provincial level will be conducted by the NEC staff. 5.2.1 Computer hardware and software requirements  Trained and dedicated personnel for the computer system  Management, technical and logistical support  Computer hardware with at least 1Gb RAM, 80 GB hard disk space and printer  Computer software: Word processor (e.g. MS Office), Epi Info for Windows, MS Access 5.3 How should surveillance data be analyzed?  The analysis of surveillance data represents an inductive reasoning process whereby the study of individual data elements produces a more general picture of the problem in the population.  Regular analysis of data allows for describing the patterns of disease or injury in a given population represented by different measures. Analyzing surveillance data must be given the highest priority at all levels.  In analyzing surveillance data, the following approaches should be considered:

• Know the strengths and weaknesses of the data collection methods and processes to get the real sense of the disease trends.
• Start from the simplest analysis before proceeding to the more complex methods. Examine first each variables separately both by numbers and trends then examine the relationships among these variables.
• Recognize when inaccuracies in the data prevents a higher level analysis. Haphazardly collected or incomplete data cannot be corrected by complex analytical methods.

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PIDSR Manual of Procedures 46  Analysis of information depends on the accuracy of the surveillance data. It is a waste of time and resources to analyze data that are erratically collected or with varying case definitions. Reliability and validity determines the accuracy of surveillance data.

• Reliability refers to the consistency of reporting of a condition even by different observers from different locations.
• Validity refers to whether the condition reported reflects the “true” condition as it occurs.
• The accuracy of data can be more completely assured when biologic measures complement clinical case definitions like laboratory testing.
• Accuracy of data is more difficult to confirm in subjective behavioral situations such as lifestyle studies.  Surveillance data should be used to describe health problems or situations in terms of the basic epidemiological variables of time, place and person. Use and analysis of these epidemiological variables allows the following to be carried out:
• Comparison of patterns and risks of disease at different time periods, place or among population groups
• Calculation of rates of disease (when appropriate denominators are used)
• Detection of epidemics for early control and prevention
• Project future occurrence of disease to facilitate prompt public health response
• Evaluation of public health policy
• Identify new or emerging syndromes or conditions 5.3.1 Analyze Data By Time  Time analysis answers the questions “When does the disease occur commonly or rarely?” and “Is the frequency of disease at present different from the frequency in the past?”  Analysis of surveillance data by time detects increasing or decreasing trends of disease or condition. Bear in mind that there is an interval or delay that can be measured between the exposure and the appearance of the problem. Time intervals of importance to surveillance are the following:
• Incubation period for communicable diseases which refers to the time from exposure to the appearance of signs and symptoms
• Interval between appearance of symptoms and when the diagnosis is made
• Interval between diagnosis and eventual reporting and inclusion of the disease in the surveillance data

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Section 5: Data Analysis and Interpretation 47 5.3.1.1 Techniques in Time Analysis  The following are the different techniques in the analysis of surveillance data by time, these are:

• Simple comparison of the number of cases reported in a particular time period such as in weeks or in months. The data can be arranged in tables or graphs to visually show an increase, decrease or stability in the disease trend. Figure 6 below is an example of simple graph.
• Comparison of the number of cases reported for a current time period with the number of cases reported during the comparable period for the past year or several years. An example is Figure 7 below which is an enhancement of the dengue fever analysis shown in Figure 6 above. Figure 6: Dengue Fever Cases in City X by Month (N=117) January 1, 2007 to September 15, 2007 Figure 7: Dengue Fever Cases in City X by Month (N=117) January 1, 2007 to September 15, 2007 vs. 2006

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PIDSR Manual of Procedures 48

• Analysis by date of onset rather than by date of report. This provides a better representation of the disease incidence because it eliminates the delays between diagnosis and reporting. Figure 8 below is an example.
• Graph surveillance data over time for long-term or secular trends analysis indicating events that may have influenced the trend such as: Changes in the case definitions New diagnostic criteria Changes in reporting requirements New control programs Changes in the surveillance system Sudden increase or decrease in population such as displacement due to military activities or conflicts Figure 8: Food Poisoning Cases by Time of Onset of Illness BIR, Quezon City, August 2, 2004 (N=55)

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Section 5: Data Analysis and Interpretation 49 Source: NEC Figure 9 below is an example of surveillance data starting from the absence of surveillance to the establishment of a surveillance system and institution of intervention. 5.3.2 Analyze Data by Place  Place analysis of surveillance data answers the question “Where are the rates of disease highest or lowest?”  The next step is to analyze the surveillance data by place where the disease or condition occurred and not necessarily where the report came from. Surveillance data reports from health faculties do not necessarily mean that the disease or condition happened in that place.  Place analysis provides important information such as:

• Identify areas with highest rates of disease or condition that will facilitate efforts to identify the causes and institution of proper interventions
• Characteristics of the population involved such as density and distribution
• Presence of important facilities such as hospitals, clinics, and structures that can be used for evacuations or other emergency activities Figure 9: Hepatitis A Cases in City Y by Month January to December 2007

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PIDSR Manual of Procedures 50 Figure 10: Spot Map of Typhoid Fever Cases and Water Sources Iligan City, 1995

• Presence of environmental resources such as lakes, rivers, streams, springs, land forms and vegetation that are important to the analysis of the disease or condition
• Modern technology such as computers and mapping software permits sophisticated analysis of surveillance data by place and monitor in real time the geographical course of a disease or condition  Maps are used to graphically represent surveillance data by place. Figure 10 below is an example of a spot map.

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Section 5: Data Analysis and Interpretation 51 5.3.3 Analyze Data By Person  Person analysis answers the question “Who are getting the disease?”  Person analysis of surveillance data is used to describe the population at risk of a particular disease or condition. Person can be characterized by an infinite number of variables. The person or demographic variables most frequently used are age, gender and race. Less commonly used variables are marital status, education, religion, occupation, social and economic status.  Age is the most important characteristic because majority of health related events differ with age. Analysis of surveillance data by the variable “age” is dependent on the specific disease or condition under study. For childhood diseases, a narrow age interval could identify peak incidence of the disease. While for diseases or conditions that affect adults, a broader age interval is appropriate. Other factors associated with age include host susceptibility, incubation period of the disease, physiologic response and opportunity for exposure.  In most situations, a simple analysis of the count or number of cases is sufficient but does not provide other information to fully understand the impact of the disease or condition in the given population. To allow better comparison of risks among different population groups, variable specific rates should be computed and analyzed.  A rate measures the frequency of occurrence of an event or condition. Calculation and analysis of rates is very important in epidemiology. It allows valid comparisons within or among different populations for a given specific period of time. The general formula for rate computation is: The numerator is the upper portion of the fraction representing the number of cases or events during the specified time period. The denominator is the lower portion of the fraction indicating the population size in which the cases or events occur. The size of the n ranges from 2 to 6 and is dependent on the incidence or prevalence of the disease or condition.  This can be done by analyzing the person variables in relation to denominators. The denominator is the number of all events being measured such as the total population from which the cases occurred or the total population at risk of the disease or condition.  There are several different rates used in surveillance and public health in general. These rates are shown in Table 4 below. Number of cases/events in a specified time Rate = x 10n Average or mid interval population

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PIDSR Manual of Procedures 52 Table 4. Rates Commonly used in Public Health and Epidemiology Measure Numerator Denominator Expressed per number at risk Measures of Morbidity Incidence rate Number of new cases of a specific condition per given time period Population at the start of the time period Variable: 10n where n = 2,3,4,5,6 Attack rate Number of new cases of a specific condition per epidemic period Population at the start of the epidemic period Variable: 10n where n = 2,3,4,5,6 Secondary attack rate Number of new cases of a specific condition among contacts of known patients Size of contact population at risk Variable: 10n where n = 2,3,4,5,6 Point prevalence Number of current cases of a specific condition at a given time Estimated population at same point in time Variable: 10n where n = 2,3,4,5,6 Period prevalence Number of old cases plus new cases of a specific condition identified in a given time interval Estimated mid-interval population Variable: 10n where n = 2,3,4,5,6 Measures of Mortality Crude death rate Total number of deaths in a given time interval Estimated mid-interval population 1,000 or 100,000 Cause-specific death rate Number of deaths from a specific cause in a given time interval Estimated mid-interval population 100,000 Proportionate mortality Number of deaths from specific cause in a given time interval Total number of deaths from all causes in the same time interval 100 or 1,000 Case fatality rate Number of deaths from a specific condition in a given time interval Number of new cases of that condition in the same time interval 100 Neonatal mortality rate Number of deaths among the < 28 days of age in a given time interval Number of live births in the same time interval 1,000 Infant mortality rate Number of deaths among the < 1 year of age in a given time interval Number of live births in the same time interval 1,000 Maternal mortality rate Number of deaths form pregnancy-related causes in a given time interval Number of live births in the same time interval 100,000 Measures of Natality Crude birth rate Number of live births in a given time interval Estimated total mid-interval population 1,000 Crude fertility rate Number of live births in a given time interval Estimated number of women ages 15-49 years at mid- interval population 1,000 Crude rate of natural increase Number of live births minus number of deaths in a given time interval Estimated total mid- interval population 1,000 Adapted from the “Principles and Practice of Public Health Surveillance”, Teutsch & Churchill.1994

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Section 5: Data Analysis and Interpretation 53 5.3.4 Graphical Presentations of Surveillance Data  Graphical presentation of data plays a very important role in surveillance in organizing, summarizing and displaying information clearly and effectively. Graphics visually display data using lines, points, symbols, numbers, coordinates, color and shading.  The graphical tools available for visually displaying surveillance data are tables, graphs, charts and maps. 5.3.4.1 Tables  A table is a brief and concise way of presenting large sets of detailed information using rows and columns. It shows trends, comparisons, and interrelationships among variables. It should be simple, direct and clear. Tables usually serve as the basis for preparing more visual presentation of data such as graphs and charts.  The following are the characteristics of an effective table:

• Simple with 2-3 variables
• Self-explanatory
• Codes, abbreviations, and symbols should be explained in detail in a footnote
• Specific units of measure for the data should be given
• Totals should be provided
• If the data is not original, source should be provided in a footnote at the bottom of the table  Tables can be one-variable or multivariable tables. The most basic table is a frequency distribution with only one variable as shown in Table 5 below. The first column shows the categories of the variable represented by the data. The second column shows the number of events that fall into each category. The third column often shows the percentages. Table 5: Rectal Swab Results of Ill Patients Food Poisoning in Barangay X, May 2007 Microorganisms Number Of Subjects Percentage Vibrio parahemolyticus 40 20.5 Plesiomonas shigelloides 3 1.5 Staphylococcus aureus 3 1.5 Aeromonas sobria 3 1.5 Aeromonas hydrophila 1 0.5 Aeromonas caviae 1 0.5 No organism isolated 144 74 TOTAL 195 100

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PIDSR Manual of Procedures 54 Figure 11: Line Graph of Reported Acute Bloody Diarrhea Province Z, 2006 5.3.4.2 Graphs  A graph is a method of showing quantitative data using the x-y coordinate system. The x-axis is used for classification (independent variable, e.g. time) and the y-axis is used to show frequency (dependent variable, e.g. no. of cases)  Graphs are more appealing and effective tool than a table in delivering information. It is a primary analytic tool that assists the reader to visualize trends, patterns, differences and similarities in the data.  In constructing a graph, the following should be observed:

• It should be simple and self explanatory
• Label titles, axes, source, scales and legends
• Each variable should be clearly differentiated by legends
• Ensure that scales for each axes is appropriate for the data
• Minimize the number of coordinate lines
• Define all abbreviations and symbols
• Note all data exclusions
• If the data is not original, source should be provided in a footnote at the bottom of the table  The most commonly used graphs are the following:

1. Histogram: a graph wherein the frequency distribution is represented by adjoining vertical bars where in the cases are stacked in adjoining columns. The area of each bar is proportional to the frequency of the interval. It uses squares to represent cases rather than a line to connect plotted points. Histograms are used to analyze outbreak data and to show an epidemic curve. In a histogram, the cases are stacked on the graph in adjoining columns. Figure 8 on page 42 is an example of a histogram.
2. Frequency Polygon or Line Graph: a graph created from a histogram by connecting the midpoints of the interval using a straight line instead of making a bar or filling in squares. It is very useful in comparing frequency distribution from different sets of data. See Figure 11.

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Section 5: Data Analysis and Interpretation 55  Basic steps in making a histogram:

1. Determine the information to be shown on the graph.
2. Put a title on the graph. The title should include: The Figure number The name of disease or event The description of the population such as by age group, by gender, by date of consultation or by date of admission. The place of disease occurrence The dates of disease occurrence The total number of person affected
3. Write the range of numbers on the x and y axes by: Starting with zero (0) as the lowest number. Writing the numbers until a number higher than the number of cases Choosing an appropriate interval for the y axis if the values are too large and label appropriately Marking the time units on the x axis and label. Divide the x axis into equal units of time starting with the beginning of an outbreak, morbidity weeks, or the beginning of a calendar period, such as a month or year.
4. Each bar on the graph should have the same width. For each unit of time on the x axis, find the number of cases on the y axis and fill in one square for each case. 5.3.4.3 Charts  In contrast to graphs, charts show epidemiologic data using only one coordinate. Charts effectively show comparative data.  The most frequently used types of charts are as follows:
5. Bar charts: this is the simplest and most effective way to present comparative data. It uses bars of the same width to represent different categories of a factor. Unlike a histogram, the bars of the different categories are separated by spaces because they do not show a continuum on the x axis. Bars on the chart maybe vertically or horizontally drawn. Figure 12 is an example of a horizontal bar chart.
6. Pie charts: A pie chart is a chart in which the sizes of the slices show the proportional contribution of each component part. Since it is difficult to gauge the area of the slices, it is important to indicate what percentage each slice represents. The whole chart should total 100 percent. An example of a pie chart is shown in Figure 13.

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PIDSR Manual of Procedures 56 Figure 12: Number of Injuries by Type ER Complex of Hospital Z, 2006 Figure 13: Measles Vaccination Status of Children 2 Years And Below City X, 2007

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Section 5: Data Analysis and Interpretation 57 5.3.4.4 Maps  Maps or geographic coordinate charts are used to show the location of events. An example of a spot map is shown in Figure 10 on page 44. Spot maps use dots or other symbols to show the location of an event or where a disease condition took place. It is very useful in showing the distribution of an event. Since it does not take into account the population size at risk, it cannot indicate the risk of the residents in acquiring a particular disease. 5.3.5 Interpretation of Surveillance Data  Compare the current situation with previous weeks, months, or years. Observe keenly whether the number of cases and deaths for the given disease is stable, decreasing or increasing by looking at the line or bar graphs.

1. Ascertain if thresholds for action for the disease have been reached. Thresholds are indicators when something should happen or change. It is a decision guide as to when to take action, and what actions to take. Alert Threshold: refers to the level of occurrence of disease that serves as an early warning for epidemics. An increase in the number of cases above the alert threshold level should trigger an investigation, check epidemic preparedness and implement appropriate prevention and control measures. Epidemic threshold: refers to the level of occurrence of disease above which an urgent response is required. The threshold is specific to each disease and depends on the infectiousness, other determinants of transmission and local endemicity levels. For some diseases, such as poliomyelitis or SARS, one case is sufficient to initiate a response.
2. Concerning the national data for disease of epidemic proportions, the alert and epidemic thresholds are computed as follows: To compute for the alert threshold: compute for the weekly/monthly average of a particular disease during the past 3 to 5 years and add 1 standard deviation To compute for the epidemic threshold: compute for the weekly/monthly average of a particular disease during the past 3 or 5 years and add 2 standard deviation
3. Suggested thresholds that alert health staff to a possible outbreak are shown in Table 5.

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PIDSR Manual of Procedures 58 Table 5: Recommended Thresholds for Specific Diseases Disease/Condition Alert Threshold Action/Epidemic Threshold Acute Bloody Diarrhea Increasing number of bloody diarrhea over a short period of time If the suspect cases has been confirmed Acute Flaccid Paralysis (AFP/Polio) 1 suspect case 1 confirmed case Acute Hemorrhagic Fever 1 suspect case 1 confirmed threshold AIDS Intervention targets prevention so there is no need to wait for index case or number of cases as threshold to take action Bacterial Meningitis In a population greater than 30,000: 5 cases per 100,000 inhabitants per week In a population less than 30,000: 2 cases in 1 week or an increase in the number of cases compared to the same time in previous years In a population greater than 30,000: 15 cases per 100,000 inhabitants per week confirms epidemic in all situations. If no epidemic during last 3 years and vaccine coverage for meningococcal meningitis is <80% epidemic threshold is 10 cases per 100,000 inhabitants per week. In a population less than 30,000: 5 cases in 1 week or doubling the number of cases over 3-week period Cholera 1 suspect case 1 confirmed case where it has not been reported before Malaria Hyper-endemic, threshold not applicable Measles 1 suspect case Confirmed outbreak Neonatal Tetanus 1 suspect case 1 confirmed case through investigation Viral Hepatitis If there is an unusual increase in the number of new hepatitis cases or deaths as compared to the same time period in previous years

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Section 5: Data Analysis and Interpretation 59  When interpreting the surveillance data, the following should be considered:

1. Severe cases and deaths are most likely to be detected as hospitalized inpatients meaning the use of the case definition is likely to be more accurate than those reported for outpatient cases.
2. Increases and decreases in the number of cases may be influenced by other factors other than a true increase or decrease being observed. Some of these factors that may affect the trend of disease are: Change in the number of disease reporting units Changes in the case definition being used to report the disease or condition Changes in the denominator Changes in the health seeking behavior in the community Changes in the population because of recent immigration to or emigration from the area or increase in refugee or internally displaced populations 5.3.6 Using the Results of Analysis  Conduct an epidemiological investigation  After conducting the investigation and sufficient evidences have been gathered, it is possible to plan control and prevention measures. It is the primary public health reason why the investigation was conducted in the first place.  Attempt to limit spread and occurrence of additional cases even at the onset of the investigation.  Plan also for a complete prevention program to prevent the occurrence of similar outbreaks in the future.  Collaborate with specific disease reduction programs to intensify surveillance if an alert threshold has been crossed.  Advocate with political leaders and the community for more resources, if inadequate resources is identified as a cause for the increased number of cases.  Provide feedback to lower levels.

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61 Section 6: Feedback This section describes how to:  Provide feedback mechanisms and its importance to the surveillance system  Prepare and disseminate of information summary sheets, public health bulletins, newsletters, fact sheets and reports  Prepare and write disease surveillance report

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PIDSR Manual of Procedures 62 6.0 Feedback 6.1 What is feedback?  Feedback reinforces health staff’s participation in the surveillance system. It also raises awareness about certain diseases and any achievements of disease control and prevention activities in the area. There is the need to institute regular and timely feedback within and between levels of the health delivery system. Data, ideally, should be reported routinely from the lower to the higher levels of the health care system and vice versa. Figure 14 illustrates this relationship among the different levels of the health care system.  When the district, provincial or regional health management teams or National Surveillance Unit receive and analyze data, they should promptly disseminate results to the entities that provided the data. 6.1.1 Verbal Feedback  Verbal feedback from one health unit to another can take place in various venues, as follows:

• Supervisory visits
• Telephone calls
• Meetings: weekly, monthly, quarterly, half-yearly and annually
• Health education activities  During a visit or meeting, give a verbal report or comment about the data that were reported by the health facility during a given period of time. Display the data in a simple table. Sit with the health staff and show them the data. Discuss the likely conclusions that can be drawn from the data. Consider conclusions not only for the health unit, but also for the locality as a whole. Figure 14: Flow of Information Feedback

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Section 6: Feedback 63 6.1.2 Written feedback 6.1.2.1 Outbreak Response Report  After an outbreak response has been conducted, the lead or main investigator (person or office) should prepare a report. Use a copy of the report as feedback to the unit or entity that first reported the case and to all other concerned stakeholders. 6.1.2.2 Information Summary Sheets  An information summary sheet is a “report” that presents data and its interpretation in a table or other graphic format. It is particularly useful as back-up to a verbal presentation. The summary sheet can be a simple table that shows how the data reported for this period differ from the data reported for some other period or target population: For example, show the number of cases of diarrhea with dehydration in children less than 5 years of age from a given period last year.  Share information summary sheets with other surveillance entities, and use them to support requests made to higher levels for additional funds, supplies and other resources. 6.1.2.3 Public Health Bulletin  The purpose of a public health bulletin is to present facts in a limited format and time frame. The bulletin should contain at least:

• A summary table showing the number of reported cases and deaths to date for the epidemic-prone diseases
• A brief, reader-friendly summary, commentary or message on surveillance of a given priority disease or other topic, such as health facility, sub-district or district performance
• A map showing geographical distribution of priority diseases
• Data reported from lower levels during the period. This will act as feedback, enabling units at the same level to compare their data with that of each other, and trigger correction of inaccurate data
• Alert messages on epidemic-prone diseases  If a public health bulletin is sent to your office, display it where others can see it. Make copies to distribute to health facility staff. Take copies of the bulletin on supervisory visits to show health staff how the data they report contributes to public health.  All levels must produce a monthly bulletin covering the priority conditions and any other diseases relevant to the local area. The national level will continue to produce weekly and monthly bulletins on all the priority diseases.

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PIDSR Manual of Procedures 64 6.1.2.4 Newsletter  The newsletter could be produced by health units at the local levels (municipal, district, provincial or regional)  The newsletter can be produced simply with a computer or typewriter composed of two to four pages containing a summary of articles such as:

• Respective local data for a given priority disease
• Report of progress towards a specific public health target
• Report of a specific achievement towards public health by an individual health worker or a group of health workers
• Description of special events or activities (public festivals, religious gatherings, floods etc.) 6.1.2.5 Fact sheets  Fact sheets are brief summaries of one to two pages prepared by health staff for the general public. They usually deal with a single topic or message. For example, if the district would like to give the community information about a Shigella outbreak, the fact sheet states the steps for hand washing and clean food preparation in addition to a table with the number of cases and deaths. These are sheets that could be hung on a bulletin board or distributed to community groups that are planning health education campaigns. 6.1.3 Other methods of providing feedback  Electronic reporting (E-mail, for example)  Guidelines and technical manuals  Health education materials  Radio plugs/program  Briefing reports 6.2 What method of feedback is most appropriate at the level of the RHU/CHO, PHO, CHD and DOH-Central Office?  Data use is not an isolated activity – it is the final stage in a series of activities that begins with planning health information systems and continues through collecting, managing and analyzing data.

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Section 6: Feedback 65  Data, and the information they relate, cannot be used well unless they are of high quality. Public health professionals use the output of the surveillance system as the raw material for data use. The data they present to policy-makers, fellow health workers, the public and communities at risk are only as good as the surveillance systems that produce them. If surveillance systems produce poor data that lead to policy conclusions that are irrelevant or even inaccurate, then efforts to prevent epidemics or reverse disease occurrence will be undermined.  Here is a simple checklist to help evade common weaknesses encountered in surveillance data:

• Does the surveillance system cover the right populations?
• Is the sample population clear?
• Is the sample size adequate?
• Did the surveillance take place in a site used consistently over time?
• What is known about testing?
• What is being measured?
• Are data interpreted correctly?  There is no hard and fast rule on what form of feedback is appropriate for use by a specific unit of the health system. The choice of format to be used is better guided by the objective or intended purpose of the user. Whether the use of the data is for program planning, program monitoring and evaluation or for advocacy, the format to be chosen should be the one which would best present the message in a clear and straightforward manner and would fit the intended audience.  For program planning, surveillance data should be used to determine the magnitude of the disease and its distribution in different geographical areas and subpopulation. Estimating the number and distribution of those already infected is important in deciding how prevention resources should be distributed as well as in planning care and support needs. Within prevention programs themselves, surveillance data can be used to identify problem areas, to seek solutions and to devise strategies appropriate to the ever- changing disease occurrence.  In the commercial sector, manufacturers of breakfast cereals or cosmetics have recognized that they sell their products better if they package and advertise them differently for different target markets. The same principle should apply to surveillance data. The same data need to be presented very differently for different audiences to be able to sell the messages implied by the data and ensure that they get acted upon.  Successful advocacy follows a number of relatively well defined rules. Choosing the right product for the right audience requires:
• Defining your goals
• Defining your audience
• Finding out what influences their thinking
• Using the data to address their concern
• Using the right language
• Getting the length right

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PIDSR Manual of Procedures 66

• Choosing the best messenger
• Timing it right 6.3 How do I prepare a written disease surveillance report?  A surveillance report must be succinct. As the report is intended to give decision makers the bases for future action, it must be written clearly based on accurate information derived from accurate and reliable data.  The written report follows the IMRAD format in includes the following:
• Introduction
• Methods
• Results
• Analysis
• Discussion
• Conclusions and Recommendations  In the introduction, the objective of the report must be stated clearly. The background of the report must be described. It should include what the report is all about, the circumstances why the report is focused on a particular disease or its issues, the significance of the health event and its nature.  Methods include a description of how the report was obtained, the reporting sites included, how data was collected and an explanation on the laboratory procedure and requirement if diagnosis relies heavily on laboratory examination. Case definitions must be stated exactly how it was applied to standardize the perspective of the reporter and the reader.  Results of the Surveillance activities must be presented in a manner that even a layman can understand. We present results not to impress or overwhelm our readers but to put our narrative messages across. Our objective is to draw the main point of the surveillance activities and results as well as generate public health actions from decision makers. We must always remember that most of the decision makers at the LGU level have no clinical experience and may just have very little statistical background. Here, the value of the graphical presentations is heightened as readers find it easier to comprehend than a litany of scientific statements describing the surveillance findings. However, excitement on overdoing the graphs must be held back as a complicated graph will even confuse the reader more. Simple presentation with one or two variables describing the health event would be ideal for a layman’s understanding. We must refrain from doing graphics with bars overlapping with lines and notations that the reader cannot decipher where to look first and which part of the complex graphical presentations is indeed important. When graphs and charts use multiple colors, make sure that the report is printed in multiple colors too. A profusion of slices and lines in black or its shades and white will lead to severe frustration.  Analysis, Discussion, Conclusions and Recommendations are related. Each result that is presented must be accompanied buy succinct explanations including the meanings of the graphics. The discussion must be focused on the health event, what the surveillance data

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Section 6: Feedback 67 implies and the actions that are highly necessary to address the health problem. Honest interpretation of the surveillance data will greatly help in accomplishing what we would want our readers to do next.  To guide the decision makers and the general public, the surveillance officer must come up with conclusive statements to guide the next action of the stakeholders. The conclusions must be able to generate more interest on the issue and prompt action focused on prevention and control of the health problem.  The recommendations that we give must be addressed to the right persons. It is ideal to identify the sector to which we address the issue. The specificity of the recommendation as in asking the local waterworks system to repair the busted pipes in a specific street will generate more cooperation than general recommendatory statements such as “improving water supply system”. If we truly need to recommend a complex activity, it must be broken down to tasks addressed to specific persons so that they will not be overwhelmed. The simpler the statements, the better it is. The simpler the action, the easier it is to do.

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69 Section 7: Use of Information This section describes:  The knowledge-driven model of decision-making  Converting information to knowledge  How surveillance information can be used  The ways to enhance the use of surveillance information in all levels of the health system

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PIDSR Manual of Procedures 70 7.0 Use of Information 7.1 What is the knowledge-driven model of decision- making?  In the knowledge-driven model of decision-making, data are the raw products of the health information system. Data themselves have little value until sorted out, verified, checked and certified correct, organized and analyzed. Through these processes, data become information. Yet information is of limited value until it is integrated with and evaluated in terms of issues confronting the health system.  When the significance of the information is obtained, understood and accepted, becomes evidence of use to decision-makers. The synthesis of evidence is still insufficient however until packaged, communicated and disseminated to decision-makers in a form that changes their understanding of the issues and needs. At this stage, the evidence becomes knowledge. Once knowledge is applied through the planning process to result in action and change, an impact on the indicators can be expected. And such impact should be measurable through change in the source data for the indicators.  The Health Metrics Network visualizes a continuous cycle of data processes to obtain the greatest possible impact, thanks to a comprehensive health information system. Figure 15: Relation of Data and Health System Impact in the HMN Framework

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Section 7: Use of Information 71  Health information systems in low- and middle-income countries tend to be data-rich, but information-poor. This is a consequence of the belief that data can be used directly for decision-making. Raw data alone are rarely useful. The point of the system is not just to generate data and hope that it will be used. Raw data must be cleaned, validated, organized and entered into a first-level data repository or warehouse. At the same time, preliminary analysis of data converts them to initial information at the primary level that is already useful for front-line program management, monitoring and measurement of progress on local targets. Such a preliminary analysis of data should be done as close to the level of data collection as possible. In this process, raw data are converted into immediate information and evidence for local decision-making within the system.  Once the health information system has started to convert data into information, the information should be used on a regular basis at meetings, and displayed where it can be seen by staff and the public. By being used, the information system, and the quality of its information, is gradually improved through a cyclic learning process. By learning through hands-on experience, problems are identified, new needs defined, and new features added that will be refined and improved upon in the next cycle. This low-level analysis of primary data requires an appropriate and simple tool-kit of targeted methods aimed at providing relevant feedback to the front lines. 7.1.1 Converting information to knowledge  As data and information move up the line to higher levels of the health system via the data repositories at these levels, they can be synthesized and triangulated (compared) with other sources and compiled into usable statistics for deeper analysis and comparison across the health system. A critical aspect is that of analysis, i.e. identifying results from the synthesis of data from multiple sources, examining inconsistencies and contradictions, identifying and accounting for biases, and summarizing into a consistent assessment of the health situation and trends. Such higher-level analysis provides estimates, i.e. knowledge on the burden of disease, patterns of risk behavior, health service coverage, trends in indicators, and health system performance. The current fragmentation of data sources and subcomponents of the health information system represents a serious obstacle in this regard.  Establishing a data and information repository as a shared resource at national, sub-national and local levels is therefore an important step in improving information practices and enabling the necessary high-quality data analyses. It is from this level of analysis that results are used for policy development and strategic planning. Such analysis, interpretation and advocacy do not take place spontaneously, and need to be driven. They require the packaging, communication and dissemination of evidence in a format and language accessible to the higher level policy and decision makers. This is a generally neglected aspect of most health information systems that tend to short-circuit the cycle illustrated in Fig.15 by providing data direct to decision-makers without appreciating the need for intermediate steps. 7.2 How can surveillance information be used?  Public health surveillance focused almost exclusively on the detection and monitoring of cases of specific communicable diseases and surveillance data were disseminated primarily in tables. However, surveillance efforts have expanded rapidly and may eventually include chronic diseases, injuries, occupationally acquired conditions and other

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PIDSR Manual of Procedures 72 problems. Because of the fundamental changes in public health programs and priorities, programs at all levels require innovative approaches to convey surveillance findings to new and more diverse audiences.  Surveillance has been characterized as a process that provides “information for action”. This concept is inherently consistent with the definition of communications as “…a process, which is a series of operations, always in motion, directed toward a particular goal.” Therefore, public health programs must ensure more than the mere transmission or dissemination of surveillance results to others; rather, surveillance data should be presented in a manner that facilitates their use for public health actions.  One fundamental concept is that the terms dissemination and communication cannot be used interchangeably. Dissemination is a one-way process through which information is conveyed from one point to another. In comparison, communication is a loop – involving at least a sender and a recipient – a collaborative process. The communicator’s job is complete when the targeted recipient of the information acknowledges receipt and comprehension of that information.  Table 6 summarizes a model that emphasizes the effect of communications and includes the sender, the message, the receiver, the channel and the impact: Table 6. Controlling and Directing Information Dissemination Steps Questions to be Answered Establish communications message What should be said? Define the audience To whom should it be? Select the channel Through what communication medium? Market the message How should the message be stated? Evaluate the impact What effect did the message create?  Surveillance data should be analyzed at the local level and at the regional level of the health system in the timeliest fashion possible to determine the public health response required from each level. Those actions include:

• Notification, investigation and intervention of epidemics
• Program management
• Impact monitoring
• Problem identification
• Planning
• Social mobilization  The local level should design simple graphs and charts to illustrate the data collected for each community, so that disease trends, other public health problems and responses can be visualized. The spatial distribution of the data collected can best be presented and interpreted if projected on a map, preferably through the use of a Geographic Information System (GIS)-enabled system. The RHU staff along with the health workers regularly

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Section 7: Use of Information 73 discusses the interpretation and implications of the data collected and the interventions needed.  Monthly updates of surveillance status should be generated to describe the coverage and events being recorded and preventive actions being undertaken. Reports are disseminated on periodic bases in a format easily understood by those collecting and utilizing the information for decision-making: local leaders, health facilities, the media and collaborating agencies. 7.3 What are the ways to enhance the use of surveillance information in all levels of the health system?  Following the packaging and communications stage, data should be used for decision- making. Capacity for data analysis is often lacking at peripheral levels where the data are generated and the results should be used for planning and management. Bringing together a comprehensive analysis of the health situation and trends with data on health inputs, such as health expenditure and health system characteristics, is particularly important. The development of such analytic capacity requires planning, investment and tools.  An important function of the health information system is to connect data production with data use. Users comprise those delivering care as well as those responsible for the management and planning of health programs. More broadly, users include those financing health care programs, both within the country (health and finance ministries) and outside (donors, development banks and technical support agencies). Users of health-related data are not confined to health-care professionals, managers or statisticians. Indeed, decision-making around country health priorities necessarily involves the wider community, including civil society as well as policy-makers at the senior levels of government.  These different users of data have varying needs in terms of the level of detail and technical specificity required. Health-care planners and managers responsible for tracking epidemiological trends and responses of the health-care system generally require more detailed data than policy-makers who need data for broader strategic decision-making and investments. References:

1. Health Metrics Network: Framework and Standards for the development of country Health Information Systems. World Health Organization 2006.
2. Teutsch SM, Churchill RE. Principles and Practice of Public Health Surveillance. Oxford University Press. 2000.

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75 Section 8: Epidemic Response This section describes:  How epidemics are detected and when to investigate  The functions of the epidemic investigation control team  What agencies have the authority to declare and epidemic  The roles of the LGUs during epidemic investigation and response

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PIDSR Manual of Procedures 76 8.0 Epidemic Response The flow of investigation, reporting and response to a suspected epidemic or epidemic is presented in Figure 16 on page 86. 8.1 Epidemic Detection 8.1.1 How are epidemics detected? Epidemics can be detected through the following surveillance systems:  Case-based – routine collection of data, analyzed on a periodic basis (e.g. NESSS).  Event-based – reports are received anytime from sources outside the routine reporting system (e.g. Media reports).  Laboratory-based – reporting of laboratory results based on criteria (e.g. Influenza surveillance). 8.1.2 Who should verify reported epidemics?  The DSCs at the RHUs and CHOs shall promptly verify reports of epidemics received from health facilities, laboratories, or through community rumors. A feedback (verbal or written) to stakeholders (LCE, Province, CHD, and NEC) should be provided within 24 hours. This is important to ensure that timely decisions are made and to prevent expending resources on investigating events that are not true epidemics  Triggers for Epidemic Detection

• Case-based surveillance – Alert and epidemic thresholds have been reached.
• Event-based surveillance – Reports of public health concern have been confirmed.
• Laboratory-based surveillance – Detected laboratory results fulfills the criteria for notification. 8.1.3 What is the role of the Bureau of Quarantine in detecting epidemics?  The Bureau of Quarantine shall immediately notify NEC/CHD/local health authorities of any suspected case of notifiable disease detected in airports and ports of entries. Travel itinerary and other health-related documents shall be submitted to NEC/CHD/local health authorities.

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Section 8: Epidemic Response 77 8.2 Epidemic Investigation 8.2.1 Deciding to Investigate an Epidemic The decision to investigate an epidemic shall be based on the following circumstances:  The RHU/CHO/PHO receives a report of a suspected epidemic.  An unusual increase is seen in the number of deaths during routine analysis of data.  Alert or epidemic thresholds have been reached for specific priority diseases.  Communities report rumors of deaths or a large number of cases that are not being seen in the health facility.  A cluster or group of cases or deaths.  A report of cases or deaths for which the cause is not explained or is unusual.  The RHU/CHO/PHO receives a report of a case with any of the following diseases:

• Acute Flaccid Paralysis “Hot Case”
• Adverse Events Following Immunization (AEFI)
• Anthrax
• Human Avian Influenza
• Measles Confirmed
• Meningococcal Disease
• Poliomyelitis Confirmed
• Severe Acute Respiratory Syndrome (SARS)
• Other emerging or re-emerging infections In addition, the decision to investigate an epidemic may be based on the following circumstances:

Case-based surveillance  An unusual increase is seen in the number of deaths during routine analysis of data.  Alert or epidemic thresholds have been reached for specific priority diseases. 2. Event-based surveillance  The RHU/CHO/PHO receives a notification of a suspected epidemic,increase cases,deaths and unusual occurrence of health events .  Reports of public health concern have been verified .

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PIDSR Manual of Procedures 78  Communities report rumors of deaths or a large number of cases that are not being seen in the health facility.  A report of cases or deaths for which the cause is not explained or is unusual. 3. Laboratory-based surveillance – Detected laboratory results fulfills the criteria for notification. 4. Clustering and Hot Spots of cases and deaths of diseases under surveillance. 5. Single case of disease for elimination or eradication. 8.2.2 What are the roles of LGUs during epidemic investigation and response?  It is the primary responsibility of local government units to manage epidemic investigation and response. However, the next higher level will continue to exercise its technical oversight functions.  The responsibilities of the LGU during an epidemic investigation and response include:

• Immediate release of funds (local funds - surveillance funds from regular budget, ILHZ funds, congressional funds)
• Priority access to vehicles
• Provision of additional manpower
• Provision of resources for laboratory support
• Provision of resources for treatment of patients and other epidemic control measures
• Provision of access to communication  Local government unit should assess whether they have sufficient capacity to undertake the epidemic investigation and response, and arrange for additional assistance if required. 8.2.3 What are the composition and core responsibilities of Epidemic Investigation and Control Team?  An Epidemic Investigation and Control Team (EICT) shall be organized at the municipal or city level. The composition of the team may vary depending on the disease suspected and the control measures required. The team should include the Disease Surveillance Coordinator and other members as determined by the municipal or city health officer. These members may include the following:
• Municipal/City Health Officer
• Health Program Coordinator
• Clinician
• Laboratory technician

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Section 8: Epidemic Response 79

• Sanitation Engineer
• Vector control specialist
• Health educators The MHO/CHO shall automatically be the team leader, or may designate a team leader in his behalf. Each member of the team should be given a clear role.  The core responsibilities of the EICT are the following:
• Conduct epidemiologic investigation of epidemics suspected or confirmed.
• Establish active surveillance in the affected area.
• Implement the epidemic response plan.
• Identify and coordinate other sources of additional human (multi-sectoral teams in the area) and material resources (list of referral laboratories and available examinations, list of referral hospitals) for managing the epidemic
• Ensure the use of standard treatment protocols for the disease and train health workers.
• Oversee the implementation of control measures.
• Meet daily to review the latest surveillance data and implement additional control measures.
• Provide regular feedback to the community, LGU, PHO, CHD, DOH and WHO.
• Request assistance when necessary.
• Perform other tasks as instructed by the head of office or agency 8.2.4 What should the RHU or CHO do in instances when they do not have the capacity in conducting epidemic investigation?  In some instances where the RHU or CHO have no technical capacity in conducting epidemiological investigation, the MHO or CHO shall immediately request for assistance from the PHO, CHD or NEC. The investigation will be conducted by the PESU or RESU staff in close coordination with the Municipal or City EICT.  Assistance can be in three forms:
• Logistics (supplies, equipment, etc)
• Technical advise (verbal or written guidance)
• Technical assistance (investigation team, experts or consultants who will go to the field and assist in the investigation or with the control measures)
• Laboratory back-up

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PIDSR Manual of Procedures 80 8.2.5 In what instances shall the NEC and CHD-RESU provide immediate on site technical assistance during epidemic investigation? The Department of Health through the National Epidemiology Center in coordination with CHD-RESU shall provide immediate on-site technical assistance to the LGU for further epidemic investigation in the following conditions:  Epidemics of national importance as described in Section 8.3.3 of this manual of operations.  The epidemic is continuing (i.e., there is evidence of ongoing transmission).  Similar epidemics have occurred before, or are expected in the future, and more information is needed to develop preventive measures.  The epidemic is having, or likely to have, a very high impact on public health because of its size and/or the severity of illness.  The epidemic has attracted public, media or political interest.  The epidemic transmission route is new or unusual.  The causative agent is unknown.  Descriptive characteristics of the epidemic (time, place, person or organism subtype) suggest that a common source is highly likely. 8.2.6 What is the role of the National Epidemiology Center as the National IHR Focal Point?  The National Epidemiology Center is designated by the Department of Health as the National IHR Focal Point (NFP). Among its crucial responsibilities as NFP is to notify WHO of Immediately Notifiable Diseases and all events that may constitute a public health emergency of international concern within 24 hours of assessment. In line with this, the National Epidemiology Center shall carry out all appropriate and expeditious means of obtaining information to assess all suspected epidemics (including unofficial reports) in coordination with the CHD, local government units, government agencies and other parties directly or indirectly involved in the investigation and control of epidemics. 8.3 Declaring an Epidemic 8.3.1 What are the necessary information that should be used to support declaration of an epidemic? Declaration of an epidemic should be supported by sufficient scientific evidence. These include:  Surveillance information  Epidemiologic investigation (descriptive or analytic)  Environmental investigation  Laboratory investigation

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Section 8: Epidemic Response 81 8.3.2 What is the basic requirement for an LGU to declare an epidemic?  The municipal/city health office can declare an epidemic if it has a functional surveillance system. A functional surveillance system means the office can produce the necessary information stipulated section 8.3.1 above.  In case the requirements in section 8.3.1 are not met, the next higher level may provide technical assistance in the declaration of an epidemic. 8.3.3 In what instances does the Secretary of Health have the sole authority in declaring an epidemic?  The DOH Rules and Regulations Implementing the Local Government Code of 1991 (DOH RRILGC of 1991), Chapter 11, Section 44 c, specifies that the Department of Health has the final decision regarding the presence of epidemic, pestilence, or other widespread public health danger in a particular area or region. In compliance to this rule, the Secretary of Health shall have the sole authority to affirm or reverse any declaration of an epidemic.  Epidemics of National and International Concern The NEC shall take the lead in the investigation of epidemics of national and international importance, in coordination with the CHD, local government unit, and other concerned agencies. The Secretary of Health shall have the sole authority to declare epidemics of national and/or international concerns. These include the following: a. Epidemic linked with nationally or internationally distributed product: Epidemic linked by investigation to a product that has national or international distribution, such as a manufactured food item, that has the potential to affect individuals in municipalities and cities simultaneously. b. Case(s) of exotic disease acquired locally: All cases of illness due to communicable diseases that are not endemic in the Philippines should be investigated rapidly to confirm whether the illness has been acquired locally or from overseas. Human avian influenza, SARS, Ebola, poliomyelitis are among the exotic diseases that are of national importance. c. Diseases with high pathogenicity: Epidemics of highly-virulent organisms (e.g., Ebola) are likely to cause heightened public concern, and may require technical expertise and collaboration at the national level. d. Diseases with significant risks of international spread e. Epidemics in tourist facilities, among foreign travelers or at national/international events. f. Epidemics associated with health service failure: Epidemics linked to breakdown in standards of health care delivery, such as infection control failure, blood product contamination or systematic immunization failure will require a strategic national approach.

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PIDSR Manual of Procedures 82 8.4 Response 8.4.1 Investigation For specific disease investigation requirements, refer to handbook for responding to communicable disease epidemics.  Define cases.

• Case definitions should include a location, a time period, and clinical symptoms (E.g. A case is a …..)  Identify all cases and contacts.
• Obtain a line list of cases from the hospitals, barangay health stations/RHUs, ESUs, and other institutions
• Do contact tracing  Describe the cases.
• Time: When did the cases occur? Make an epidemiologic curve of onset of illness
• Place: Where so the cases live? Where were they found? Draw a spot map, number of cases per area
• Person: What were the characteristics of those affected? Age range, median age, sex distribution, symptoms, vaccination status, etc.  Describe the severity.
• Number of fatalities, case-fatality rate
• Number who were hospitalized
• Number who had complications  Confirm the diagnosis.
• Obtain and analyze specimen from cases
• Obtain and analyze specimen from environment (water, air, soil, food, etc)  Identify possible sources of the epidemic.  Identify possible causes of transmission.  The results of the epidemic investigation should be communicated to all stakeholders in two forms: (a) oral briefing for local authorities and (b) a written report. a. Oral Briefing
• Oral briefing should be attended by the local health authorities and persons responsible for implementing control and prevention measures.
• Findings must be presented in clear and convincing fashion with appropriate and justifiable recommendations for action. This presentation is an opportunity to describe what the investigation and control team did, what they found, and what they think should be done about it. The findings should be presented in scientifically objective fashion, and should be able to defend the conclusions and recommendations.

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Section 8: Epidemic Response 83 b. Written Report

• A written report of epidemic investigations should be provided to all levels of the reporting system. This includes PHOs, CHDs, NEC, WHO, etc.
• By formally presenting recommendations, the report provides a blueprint for action. It also serves as a record of performance and a document for potential legal issues.
• It serves as a reference if the health department encounters a similar situation in the future.
• A written epidemic investigation report should follow the IMRAD format which includes: a) Introduction b) Methods c) Results d) Analysis e) Discussion f) Conclusion g) Actions Taken h) Recommendation 8.4.2 Treatment of Cases  Refer to handbook for specific treatment protocols.  Hospitals should be alerted and should activate their epidemic response plans. There should be adequate antimicrobials and supplies for treatment. Needs must be immediately identified and a request for logistic assistance should be made.  Referral hospitals should be alerted about the epidemic. 8.4.3 Establish Epidemic Disease Surveillance  The location of the epidemic disease surveillance (BHS, RHU, CHO, PHO, and RESU) and the extent of its catchment area will depend on the location of the epidemic and its severity.  Information to be gathered should include:
• Name
• Age
• Sex
• Address (Sitio, Barangay, Municipality, Province)
• Date of onset of illness
• Other pertinent information depending on disease  Frequency of reporting will depend on the epidemic.

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PIDSR Manual of Procedures 84 8.4.4 Implement Public Health Measures  The data gathered in the course of investigations will be used to define the measures needed to control the epidemic and prevent a similar situation in the future.  In any epidemic, the plan of action for control measures should fall in any of the following:

• Prevention and control of exposure
• Prevention and control of infection/disease
• Prevention of spread
• Prevention of death  The selection of control measures should consider feasibility (technical/operational), availability (stockpiles), acceptability, safety (of operators and population), and cost.  For the recommended public health measures for specific diseases, refer to the handbook for responding to communicable disease epidemics. 8.4.5 Risk Communication  Coordinated communication is essential during epidemic response.  Activate the communication plan for the following areas:
• Within the Epidemic investigation and control team
• With the Epidemic management committee, the ESUs at different levels, and the NEC
• Directly with the affected community – public and local officials
• With the general public through media
• With other agencies involved (hospitals, laboratories, industries, other government agencies, etc)  Determine which level (municipal, provincial, regional, national) will be responsible for communication to each area mentioned in Section 8.4.5.2. Then identify person(s) who will take charge of communicating to each area.  Schedule regular meetings for each area. 8.5 Evaluation  After an epidemic, there should be a thorough assessment of the following component areas:
• preparedness
• surveillance
• response investigation

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Section 8: Epidemic Response 85 treatment of cases public health measures risk communication epidemic management  Each component area should be assessed according to:

• timeliness
• efficiency and effectiveness
• cost
• lost opportunities
• policy gaps and unimplemented policies  The team leader of the epidemic management committee will be the one to organize the evaluation. All members of the management committee, the investigation team and control team, and other persons involved in the epidemic surveillance and response should be present during the evaluation.  A post-epidemic assessment report should be documented and used as a reference for improving epidemic preparedness and response.

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PIDSR Manual of Procedures 86 Figure 16: Flow of Investigation, Reporting and Response to a Suspect Epidemic or Reported Epidemic

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87 Section 9: Monitoring and Evaluation This section describes:  Monitoring an evaluation activities in the context of surveillance and response  Monitoring and evaluation at the different levels of surveillance  Technical assistance visits  Indicators for monitoring and evaluation of surveillance systems

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PIDSR Manual of Procedures 88 9.0 Monitoring and Evaluation 9.1 What is monitoring in the context of surveillance and response?  Accurate, timely and accessible disease surveillance data plays a vital role in the planning, implementing, development and maintenance of the control program. In recent years, data quality has emerged as an important issue because of the need to improve the services delivered at various level of the health system.  Monitoring is needed to verify step by step, the progress of the disease Control Program at the municipal, provincial, regional and national levels e.g. to verify whether activities have been implemented as planned, to ensure accountability, and to detect any problems and/or constraints. This in turn can provide feedback to the relevant authorities for them to take remedial measures thus promote better planning through careful selection of strategies for future action.  When monitoring is conducted by the surveillance implementing team itself, it is referred to as internal monitoring. Here, the members closely observe the manner of implementing the system identifies facilitating and hindering factors and notes these down for discussion with the other members of the group. Although indicators are developed by the team by which they will monitor their own performance, the manner of self-monitoring may sometimes become subjective. Thus, is it highly necessary to resort to external monitoring in order to ensure objectivity of the observations.  External monitoring is when another team not involved in the daily implementation of the system, for example, a staff from a higher health level such as the PESU will visit the local team and observe the implementation of the surveillance system based on certain indicators. While external monitor may already favor a certain team and give a very good feedback on their performance even if the quality of performance is not very good. It is therefore imperative that indicators used in monitoring are set in the most objective manner with objective scale for rating so that subjectivity will be minimized, if not eliminated.  Another way to increase objectivity in observation is by doing monitoring as teams so that many member of the monitoring team observe and rate the performance all at the same time. They discuss the results of their observations after the monitoring activity and share their findings with others. Other qualitative observations maybe written as a separate report. These are the observations not included in the pre=set indicators for monitoring.  Evaluation is the periodic assessment of the relevance, effectiveness and impact of activities in the light of the objectives of the surveillance and response systems. Evaluation of outcomes and impact is needed to document periodically whether defined strategies and implemented activities lead to expected results.  While monitoring is a continuous process, evaluation will need to be conducted intermittently. The periodicity of evaluation varies considerably according to the changes expected in the different areas evaluated.

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Section 9: Monitoring and Evaluation 89 9.1.1 Surveillance Indicators 1. Input indicators are the resources needed to implement the system. They include trained personnel, finance, standards and guidelines, communication facilities, forms for surveillance, computers, stockpiles for emergency response, and any other logistics as deemed necessary. 2. Process indicators are used to monitor and track implementation of the planned activities which are critical for attaining the surveillance core functions such as training, supervision, development of guidelines and tools, etc. They are used to measure the activities, systems, actions and other outputs that need to be completed in a given time (short term) to achieve improvements or increases in coverage, or delivery of services to target groups. 3. Output indicators are measures of the immediate results of the activities. They include reports from surveillance data, completeness of reporting, feedback given to the data providers, numbers/proportion of health staff trained, numbers/proportion of planned supervisory visits implemented, etc. 4. Outcome indicators are measures of the quality of the surveillance system and the extent to which the surveillance objectives are achieved. They may include indicators for assessing usefulness of the system, use of surveillance data for policy and program decisions, and appropriateness of outbreak response. 9.1.2 Objectives of M & E A. Monitoring:  To track progress of implementation of target indicators.  To ensure that planned targets are achieved in a timely manner.  To identify problems/constraints in the system in order to institute corrective measures in a timely manner. B. Evaluation:  To ensure that the surveillance system has met the objectives for which it was evaluated.  To document the status of, and any change, in the performance of the system after each evaluation period.  To identify gaps and/or enablers in the performance of the system.  To provide realistic recommendations for improving the system.  To ensure that the quality of surveillance and response adheres to a high standard of implementation with respect to the attributes of the system.

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PIDSR Manual of Procedures 90 9.2 M&E activities will happen at three surveillance levels 9.2.1 Municipality and provincial level where the program is implemented  Reporting from the barangays or villages will be validated and consolidated at the municipal level through the Rural Health Units (RHUs) on a monthly basis. These will be submitted to the PHO/CHO where they will be cross-checked by provincial/city level coordinators. Validated and cross-checked reports shall be submitted to the CHDs on a quarterly basis. 9.2.2 Regional level M&E  A team composed of staff of the DOH Centers for Health and Development (CHDs) will be visiting the provinces at a designated time period or as necessary to confirm provincial/city reports. Confirmed reports shall be submitted to the national level on a semi-annual basis. 9.2.3 National level M&E  A team from the National Epidemiology Center will visit CHDs and priority provinces/cities at least once during the year and as necessary. RESU staff will assist the team in the conduct of the activity. External Evaluation will also be considered at national level monitoring.  Likewise, all stakeholders and partners will be kept informed of the progress of the implementation of the system and the outcome of the monitoring visits and evaluation through regular briefings and meetings. 9.3 What Is a Technical Assistance Visit (TAV)?  TAV is conducted by experts from the next higher level of the surveillance system to address gaps and enablers identified in the regular monitoring and activity. This activity addresses issues on implementation and provides on-site mentoring and hands-on training to key field personnel. 9.4 Performance Indicators  Indicators are variables that can be measured repeatedly (directly or indirectly) over time and provide measures of change in a system. They provide useful information on the status of the system and flag areas that need improvement. They are usually expressed as simple counts, proportions, rates or ratios. These measurements should be interpreted in the broader context, taking into consideration other sources of information (e.g. supervisory reports and special studies), and supplemented with qualitative information.

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Section 9: Monitoring and Evaluation 91 9.4.1 AFP and Measles Specific Indicators  Diseases such as poliomyelitis and measles that have been targeted for eradication and elimination have specific indicators for monitoring the quality of surveillance. These indicators were recommended by the World Health Organization. 9.4.1.1 Indicators for quality AFP surveillance

1. 2 AFP rate - minimum number of AFP cases expected to be reported per 100,000 population of children below 15 years old
2. 80% adequate stool specimen collection rate - Adequate 2 stool samples with 24 hours interval taken from an AFP case within 14 days from paralysis onset
3. 10% NPEV rate - percentage of stool samples taken from AFP cases with NPEV isolate

80% timeliness of notification - percentage of AFP cases reported within 14 days from paralysis onset 5. 80% timeliness of investigation - percentage of AFP cases investigated within 48 hours from notification 6. 80% timeliness of 60 days follow up - percentage of cases followed up 7. 80% timeliness of case classification - percentage of cases classified within 90 days from paralysis onset 9.4.1.2 Indicators for quality Measles surveillance

1. 2 Measles reporting rate – minimum number of suspect measles cases to be reported per 100,000 of the total population.
2. 80% adequate blood specimen collection rate – 5 ml of blood collected within 28 days from rash onset (Exclude from the denominator the cases that are epidemiologically-linked to confirmed measles or to other confirmed communicable disease, ex. Rubella).
3. 80% completeness of reporting – percentage of municipalities/cities reporting at least 1/100,000 suspect cases.
4. 80% timeliness of investigation – percentage of suspect cases adequately investigated within 48 hours of notification. Adequate investigation means collection of essential data elements such as date of rash onset, date of specimen collection, vaccination status, date of last measles vaccination, date of birth, age, sex, address, and searched for epidemiologically linked cases.
5. 80% timeliness of laboratory results – percentage of specimens with lab results < 7 days after arrival to the laboratory.
6. Transmission chains (outbreaks) with sufficient samples for viral isolation – 2 or more cases in which rash onset in one is 7-21 days after the other OR an isolated confirmed measles case without history of travel within 7-18 days prior to the onset of rash.

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Section 9: Monitoring and Evaluation Annex 9: Notifiable Disease Report Register 93 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method Case Detection Health facilities with standard case definitions Proportion of health facilities with standard case definitions for notifiable diseases Available Case Definitions Compiled And/Or Posted Observation, Review Of Definitions With Key Informants Mechanism for outbreak detection within hospitals Existence of surveillance systems for the detection of healthcare-associated infections and outbreaks in hospital settings Key Informants; Hospital Records; Posted Workflow Key Informant Interviews, Records Review Existence of event based surveillance Existence of mechanism to capture unusual or public health events from non-routine sources in the health system Key Informants; Workflow Posted Key Informant Interview Capacity to detect and notify unusual/ abnormal health events Inclusion of unusual/ abnormal health events in the surveillance system for immediate reporting Key Informants, List Of Diseases/ Syndromes For Reporting Document Review, Key Informant Interview Case Registration Availability of registers Proportion of health facilities with standardized registers Health Facility Records Observation; Records Review Correct filling of registers Proportion of HF with correctly filled registered Registers At Health Units Review Of Documents Routine validation of surveillance data Existence of routine data validation Surveillance Reports Review Of Documents Case Detection Health facilities with standard case definitions Proportion of health facilities with standard case definitions for notifiable diseases Available Case Definitions Compiled And/Or Posted Observation, Review Of Definitions With Key Informants Case Confirmation Confirmation of priority diseases Capacity to confirm selected priority diseases either within the laboratory or at a reference laboratory Key Informants, Laboratory Test Results Key Informant Interview, Observations Capacity to refer samples in a timely manner Capacity for timely referral of samples to reverence labs for rapid confirmation of causative agents Key Informants, Record Review, Public Health Laboratories Key Informant Interview Laboratory reagents Presence and maintenance of laboratory reagents Key Informants, Reagents Key Informant Interview, Observation Supplies for Presence and Key Informants, Key Informant,

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PIDSR Manual of Procedures 94 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method specimen collection and transportation maintenance of supplies for specimen collection and transportation Supplies Interview, Observation Laboratory confirmation of outbreaks Proportion of outbreaks that have lab-confirmed Outbreak Log, Outbreak Reports Key Informant Interview, Document Review Presence of quality assurance system Performance of routine external quality assurance Laboratory Personnel, Certification Documents Interview, Review Of Certification Documents Data Analysis and Interpretation Routine analysis of data by surveillance units Proportion of health facilities w/ evidence of data analysis by time, place & person for selected indicator diseases Summary Reports, Charts On The Walls, Computerized Analysis Output Observation; Review Of Written Reports Surveillance units having epidemic threshold values Proportion of surveillance units w/ defined epidemic threshold values for priority diseases National Set Guidelines Key Informant Interview, Observation; Review Of Reports Capacity for routine laboratory data analysis & interpretation Evidence of routine laboratory data analysis National Public Health Laboratories; List Of Local Laboratories Key Informant Interview, Observation; Review Of Reports Reporting Case-based reporting rate Proportion of cases of diseases targeted for elimination/ eradication line listed or reported using case-based reporting forms in the past 12 months Reporting Forms, Registers Document Reviews, Timely notification of epidemics Proportion of epidemics (above epidemic threshold) detected in previous 12 months that were notified to the next higher level within 2 days of detection Outbreak Files Review Of Outbreak Files Reporting of healthcare- associated infections/ outbreaks in Proportion of hospitals that routinely report outbreaks occurring within the health-care setting Outbreak Files, Hospital Registers, Key Informants Document Review, Key Informant Interview

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Section 9: Monitoring and Evaluation Annex 9: Notifiable Disease Report Register 95 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method hospitals Epidemic Preparedness Epidemic preparedness plan Presence of epidemic preparedness plans Key Informants, Annual Workplans Observation/ Review Emergency funds Existence of funds for emergency response Key Informants Key Informant Interview, Budget Review (Disaster/ Epidemic Preparedness Plans, Disease- Specific Plans Availability of contingency stocks Proportion of surveillance units that have contingency stocks for at least 6 months Key Informants, Stock Cards, Logistic Management Record Key Informant Interview, Document Review Availability of IEC materials for surveillance and response Proportion of surveillance units with IEC materials/ activities Existing IEC Strategy And Materials Document Review, Key Informant Interview Response and Control Epidemic preparedness committee Presence of functional epidemic preparedness committee Key Informants. Minutes Of EPR/DMC Meetings Review Of Minutes, Key Informant Interview Rapid Response Teams (RRT) Presence of RRT at all levels Key Informants Key Informant Interview, Reports Of Outbreak Investigation Capacity for outbreak response Proportion of outbreaks responded to in the previous 12 months Key Informants, Outbreak Files And Reports Review Of Documents Availability of isolation facilities Proportion of hospitals w/ isolation facilities Key Informants Key Informant Interview, Observation Feedback Existence of regular feedback & dissemination Presence of feedback mechanism Key Informants, Feedback Reports Key Informant Interview, Observation Surveillance Legislation (Laws and Regulations) Availability of legal mandate on PIDSR Requirement for update or amendment of legislation (laws and regulations for communicable disease surveillance & response Existing Public Health Legislation (Laws & Regulations), Key Informants Document Reviews, Key Informant Interviews

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PIDSR Manual of Procedures 96 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method Compliance with IHR 2005 Presence of national IHR Focal Point Presence of a National IHR focal point which is accessible at all times for communications with WHO IHR Contact Points under the IHR 2005 Key Informants Key Informant Interview Functioning IHR communication facilities Evidence of functional e- mail/ telephone at the IHR focal point for international notification and reporting Key Informants Key Informant Interview, Timely notification to WHO of outbreaks of international importance Proportion of outbreaks of international concern that were notified to WHO within 24 hours of detection Outbreak Reports Review Of Documents Surveillance Strategy and Coordination Assessment of integrated disease surveillance Assessment of the national surveillance systems for integrated disease surveillance Assessment Reports, Head Of Surveillance Programs Review Of Assessment Reports, Key Informant Interview Plan of Action for integrated disease surveillance Presence of a strategic and operational plans for implementing and strengthening integrated disease surveillance Strategic POA, Operational POA, Key Informants Observation And Review Of POAs, Key Informant Interview Implementation of Plan of Action Proportion of activities implemented according to plan POA, Activity Reports, Key Informants Review Of Documents, Key Informant Interview Monitoring for Infectious Disease Surveillance Proportion of surveillance units that perform routine monitoring of the Infectious Disease Surveillance Monitoring Reports Key Informant Interviews, Document Review Performance of routine evaluation Whether evaluations are conducted according to plan Evaluation Reports Presence of surveillance coordinating body Presence of *functional surveillance unit at national level for coordination of integrated disease surveillance Key Informants, Organogram Key Informant Interview Existence of documented roles and Roles and responsibilities are well-documented at each level of surveillance Documented Functions And Responsibilities, Document Review, Key Informant

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Section 9: Monitoring and Evaluation Annex 9: Notifiable Disease Report Register 97 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method responsibilities system Terms Of Reference, Surveillance Guidelines Interview Evidence of sharing resources Evidence of sharing resources/ activities between different surveillance programs Key Informants Key Informant Interview Networking and Partnership Intersectoral collaboration, networking and partnership Existence of intersectoral collaboration, networking and partnerships with other sectors ( water and sanitation, agriculture, animal health, etc. Key Informants, Reports, Minutes Of Meetings Key Informant Interviews, Observation Functional laboratory networks Existence of functional laboratory networks established National Level Key Personnel, Surveillance And Laboratory Guidelines Interview, Review Of Documents Standards and Guidelines Surveillance units with standards and guidelines Proportion of surveillance units with standards and guidelines for surveillance Key Informants, Existing Surveillance Guidelines Key Informant Interview, Observation Standard case management protocols Proportion of surveillance units with standard case management protocols or guidelines for case management Surveillance Units Key Informant Interview, Observation Infection control guidelines Proportion of health facilities using guidelines for infection control Health Facilities Observation Guidelines for specimen collection, packaging and referral Proportion of specimen collection units with SOPs for collection, packaging and referral of specimens of targeted epidemic- prone pathogens National Public Health Laboratory, Other Laboratories And Collecting Units Observation Availability of reporting forms at Health Facility/ reporting units Proportion of HF/ reporting units were not short of reporting forms in the previous 6 months Key Informants Key Informant Interview, Observation Training Availability of training manuals/modules for surveillance Proportion of surveillance units w/ surveillance training manuals/modules Surveillance Units Key Informant Interview, Observation

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PIDSR Manual of Procedures 98 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method Availability of surveillance training plan Proportion of surveillance units w/ a training plan for surveillance Training Plans Observation Staff trained on surveillance/IDS Proportion of surveillance staff/HCWs trained in surveillance/IDS Key Informants, Training Reports Key Informant Interview, Document Review Laboratory personnel trained in innovative techniques Proportion of laboratory personnel trained on innovative techniques Key Informants, Training Reports Key Informant Interview, Document Review Surveillance units with trained epidemiologists Proportion of surveillance units w/ at least one trained epidemiologist Key Informants Key Informant Staff receiving refresher course on surveillance Proportion of health staff that have received at least one refresher course on surveillance in the previous 2 years Key Informants, Training Reports Key Informant Interview, Document Review Resources Availability of budget line for surveillance activities Evidence for a budget line for surveillance activities (reporting forms, feedback bulletins, communication, supervision, training, etc. Workplan And Budget Document Reviews, Key Informant Interview Availability of functioning computers Proportion of surveillance units for surveillance purposes Key Informants Key Informant Interview Supervision and Communication Supervisions conducted Proportion of supervisions conducted according to plan Key Informants, Surveillance Levels, Supervisory Reports Key Informant Interviews, Document Reviews Availability of communication facilities Proportion of surveillance units with functional communication facilities for intermediate, weekly, and monthly reporting Key Informants At Different Surveillance Units Key Informant Interview, Observation Timeliness Timeliness of submission of surveillance reports Proportion of surveillance units that submitted surveillance reports to the next higher level on time Reporting Log, Newsletter Review Of Documents Timeliness of receipt of surveillance Proportion of expected surveillance reports (weekly or monthly) Reporting Log, Newsletters Review Of Documents

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Section 9: Monitoring and Evaluation Annex 9: Notifiable Disease Report Register 99 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method reports received on time Timeliness of notification of suspected outbreaks Proportion of outbreaks (with observed no. of cases > threshold values) notified to the next higher level within 24 hrs of detection Outbreak Logs And Reports Review Of Documents Timeliness of response to suspected outbreaks of immediately notifiable diseases Proportion of suspected outbreaks that were verified within 24 hours of detection Outbreak Logs And Reports Review Of Documents Completeness Completeness of reporting Proportion of total expected Surveillance reports received, regardless of the timeliness of submission Reports Review Of Reports Completeness of data reported Proportion of surveillance reports/registers with no missing required information Reports Review Of Reports Reliability Reliability of surveillance Data reports Rating of the reliability of the surveillance data/ reports by implementers and users of the system Key Informants Key Informant Interview Usefulness, Simplicity, Flexibility, Sensitivity, Acceptability Usefulness Of surveillance data Rating of the usefulness of the surveillance system (for case detection, planning, priority setting and interventions) Key Informants Key Informant, Interview Simplicity of the surveillance system Rating of the simplicity of the surveillance system (in terms of data collection, compilation, reporting, analysis and utilization) by implementers and users of the systems Key Informants Key Informant Interview Flexibility/ adaptability of the surveillance system Rating of the ability to adapt to changing needs, as perceived by the national health managers and evaluators Key Informants Key Informant Sensitivity of Rating of the sensitivity of Key Informants, Key Informant

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PIDSR Manual of Procedures 100 Table 6: Indicators For Monitoring Quality Of Surveillance And Response Element of Surveillance Indicator Indicator Definition Data Source Method outbreak detection the surveillance system to detect outbreaks Databases Interview, Review Of Database Acceptability of the surveillance system Rating of the acceptability of the surveillance system by users and implementers Key Informants, Key Informant Interview 