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WORLD HEALTH ORGANIZATION
Response to Shigellosis Outbreak Sierra Leone February 2000
Preliminary report and recommendations of mission to Sierra Leone
28/1/00 - 5/2/00 (a final report will be made when all results from the field and laboratory are available)
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Dr Mike Ryan, Medical officer
Communicable Diseases Surveillance and Response
Tel +41 22 791 3691 Fax: +41 22 791 4198 e-mail:
TABLE OF CONTENTS
Page
1. Background 3
2. Objectives of the mission 3
3. Work Process 3
4. Field Response 4
5. Epidemiological Data 7
6. Laboratory data 9
7. Sub-Regional issues 9
8. Drug policy issues 9
9. Opportunities for further research 10
10. Follow up activities 10
11. Recommendations 10
LIST OF ANNEXES
Annex 1 Case Management algorithm 11
Annex 2 Patient Treatment Coupon 12
Annex 3 Feeding during and after Diarrhoea 13
Annex 4 Public Health Action to Control Shigellosis in Sierra Leone 14
Annex 5 Laboratory Request Form 15
Annex 6+7 Surveillance Forms 16
Annex 8 Record review form 18
Annex 9 Assessment of Dehydration 19
Annex 10 Guidelines for management of dehydration 20
1. Background
In late 1999 an outbreak of bloody diarrhoea was detected in the Western Area of Sierra Leone. At that time Shigella flexneri was isolated by IP Abidjan. The outbreak has continued to spread and is now affecting all districts. On 29 December 1999, Institut Pasteur (IP) Paris isolated Shigella dysenterie type 1 (Sd1) with a further 10 isolates in the first three weeks of 2000 from cases in Kenema District (Eastern Region), Moyambe District (Southern Region) and Koinadugu District (Northern Region).
The MoH and WHO continued to receive reports of bloody diarrhoea. However, the true situation was unclear as the surveillance system is functioning very poorly and some areas are very difficult to access due to security reasons. The emergence of Shigella dysenterie type 1 was of great concern to the MoH, WHO and the NGOs.
WHO received an official request for assistance from the Government of Sierra Leone on the 25th January 2000. WHO AFRO and HQ fielded a two-person team (Professor Koumare, Dr. Mike Ryan). The team left for the field on 27th January and had a preliminary briefing together in Conakry before travelling to Freetown together. A consultant seconded to MSF-F from Epicentre (Dr. Phillipe Guerrin) joined the team in Freetown.
2. Objectives of mission
The objective of the mission was to support the WRO and the Ministry of Health in Sierra Leone to:
¨ assess the extent, impact and exact pathogens causing of the outbreak in 9 accesible districts.
¨ provide training in case management to district health workers
¨ distribute drugs and equipment for outbreak response
¨ educate the population on how to avoid infection
¨ institute intra-epidemic surveillance for bloody diarrhoea
3. Work Process
On arrival on 28th January the WHO team were briefed by Dr. Wurie, DPC/WRO and a series of meetings planned with the Director General of Medical Services (Dr. Kamara), the DPC/MOH (Dr. Thuray) and health NGOs active in the health area.
A meeting of the Epidemic Response Committee was held on Monday 31st and the current situation discussed. It was decided that a small technical group would meet intensively over two days to plan a field assessment and response. This group consisted on MoH, WHO and two NGOs (MSF-F and MERLIN).
A series of intensive planning meeting were held on Tuesday and Wednesday with the production of a national plan for outbreak response including logistic arrangements. During these two days Professor Koumare commenced training of staff at the medical laboratory at the Connaught Hospital in Freetown. The WHO team had brought enough laboratory materials for the collection, transport, isolation and serotyping of up to 600 specimens.
The team had also hand carried 3,000 tablets of nalidixic acid and WHO provided a further 100,000 tablets arrived by air and sea over the subsequent days. In addition WHO provided $10,000 for the overall field response, to procure ORS, IV fluids and carry out health education campaigns
4. Field Response
By Friday Feb 4th all arrangements had been put in place for 4 teams to leave for the field visiting all regions spending 4-6 days with the following objectives;
¨ To train PHU and Hospital health care workers in the diagnosis treatment, registration and reporting of bloody diarrhoea/shigellosis
¨ To distribute antibiotics (Nalidixic Acid), IV fluids, ORS and health education material to hospitals and PHUs
¨ To collect quantitative information on bloody diarrhoea from registers in PHCUs from June 1999 to February 2000
¨ To systematically collect stool specimens from new cases and transport them in Cary Blair medium in a cold chain to Freetown (Connaught Hospital) where WHO has equipped and trained the staff in the recognition of shigella sp.
¨ To institute intra-epidemic surveillance of bloody diarrhoea at PHUs and hospitals using existing surveillance officers used in AFP surveillance
4.1 Diagnosis and Case Management
The case definition to be used was: "Diarrhoea with visible blood in the stools observed by a health care worker "
Treatment centres: Patients will be treated at PHUs where there is a Clinical Health Officer (CHO), Nurse Dispenser or a SECHN (State Enrolled Community Health Nurse).
Selection of cases for treatment:: Nalidixic acid is in limited supply. Therefore treatment for the moment will be reserved for only "High Risk" patients. All diarrhoea cases with bloody diarrhoea should be examined and asssessed. The criteria for the use of Nalidixic Acid are
¨ Severe illness (dehydration, temperature >38.5C, altered consciousness convulsion, coma) OR
¨ Age less than 5 years or over 50 years OR
¨ Malnourishment (visble wasting and/or bipedal oedema)
If the patient fulfills ANY of the above criteriae then use the treatment algorithm provided in Annex 1:
See Treatment Algorithm (ANNEX 1)
Note: If it is not possible to keep the patient for the full 5 days then they should be discharged with enough antibiotics to finish therapy. A relative should be instructed on the number and timing of tablets and should observe the patient taking the tablets. A patient treatment coupon should be given to the relative to give to the "Blue Flag" village volunteer who will ensure that the antibiotic course is finished.
If the patient is NOT "High Risk and does not meet the criteria for antibiotic therapy then
1. Give supportive therapy according to level of dehydration (ORS)
2. Encourage the patient to continue feeding
3. Give health education
4. Discharge the patient and tell then to return if their condition does not improve
IT IS VERY IMPORTANT THAT ALL PATIENTS COMPLETE
THERAPY WITH NALIDIXIC ACID FOR A FULL FIVE DAYS !
Completion of the full five days will help the patient to make a full recovery and will also help to prevent shigella becoming resistant to Nalidixic acid.
THEREFORE
ALL TREATMENT WITH NALIDIXIC ACID MUST BE SUPERVISED !
4.2 Health Education
This activity is planned in collaboration with Mr B.A. Kawa from the Health Education Department. Public health messages have been selected for dissemination by radio poster and community meetings.
Ø Existing posters will be adapted and printed
Ø Posters will be taken to the field by teams as well as health education materials for community workers.
Ø Radio messages will be disseminated on national radio and on local FM radio where available
Sample Messages
TO PROTECT FROM BLOODY DIARRHOEA AND DYSENTERY
Ø Wash hands with soap and water
- After using the toilet, changing nappies or cleaning child
- Before preparing food and eating
Ø Always use a latrine when going to the toilet
Ø Eat only fruits that have been freshly peeled
Ø Cook all meats, fish and vegetables thoroughly
Ø Make water safe for drinking by boiling
Ø Store drinking water in a clean container with a small opeing or cover
- Pour water from the container - do not dip a cup in the container
4.3 Specimen collection and Laboratory Testing
The field teams will collect at least 20 samples per district. Specimens will be collected according to the following criteria
Ø case with current bloody diarrhoea
Ø onset of illness < 4 days
Ø who have not received antimicrobials for this illness
1. Before sampling the specimen containers with Cary-Blair medium should be cooled in a cool box to +4c. The liquid medium will become semi-solid and the cooler temperature facilitates the viability of the organism later.
2. Collect fresh stool in sterile petri dish (dishes will be provided to each team).
3. Verify that the stool is characteristic (presence of blood).
4. With the spoon contained in the faecal specimen container, take a small amount of bloody part of the stools.
5. Place the spoon in the container which already contains the Cary-Blair transport medium and screw tightly shut. (make sure that the faecal specimen itself rests in the Cary-Blair medium)
6. On the container please with an indellible pen write the patient name, village and the date
7. The samples should be placed in a vaccine carrier and kept at 4 Celsius.
8. For each patient from whom a sample is collected please fill in a lab request form (see Annex 3)
4.4 Data collection in the Field
While visiting health facilities one team member should look through the case registers if available and extract information on cases of bloody diarrhoea (June 1999 - January 2000)
A table for each PHU visited should be completed (see Annex 8: record review form)
These data wil be anaysed in the field and copies taken back to the national MoH for further analysis
4.5 On-going intra-epidemic surveillance
There is a need to collect on-going data on the evolution of the outbreak. AFP surveillance officers will be used to collect weekly data from PHUs on Bloody diarrhoea and watery diarrhoea. These data will be aggregated and analysed by the DMO team and also reported to MoH Freeown via radio.
1. A bloody diarrhoea surveillance form will be filled in at all centres providing treatment of cases.
2. Each form will cover one week and will be completed daily
3. Surveillance officers will visit on a weekly basis and collect aggregate data for the week
Training in how to complete forms will be provided.
See Annex 6 + 7 for data recording and collection forms
4.6 Logistics and Supplies Needed
Logistics
Four investigation teams will be required in the field for 4-6 days. The teams plan to leave for the field on Sunday February 6th. Each team will have a vehicle from national level and one from the district. The teams will consist of national and district MoH staff and international staff as required. The teams will require vehicles, fuel, accomodation and DSA. In addition they will take health education materials, IV fluids, ORS, antibiotics and basic medications to treat other illnesses in the villages visited. Data entry and analysis will take place afterwards in Freetown as well as laboratory investigations.
Supplies needed
1. Fuel 100 gallons @5,000 per gallon
2. 1000 copies of standard case management protocol + alogrithm
3. Nalidixic acic (50,000 x 500mgs)
4. ORS (20,000 packets)
5. IV fluids (ringers lactate x 1 litre) + giving sets (900)
6. Additional cannulae (200)
7. 20,000 packets of ORS
8. Health Education Posters (1,000)
9. Health Education Handouts (1,000)
10. Sterile Petri dishes (x 300)
11. Sool specimen containers with Cary-Blair medium (x 300)
12. Ice packs (x 100)
13. Cool boxes/Vaccine carriers (x 20)
14. UNICEF Vaccine shippers (x 8)
15. Laboratory request forms (x 200)
16. Record review forms (x 500)
17. PHU bloody diarrhoea recording forms (x 2000)
18. Weekly bloody diarrhoea forms- Surveillance Officer (x 300)
19. Notepads, pens and pencils (x 1000)
20. Rulers (x 200)
21. A4 paper (x 5 reams)
5. Epidemiological data
At time of writing the 4 investigations teams are just back from the field and the data collected has not yet been analysed. However, a review of available data was carried out and is presented here for background. More detailed data will be preseted later as soon at it is available (see Final Report)
The team reviewed available data from the Ministry of Health on reported cases of "bloody diarrhoea" since January 1999. It must be noted that in none epidemic periods many cases of bloody diarrhoea in Sierra Leone may be caused by schistosomiasis which is endemic.
However, it is clear that "bloody diarrhoea" became an increasing problem in many districts of Sierra Leone relatively early in 1999. Figure 1 shows reported cases of "bloody diarrhoea reported by month in 4 districts. It can be noted that there was a rise in reportes cases over the months of February to July with a plateau after this. Shigella flexneri was isolated in IP Abidjan from cases in the Western area (1 case in Port Loko districts and 2 cases in IDP camps near Freetown). At this time there were very few reports of fatalities but evidence to confirm this finding.
These data are supported by data produced by MERLIN which shows similar patterns in Freetown and Newtown over the period July to November 1999.