Communicable Disease Control in Emergencies - A Field Manual (WHO - OMS, 2003, 223 p.): ANNEX 4: SAMPLE WEEKLY SURVEILLANCE FORMS

Communicable Disease Control in Emergencies - A Field Manual (WHO - OMS, 2003, 223 p.)

		(introduction...)
		ACKNOWLEDGEMENTS
		INTRODUCTION
		CHAPTER 1: RAPID ASSESSMENT
		CHAPTER 2: PREVENTION
		CHAPTER 3: SURVEILLANCE
		CHAPTER 4: OUTBREAK CONTROL
		CHAPTER 5: DISEASE PREVENTION AND CONTROL
		ANNEX 1: WHO REFERENCE VALUES FOR EMERGENCIES
		ANNEX 2: SAMPLE HEALTH SURVEY FORMS
		ANNEX 3: NCHS/WHO NORMALIZED REFERENCE VALUES FOR WEIGHT FOR HEIGHT BY SEX
		ANNEX 4: SAMPLE WEEKLY SURVEILLANCE FORMS
		ANNEX 5: RECOMMENDED CASE DEFINITIONS
		ANNEX 6: OUTBREAK INVESTIGATION FORMS
		ANNEX 7: ORGANIZATION OF AN ISOLATION CENTRE
		ANNEX 8: BASIC LABORATORY SERVICES
		ANNEX 9: LABORATORY INVESTIGATION KIT
		ANNEX 10: TREATMENT GUIDELINES
		ANNEX 11: MANAGEMENT OF THE CHILD WITH COUGH OR DIFFICULTY IN BREATHING6
		ANNEX 12: ASSESSMENT AND TREATMENT OF DIARRHOEA
		ANNEX 13: FLOW CHARTS FOR SYNDROMIC MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS
		ANNEX 14: SAMPLE HEALTH CARD
		ANNEX 15: LIST OF WHO GUIDELINES ON COMMUNICABLE DISEASES
		ANNEX 16: LIST OF PUBLISHERS
		ANNEX 17: GENERAL REFERENCES

ANNEX 4: SAMPLE WEEKLY SURVEILLANCE FORMS

1. WEEKLY MORBIDITY REPORT

AGENCY:_______________________________ HEALTH FACILITY:____________________
REPORTING PERIOD:_________TO_______TOWN/DISTRICT:_______________________
POPULATION COVERED:______________________________________________________
NAME/TITLE OF SURVEILLANCE OFFICER:_______________________________________

	NEW CASES
	Under 5 years	5 years and over	TOTAL
Bloody diarrhoea
Watery diarrhoea
Suspected malaria
Pneumonia/lower respiratory tract infection
Measles
Suspected meningitis
Acute jaundice syndrome
Suspected poliomyelitis/acute flaccid paralysis
Neonatal tetanus
Scabies
Sexually transmitted infections
Fever (unknown)
Other communicable diseases (specify)
Trauma/injury
Malnutrition
Mental health problems
Other non-communicable diseases

Diseases with epidemic potential - report as soon as possible to your Health Coordinator

2. WEEKLY/MONTHLY DEMOGRAPHY FORM
Town/Village/Settlement/Camp:
Clinic:
Reporting period:
Name of surveillance officer:
Population at beginning of week/month	Children under 5 years of age	Total population
Births this week/month
Arrivals this week/month
Deaths this week/month
Departures this week/month
Estimated population at end of week/month

These forms may need to be adapted for specific situations.

The health worker must select the main cause for the consultation, i.e. one disease/syndrome for each case reported.

The first referral only should be reported; follow-up visits for the same disease should not be reported.

The list of diseases may require adaptation to local circumstances - refer to the rapid health assessment done early in the emergency phase or WHO data if available for that country/region.

In the event of an increase in the number of cases of a disease/syndrome being reported, surveillance activities may need to be enhanced For example, active case finding and case definitions may need to be revised, such as in the event of an outbreak of viral haemorrhagic fever.

At the end of each week, the reporter must count up all the cases and deaths from each disease as recorded in the outpatient and inpatient records. It is essential that the EXIT diagnosis is the one recorded in the weekly surveillance form.

3. WEEKLY MORTALITY REPORT

SITE.............................................
Date from Monday:....................... To Sunday:.............................
Total Population at beginning of this week:..........................
Births this week: ..........................	Deaths this week:.........................................
Arrivals this week (if applicable):........................	Departures this week:.......................
Total population at end of week:........................		Total population under 5 years:...........................

Direct Cause of Death

Underlying Causes

First name

Family Name

Sex

Age (mos/ yrs)

Diarrhoea-bloody

Diarrhoea-Acute watery

Suspected Malaria

ALRI

Measles

Meningitis (suspected)

Acute jaundice syndrome

Neonatal (0-28 days)

Non accidental injury

Other (specify)

Unknown

AIDS

Malnutrition

Other (specify)

Date (dd/mm/yy)

Location in camp/ site

Died in hospital (hosp)/ home

-frequency of reporting (i.e. daily or weekly) depends upon number of deaths
-deaths should not be reported solely from site health facilities, but should include reports from site and religious leaders, community workers, women's groups, and referral hospitals
-whenever possible, put case definitions on back of form

Crude mortality rate: Number of deaths/total number of population X 10,000 persons /7 persons = deaths/10,000 persons/day

<5 mortality rate: Number of deaths among children <5 years/total population <5 years x 10,000 persons / 7 days = deaths/10,000/day