communicable diseases surveillance system in thailand · surveillance system in thailand...
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Communicable diseases surveillance system in Thailand
Pawinee Doung-ngern, MD, MPH, PhD,
Community Diseases Unit, Bureau of Epidemiology, Department of Disease Control
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Surveillance system in Thailand
Epidemiology division worked under the Department of Sanitary and Hygiene since 1958
Officially established as Division of Epidemiology, Permanent Secretary Office, in 1972
Bureau of epidemiology has reallocated to Department of Disease Control in October 2002
Responsible mainly on national disease surveillance, outbreak investigation, and training for field epidemiologists
National diseases surveillance:
Communicable diseases surveillance
Non-communicable diseases surveillance
Injury surveillance
Occupational diseases surveillance
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Communicable disease unit
Passive surveillance for communicable diseases
except STI/ TB/ Malaria
Laboratory surveillance for important diseases
Special surveillance for diseases in elimination or
eradication program – measles & AFP
Adverse Event Following Immunization (AEFI)
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Communicable Diseases Surveillance in Thailand
Passive surveillance (R506)• 70 diseases under surveillance• 8 groups
1. CNS infection2. Vector borne diseases3. Vaccine preventable diseases/AEFI4. Zoonotic diseases5. Respiratory illness6. Food and water borne diseases7. STI 8. Others
• TB and HIV surveillance systems are responsible by different bureau
• Data to be collected: demographic information, date of onset, hospital, outcome of treatment
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Food and water borne diseases Vaccine preventable diseases
Diarrhoea Chickenpox
Food_Poisoning Measles
Dysentery,Amoebic Mumps
Dysentery,Bacillary AEFI
Mushroom poisoning Rubella
Typhoid Measles c Complication
Paratyphoid AFP
Cholera Pertussis
Botulism Tetanus exc.Neo.
Respiratory diseases Diphtheria
Pneumonia Tetanus neonatorum
Influenza Poliomyelitis
Avian Influenza Zoonoses
CNS infection Scrub Typhus
Meningitis,uns. Leptospirosis
Encephalitis uns. Streptococcus suis
Eosinophilic Meningitis Rabies
Japanese B encephalitis Brucellosis
Meningococcal Meningitis Trichinosis
Vector borne diseases Anthrax
DHF+DSS+DF STI
Dengue fever Other STI
D.H.F. Gonorrhoea
Malaria Syphilis
D.H.F.shock syndrome Condyloma Acuminata
Zika virus N.S.U./V
Chikungunya Genital Herpes Simplex
Filariasis Chancroid
Others L.G.V.&other&unsp.V.D.
PUO Vaginal trichomoniasis
H.conjunctivitis Genital Molluscum Contagiosum
HFM Pediculosis Pubis
Scarlet fever Hepatitis
Melioidosis HepatitisB
Hepatitis_uns. HepatitisC
Leprosy HepatitisA
Enterovirus Fever HepatitisE
Kala azar HepatitisD
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Flowchart of Agencies in the National Surveillance System
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ระบบเฝาระวงทางระบาดวทยาโรคตดตอทวไป
1. โรคตดตอจากสตวสคน
2. โรคทางเดนอาหารและน า
3. โรคตดตอนาโดยแมลง
4. โรคของระบบประสาทสวนกลาง
5. โรคทปองกนไดดวยวคซน และอาการไมพงประสงคภายหลงการไดรบวคซน
6. โรคตดตอระบบทางเดนหายใจ
7. โรคจากการสมผส
8. โรคตดเช อในสถานพยาบาล (New)
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Weekly summary report of surveillance data
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Monthly surveillance report
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Annual epidemiological report of surveillance data
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Relies on the
cooperation
Health-care providers
Laboratories
Hospitals
Health facilities
Private practitioners
Report
Receive Compiled Analyzed Monitor
IdentifyFeedback
Challenge
- Difficult to ensure timeliness,
sensitivity, and completeness
of data
- No laboratory data
- Limited information on risk factors
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Why laboratory surveillance?
67 Infectious diseases under National Notifiable Disease Surveillance (R.506) – less than 10% diseases had laboratory confirm
Not sufficient information to understand the etiology of the diseases
Sentinel laboratory surveillance of some important diseases have been launched in collaboration with the Thai National Institute of Health, Chulalongkorn University, and selected community/provincial hospitals
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Objectives
Understand the etiology and describe the epidemiology
of the selected diseases:
- Hand foot mouth diseases, influenza, encephalitis,
and diarrhea
Output
Weekly and annual report
Expected outcomes
- To better understand and respond to the emerging
and re-emerging infectious diseases in a timely fashion
- To provide scientific information for policy makers for better
prevention strategies
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เหนอเชยงใหม- สนปาตอง- ฝาง- นครพงคเชยงราย- เชยงรายฯ- แมจนตาก- แมสอด
พะเยา
นาน
- นาน
- ทาวงผาสโขทย
กลางกทม.-พญาไท3-พระมงกฎฯ-ตากสนฯอยธยา- อยธยา- เสนานนทบรลพบรกาญจนบรราชบรจนทบรเพชรบร
40 hospitals from 30 provinces
ตะวนออกเฉยงเหนอ
นครราชสมา- ครบร- ดานขนทดหนองคายอดรธานนครพนมยโสธรมกดาหารสกลนครมหาสารคามเลย
ใตประจวบครขน
ธ- ประจวบฯ- หวหน
นครศรธรรมราช
สราษฏรธาน
- สราษฎรธาน
- เกาะสมย
ตรง
สตล
สงขลา
ภเกต
Sentinel sites: hospital based
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Diseases under surveillance
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Syndrome/disease
Year launched
Focus pathogen Laboratory Laboratory method
Encephalitis 2014 Both viruses and some important bacteria
- King Chulalongkorn Memorial Hospital*- AFRIMS**
- Realtime PCR
- Serology test for JE, Dengue
Hand foot and mouth disease (HFMD)
2015 Viruses - King Chulalongkorn Memorial Hospital*
Realtime PCR
Respiratory illness Jan 2016 Influenza - Thai – National Institute of Health
Realtime PCR
Diarrhea Jan 2018 Viruses - King Chulalongkorn Memorial Hospital*
Realtime PCR
*Thai Red Cross Emerging Infectious Diseases - Health Science CentreWHO Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University** AFRIMS: Armed Forces Research Institute of Medical Sciences
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Flow of the laboratory surveillance system
Focal point of each hospital contact
BOE staff in order to have
specimen transported to the lab
Any suspected case who met
the case definition was detected
and investigated
BOE staff contact the transportation
company to pick up the specimen
at the hospital
Laboratory investigation
using Real time PCR
Laboratory staff send out the
laboratory result to BOE focal pointBOE staff enter data into the program BOE notified CDCU/SRRT
in order to conduct field
investigation if necessary
BOE staff analyse and report the
result weekly, and annually
to all stakeholders
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Hand Foot and Mouth Diseases
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Target pop
- Children age ≤ 5 yr
- Regardless of nationality
- Visited either OPD/IPD
Severe symptoms
Fever, dyspnea, and have sign or symptom of CNS involvement regardless
of HFM lesion
Fever with suspected lesion for
HFM/Herpangina, with vomiting, dyspnea,
drowsy, or CNS involvement
Mild symptoms
Suspected HFM/ Herpangina
Flow of HFM surveillance
Samples ( e.g., Throat swab/ tracheal suction/CSF) will be collected and sent to laboratory at Chulalongkorn Hospital for PCR testing
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Encephalitis
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Target pop- All ages, all nationality, all gender- Symptoms/sign
- Doctor suspected encephalitis/meningitis/meningoencephalitis or;
- Fever with at least 2 symptoms: headache, confusion or unconscious, convulsion
Serum 2 cc CSF
• Contact BOE staff who is responsible for encephalitis for specimen transportation• Laboratory testing will be performed at two laboratory
• CSF samples will be tested using realtime PCR at Thai Red Cross Emerging Infectious Diseases - Health Science Centre, WHO Collaborating Centre for Research and Training on Viral Zoonoses, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University
Flow of laboratory surveillance for encephalitis cases
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จ ำนวนตวอยำงผปวยสมองอกเสบทสงตรวจทำงหองปฏบตกำร ป 2557 - 2561
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Percent of laboratory result of encephalitis cases by pathogen and region, 1st Oct 2016 – 30th Sep 2017
84/491 (17.1%) had laboratory positive
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Influenza surveillance
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Criteria 1 Criteria 2 Criteria 3
Influenza Like Illness: ILI
• Age ≥ 2 months who
has
– Fever or feel like
having high grade
fever with
– Cough in the past 5
days or
– Doctor suspect
influenza
Severe Acute Respiratory
Infection: SARI
• Age ≥ 2 months who has
• Fever with
• Respiratory illness
including
– Cough in the past 5
days
– Dyspnea
• Hospitalized
Pneumonia
• Patients with
doctor’s
diagnosis of
Pneumonia
(Community
Acquired
Pneumonia:
CAP)
Two target populations:- Influenza Like Illness (ILI) - OPD case- Severe Acute Respiratory Illness (SARI) –
Pneumonia - IPD case
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Flow of influenza
surveillance
No intubation On intubation
Contact the responsible staff before sending
Collect throat swab, nasal
swab to VTM tube
Patients who meet surveillance case definition
Fever ≥ 38 °C with cough, or ILI,
or suspected influenza
Collect Tracheal secretion
in sterile tube
Patient with SARI or CAP and admitted
to the hospital
Keep in the ice box or refrigeration at 4 °C, label, and fill in the form
Real time RT-PCR for influenza type A/H1, H3 และ B
Report the lab result back to the hospital by fax/email within 48 hours 26
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Acute diarrhea
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Why viral diarrhea?
What is the burden of rota virus diarrhea in Thailand ? Why the disease is severe in adult?
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Definition and flow of acute diarrheasurveillance
Any patients regardless of their age and nationality presented at the hospital with acute diarrhea*
Collect stool specimen (4-8 gram)
Conduct case investigation
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Notify BOE staff to arrange for specimen transportation
*Acute diarrhea: • Loose stool 3 times or more, or• At leas t1 time of watery or mucous diarrhea
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Number and percent of pathogen identified among acute diarrhea patients,
18th Jan 2018 – 17th Mar 2018
List Pathogen Number %
1 Rotavirus 292 66.4
2 Norovirus G II 70 15.9
3 Sapo virus 26 5.9
4 Noro virus G I 21 4.8
5 Astro virus 16 3.6
6 Adeno virus 15 3.4
*remark: some patients had positive result for more than 1 pathogen
A total of 406 samples were collected, and 333 (82%) had positive results
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จ านวนตวอยางทตรวจพบเชอโครงการเฝาระวงเชอไวรสกอโรคอจจาระรวงของส านก ระบาดวทยา จ าแนกรายเดอน ระหวางวนท18 มกราคม 2561 – 4 กมภาพนธ 2562
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Flowchart of Agencies in the National Surveillance System
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Outbreak/ abnormal events
DDC hotline
Local SRRT
Detect
Response
Region: Situation Awareness Team (SAT)
Central: Situation Awareness Team (SAT)
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โรคทตองก าจด กวาดลาง
• Three indicators were considered to be of primary importance for disease eradication and elimination: – An effective intervention is available to interrupt transmission of the
agent;
– Practical diagnostic tools with sufficient sensitivity and specificity are available to detect levels of infection that can lead to transmission;
– Humans are essential for the life-cycle of the agent, which has no other vertebrate reservoir and does not amplify in the environment.
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Elimination Eradication
Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Example: neonatal tetanus.
Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: smallpox
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กำรเฝำระวง Acute Flaccid Paralysis (AFP)
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หากพบเหนเดกอายต ากวา 15 ป
มอาการแขนขาไมมแรงยนเดนไมได
Polio Eradication Program
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Global situation of poliomyelitis as of September 2018
http://polioeradication.org/polio-today/polio-now/
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แนวทำงกำรด ำเนนงำนเฝำระวง AFP
แพทย/ พยาบาลตรวจพบผปวยแขนขาออนแรงเฉยบพลน
งานระบาดวทยาเพอทาการสอบสวนโรคและเกบอจจาระ ภายใน 48 ชวโมงรวมถงตดตามเกบอจจาระคร งท 2 ภายใน 24 - 48 หลงจากการเกบอจจาระคร งแรก
ระบาดวทยาท สสจ.
สครสานกระบาดวทยากรมวทยาศาสตรการแพทย
แจง
แจง และสงแบบสอบสวนโรค
แจง และสงแบบสอบสวนโรคทางอเมลท [email protected] หรอโทรสาร 025901784
แจง และสงแบบสอบสวนโรค
สงตวอยาง
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แนวทำงกำรด ำเนนงำนเฝำระวง AFPกำรคนหำผปวย AFP• Zero reporting
– เจาหนาทระบาดวทยาของโรงพยาบาลตรวจสอบวามผปวยแขนขาออนแรงเฉยบพลนทไมใชจากการบาดเจบหรอไม (โดยไมคานงถงการวนจฉยแพทย) ทหอผปวยใน และบนทกขอมลลงใน zero report form ประจาสปดาหสงไปท สสจ.
– สสจ.รวบรวมสงมาท [email protected]
• Active search– ใชระบบคอมพวเตอรคนหาผปวยทอายตากวา
15 ป ทปวยเปนโรคตามรหส ICD 10 ในชวง 3 เดอนกอน
– ทบทวนเวชระเบยนผปวย หากผปวยมอาการแขนขาออนแรงเฉยบพลนจรง ใหทาการตดตามผปวย เพอสอบสวนโรคและเกบอจจาระตรวจ
– สงแบบสอบถามและตวอยางกลบมาตามแนวทางการเฝาระวงโรค
Disease ICD10
1 AFP G82, G82.0,G82.3
2 Acute anterior poliomyelitis A80
3 Acute myelopathy G95.9
4 Guillain-Barre sydrome G61.0
5 Acute demyelinating neuropathy G36.9
6 Acute axonal neuropathy G58, G58.9
7 Peripheral neuropathy G62.9
8 Acute intermittent porphyria E80.2
9 Critical illness neuropathy G58, G58.8
10 Myasthenia Gravis G70.0
11 Botulism A05.1
12 Insecticide intoxication T60
13 Tick paralysis T63.4
14 Idiopathic inflammatory myopathy G72.4
15 Trichinosis G75
16 Hypokalemic, Hyperkalemic paralysis G72.3
17 Traumatic neuritis M79.2
18 Transverse myelitis G37.3
19 Myalgia M79.1
20 Weakness (Malaise,Fatigue) R53
21 Hemiplegia G80.2, G81
22 Acute paralytic poliomyelitis, vaccine-associated A80.0
23 Acute paralytic poliomyelitis, wild virus, imported A80.1
24 Acute paralytic poliomyelitis, wild virus, indigenous A80.2
25 Acute paralytic poliomyelitis, other and unspecified A80.3
26 Acute nonparalytic poliomyelitis A80.4
27 Acute poliomyelitis, unspecified A80.9
28 Flaccid hemiplegia G81.0
29 Paraplegia, unspecified G82.2
30 Tetraplegia, unspecified G82.5
31 Other paralytic syndromes G83
32 Diplegia of upper limbs G83.0
33 Monoplegia of lower limb G83.1
34 Monoplegia of upper limb G83.2
35 Monoplegia, unspecified G83.3
36 Paralytic syndrome, unspecified G83.9
37 Other diseases of spinal cord G95
ตารางแสดง ICD-10 lists ทอาจมอาการ AFP
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AFP rate and percent of adequate stool specimen collection, 2010 – 16th Aug 2018
2.16
2.00
2.37
1.95 1.99
1.56
2.13
1.85
0.85
0
10
20
30
40
50
60
70
80
90
0
0.5
1
1.5
2
2.5
2010 2011 2012 2013 2014 2015 2016 2017 2018
Percent of adequate Stool AFP Rate
เกณฑข นตาของ AFP rate 2/100,000 ประชากรอายตากวา 15 ป
เกณฑข นตาของการเกบอจจาระใหไดตามเปาหมาย รอยละ 80
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AFP rate
2555 2556 2557 2558
2559 2560 2561
Jan-Aug
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กำรเฝำระวงไขออกผนหรอผปวยสงสยหด Measles Elimination Program
42
2514
เรมดาเนนการงานเฝาระวงหด ใน รง.506
เรมรายงานฐานขอมลกาจดหด Measles Elimination program (ME)
2554 2555 2563
ประชมสมชชาอนามยโลกรบรองแผนโครงการกาจดหด
ต งเปาไวทวโลกจะมการกาจดหดสาเรจ
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WHO: แนวทำงกำรด ำเนนกำรและจดกลมผปวยสอบสวนโรคผปวยทกราย เกบตวอยางเลอดหรอ Throat swab
สงตรวจ
จดกลมผปวยการตรวจตวอยางดวยวธ ELISA/ PCR
ผลตรวจทางหองปฏบตการหรอผลจากการสอบสวนโรค
ผปวยไข รวมกบผน maculopapular rash หรอแพทยสงสยหด หดเยอรมน
Suspected case
Adequate specimen
Laboratory positive
Laboratory confirmed
case
Laboratory negative
Discarded: non-measles non-rubella
No/ in adequate specimen
Epidemiologically linked to lab confirmed case
Epidemiologically confirmed case
No epidemiological
linkage
Clinically compatible case
Discarded: non-measles non-
rubella
Flow chart of classification for suspected measles: WHO
- แนวทางการตรวจทางหองปฏบตการคอ ตรวจ Serology for measles กอน หากผลเปนลบจะตรวจ rubella- การรายงานผล: positive, negative, equivocal
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ตวช วดความสาเรจและเปาหมายของการกาจดโรคหด
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นยำมตำมองคกำรอนำมยโลก
ผปวยทตองเฝำระวง/ผปวยสงสย (Suspect) ผปวยไข รวมกบมผนนนแดง (maculopapular rash) หรอแพทยสงสยวาเปนหดหรอ
หดเยอรมน ผปวยยนยนทำงหองปฏบตกำร (Laboratory confirmed)
ผปวยสงสยทมผลยนยนทางหองปฏบตการทไดรบการรบรองจากองคการอนามยโลก หรอผานการรบรองโดยหองปฏบตการทไดรบรองจาองคการอนามยโลก
ผปวยยนยนทำงระบำดวทยำ (Epidemiological confirmed) ผปวยสงสย ทมผลการตรวจทางหองปฏบตการเปนลบหรอไมไดตรวจทาง
หองปฏบตการ แตมความเชอมโยงทางระบาดวทยากบผปวยยนยน ผปวยทมอำกำรเขำไดกบหด (Clinical compatible with measles)
มไข และมผนนนแดง (Maculopapular rash) รวมกบอาการอยางนอยหนงอาการตอไปน ไอ (cough), มน ามก (Coryza), เยอบตาแดง (Conjunctivitis) ทไมไดรบการเกบตวอยางและไมมความเชอมโยงทางระบาดวทยากบผปวยยนยน
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กำรตรวจทำงหองปฏบตกำร
วธกำรตรวจ
หองปฏบตการ กรมวทยาศาสตรการแพทย และศนยวทยาศาสตรการแพทยทกแหง
หองปฏบตกำร
Serology test: จำกตวอยำงซรม Measles
IgM ดวยวธ ELISA ใหผลบวก
Antigen detection: จำกตวอยำง Throat
swab/ nasal swab
ตรวจพบสำรพนธกรรมของเชอ
ไวรสดวย Polymerase Chain Reaction
(PCR)
เพำะเชอจำกสำรคดหลงทำงเดน
หำยใจจำกตวอยำง Throat swab หรอ
nasal swab
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WHO: แนวทำงกำรด ำเนนกำรและจดกลมผปวยสอบสวนโรคผปวยทกราย เกบตวอยางเลอดหรอ Throat swab
สงตรวจ
จดกลมผปวยการตรวจตวอยางดวยวธ ELISA/ PCR
ผลตรวจทางหองปฏบตการหรอผลจากการสอบสวนโรค
ผปวยไข รวมกบผน maculopapular rash หรอแพทยสงสยหด หดเยอรมน
Suspected case
Adequate specimen
Laboratory positive
Laboratory confirmed
case
Laboratory negative
Discarded: non-measles non-rubella
No/ in adequate specimen
Epidemiologically linked to lab confirmed case
Epidemiologically confirmed case
No epidemiological
linkage
Clinically compatible case
Discarded: non-measles non-
rubella
Flow chart of classification for suspected measles: WHO
- แนวทางการตรวจทางหองปฏบตการคอ ตรวจ Serology for measles กอน หากผลเปนลบจะตรวจ rubella- การรายงานผล: positive, negative, equivocal
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Adverse Event Following Immunization Surveillance
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Impact of AEFI on Immunization programs
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Thank you for your attention
51