1. Liberia Field Epidemiology Training Programme (LFETP)Liberia Field Epidemiology Training Programme LFETP) Presentation on Projects 1 and 2 of Basic Field Epidemiology Training Program, Liberia Prepared By: Benjamin F. Karmo Disease's Surveillance Officer Sinoe County Health Team November 2, 2015

2. Liberia Field Epidemiology Training Programme (LFETP) Acknowledgement Sinoe County Health Team Ministry of Health, Liberia EMORY University Center for Disease Control and Prevention (CDC) World Health Organization (WHO) AFENET Medical Teams International Emergency Operation Center (EOC)/eHealth Sinoe All Mentors

3. Liberia Field Epidemiology Training Programme (LFETP)Liberia Field Epidemiology Training Programme LFETP) AFP Case Investigation Report 3

4. Liberia Field Epidemiology Training Programme (LFETP) Introduction  Sinoe county is located in the southeastern part of Liberia, shares border with Grand Gedeh, Grand Kru, River Gee and River Cess Counties  Has population of 119,668 inhabitants  Has 10 health districts with 34 health facilities (1 Hospital and 33 Clinics).  About 90% of the facilities with single clinician  Active Surveillance is one of the most successful method for controlling and managing diseases of public health concern

5. Liberia Field Epidemiology Training Programme (LFETP) Methodology  On June 20 th 2015, County health team investigated a suspected case of Acute Flaccid Paralysis reported by the district mobilization coordinator (DMC) the day before in Butaw  Materials for investigation:  AFP case investigation forms, specimen collection cups and specimen carrier with solid ice pads

6. Liberia Field Epidemiology Training Programme (LFETP) Methodology  Case Definition:  Any child < 15years from Butaw with a sudden onset of paralysis (AFP) either in the arms or legs, or a person of any age in whom the clinician suspected polio from June 19 to October 3, 2015  First visit was conducted on 20 th June, 2015  the child was examined and two (2) stool specimens were collected within 24 hours  Active case search was done  60 day follow-up visit was conducted on 3 rd October, 2015  the child was examined and history taken from the grand mother

7. Liberia Field Epidemiology Training Programme (LFETP) The Results 7

8. Liberia Field Epidemiology Training Programme (LFETP) Examination during first visit June 20, 2015 History of pulmonary tuberculosis with uncompleted treatment Poor general condition, alert, cooperative with normal speech Slightly pale conjunctivae Lungs normal on auscultation Severe deformity of the spine at the level T6-T7 Unable to stand by herself or with support Muscle tone: Spasticity on lower extremities with deficit sensation. Normal on upper extremities

9. Liberia Field Epidemiology Training Programme (LFETP) Examination during the second visit October 3, 2015 Good general condition, alert, cooperative with normal speech Pink conjunctivae Lungs normal on auscultation Severe deformity of the spine at the level T6-T7 stay present Muscle tone: Spasticity on lower extremities with intact sensation. Normal on upper extremities Able to stand by support and take few steps

10. Liberia Field Epidemiology Training Programme (LFETP) Discussion/ Conclusion Although the patient presented with – muscular deficits with deficit sensation during first visit, –however intact sensation during the second visit suggested –the child was in the spinal shock during the first visit and not in a true acute flaccid paralysis. In conclusion, the cause of the paralysis was probably acute spinal cord compression due to tuberculosis spondylitis –Other etiologies like, cancer, fungal infection and osteomyelitis of the spine should also be considered as differential diagnosis

11. Liberia Field Epidemiology Training Programme (LFETP) PUBLIC HEALTH ACTION A wheel chair was provided to the child by the County Health Team Encouraged to go to F. J. Grante Memorial Hospital for further investigation and restart TB treatment Physiotherapy is also being performed at home –INVESTIGATORS John Doedeh, CHO; Benjamin F. Karmo, CSO; Jeremiads Naiene, WHO; Jemal Hassan, WHO; George Sie Williams, WHO; Daddy Nyenswah, EOC/E- Health

12. Liberia Field Epidemiology Training Programme (LFETP) Expanded Surveillance Reports(Wk31—Wk42), 2015 12

13. Liberia Field Epidemiology Training Programme (LFETP) Summary Summary Reports on IMRD: 630 Suspected Cases 382 suspected EVD cases reported 220 suspected Acute watery diarrhea cases reported 14 suspected Measles cases reported 12 suspected Bloody diarrhea cases reported 2 Maternal death cases reported All specimen transported to the Reference Lab. returned negative for EVD (382) and Measles (14)

14. Liberia Field Epidemiology Training Programme (LFETP) Fig 1: Reporting quality( Week 31-42), 2015, Sinoe County DistrictsWK -31 WK -32 WK -33 WK- 34 WK- 35 WK -36 WK -37 WK -38 WK -39 WK -40 WK -41 WK -42 % Cumulative wk 31-42 GREENVILLE TTTTTTTTTTTT 100% PYNE TOWN TTTTTTTTTTTT 100% TARJUOWON TTTTTTTTTTTT 100% JEDEPO TTTTTTTTTTTT 100% BUTAW LTTTTTTTTTTT 92% DUGBE LTTTTTTTTTTT 92% TARSUE TTNRTTTTTTTTT 92% KPANYAN TLNRTTTTTTTTT 83% JAEDAE TLLTLTTTTTTT 75% GBLONEE TLNRTLTTTTTTT 75%

15. Liberia Field Epidemiology Training Programme (LFETP) Legend This WeekON Time T Late L No Report received NR % Cumulative >=80% On time >=50-79.9% On time <50% on time

16. Liberia Field Epidemiology Training Programme (LFETP) Figure 2: Summary of key priority diseases (week 31-42, 2015), Sinoe County DiseasesCurrent Week31—Week42 CasesDeathsCase fatality Rate Acute Flaccid Paralysis (AFP) 000% Yellow Fever (YF) 000% Lassa Fever (LF) 000% Neonatal Tetanus (NNT) 000% Cholera (CHO) 000% Acute Watery Diarrhea (AWD) 220 00% Meningitis (MEN) 000% Measles (MEA) 1400% Bloody Diarrhea (BD) 1200% Human Rabies (HR) 000% Suspected EVD 3824210.9% Neonatal Death (ND) 000% Maternal Death (MD) 2

17. Liberia Field Epidemiology Training Programme (LFETP) Timeliness of reporting in Sinoe County of Health Districts, Epi weeks 31- 42, 2015

18. Liberia Field Epidemiology Training Programme (LFETP) Figure 3: Trend of suspected cases of Acute watery diarrhea in Sinoe County from Epi- week 31-42, 2015

19. Liberia Field Epidemiology Training Programme (LFETP) Figure 4: Trend of suspected cases and deaths of EVD in Sinoe County from EPI week31--week42, 2015