From

PRELIMINARY INVESTIGATION OF POSITIVE CASE FOR MALARIA AND RADICAL TREATMENT

Name of the District and Code No.

:

Name of the HUD and Code No.

:

Name of the Block and Code No.

:

Name of the PHC and Code No.

:

Name of the Village and Code No.

:

I(a) Name of the Patient

:

(b) Age / Sex

:

(c) Positive case No.

:

II(a) Name of Head of Family and FR number

(b) Relationship

:

III(a) Occupation

:

(b) Place of work

:

IV(a) Present address

:

(b) Permanent address

:

(c) How long ha the patient resided in the area :

VDate of investigation by MI / EA

:

VILaboratory data -

:

(a) Date of B.S. Collection

:

(b) Blood smear number

:

(c) Date of B.S. Examination

:

(d) Date of receipt of result from Lab

:

(e) Result Species and Stage

:

VIICase History

:VIIIRemedial Measures-

(a) HSC Code No.

:

(b) Date of commencement and completion of RT :

(c) Was any presumptive treatment given

:

(d) If yes, No. of patients treated

:

(e) Was any MRT given with 8 AQ

:

(f) If yes, No. of patitents treated

: Contact :Date:

Mass:Date:

IXEpidemiological Classification-

(a) Imported or Other wise

:

(b) If imported, from where

:

XSpray particulars-

(a) Was the house in which the patient fell ill sprayed:

(b) Date of last spray and insecticide used

:

(c) Period lapsed between last spray

:

(d) Description of the house

:

(e) Has any painting or white washing of wall done :

(f) No. of houses available in the surroundings:

(g) Population

:

(h) No.of houses sprayed under focal spray

:

(i) Name and quantity of insecticide used

:

(j) Spray supervision by

:

Signature

Designation

NATIONAL ANTI MALARIA PROGRAMMECROSS NOTIFICATION OF MALARIA POSITIVE CASE

S.No.Particulars

1.Name of the Patient

:

2.Age / Sex

:

3a.Permanent address

:

3b.Date of Entry

:

3c.Date of Exit

:

4a.Temporary address

:

4b.Date of Entry

:

4c.Date of Exit

:

4d.Duration of stay

:

5.Date of Onset of Fever:

6a.Blood Smear Number

:

6c.Date of Blood Smear Collection :

7.Source

:

8.Species Stage and Density:

9. Period of R.T.

:From

To

10.Epidemiological classification:

Medical Officer

LINELISTING OF MALARIA POSITIVE CASEGovernment Primary Health Centre...........................................

Month and Year

District Code

Block / Municipality Code

PHC Code

HSE Code

Village Code

PC No./Referred PC No.

If Referred From whom

Source

Name of the Patient

Age

Sex

Name of the Father / Husband

Address

Date of onset of fever

Blood smear number

Date of B.S. Collection

Date of receipt of B.S. in lab

Date of examination

Species

Stage

Date of receipt of result

Period of RT

From ToFrom

To

If RT not given Reasons

No.of contact smears

Result

Confirmation BS date

Result

Epidemiological Classification

Imported Code

Cross notification sent date

Period of spray

From

To

From

To

Target rooms

% of coverage

Code of insecticide used

Quantity consumed

MedicalOfficer,Govt.Primary Health Centre.STANDARD CASE SHEET FOR ANALYSIS AND RECORD OF EPIDEMIOLOGICAL DATA ON POSITIVE CASES(Each case history must be entered separately)

Part I

Conclusion :1. Species

:

2. Epidemiological Classification

:

3. Remedial Measures

:

4. Under which procedure was the case detected:

5. Name and signature of the officer

:

(i) Initially investigated date

:

(II) Verified and analysed date

:

Part II

I. Location of the case :

1. State:

Tamil Nadu

District :

2. Taluk

:

3. Village / Town

:

(a) Door No. of house / FR number

:

(b) Sprayed

:

(c) Unsprayed

:

(d) Date of spray

:

4.(a) PHC :

4.(b) Block :

5. HSC code No. (if under Active)

:

6. Hospital/Dispensary/PHC/PP/Other agency:II. Basic Information :

1. Name of the Patient, Age, Sex

:

2. Approximate date & duration of onset of present fever:

3. BS No. and date of collection

:

4. Date of examination

:

5. Date of reporting of result

:

6. Date of investigation

:

III. Case History :

1. History of admission to hospital and

blood transfusion, if so date of transfusion :2. Present ILLness-

(a) Date of onset and duration of fever:

(b) Nature of fever

:

3. Past ILLness-

(a) History of previous illness(fever)

:

(b) Number of attack with interval

:

(c) Duration of each attack

:

(d) Nature of fever

:

(e) History of previous blood examination

if any, though active or passive agencies:

(f) History of medications if any,

through active or passive agencies :

4. Physical examination

(a) Enlargement of spleen if any size

:

(measurement as per Hacketts method)

(b) Any other relevant information

:

(If there is a history of blood transfusion and a correlation could be established between transfusion and attack, the cases is classified as induced, if not, see point no. 2 to 4 above)

If there is a definite history of pervious illness pointing to a possible attack of malaria (but prior to the last transmission season) and there were periodical bouts of fever the present illness could be due to a relapse. Enlargement of spleen will be a supportive evidence. If not relapse see item IV below.

IV. History of movement-

1. History of movement inside, outside the PHC area :

2. 10 days before the collection of smear

:

3. 10 days before onset of fever

:

(follow up backward for 3 weeks, also fill in chart- II)

4. In case of local inhabitant-

:

(a) Date of exit

:

(b) Date of entry

:

(c) In case of new comer date of entry

:

If movement outside the unit area and night halts could be established during the period indicate under item IV above or the date of entry of new comer to the area point out to a possible infection outside the unit area, the case may be classified as IMPORTED. Absence of Indigenous cases of origin in the locality will be a supporting evidence IF NOT IMPROTED, see item V below-V. Indigenous Cases-

1. All malaria cases are to be treated initially

as of indigenous origin unless proved other wise

:2. All cases which cannot be classified under induced, relapse

or imported are to be treated as of indigenous origin:3. All cases detected in non-transmission season and proved to have contracted the infection in the same unit area during the previous transmission season are to be treated as of indigenous origin.

:4.For all practical purpose, as induced (if subsequently proved)

is to be classified as of indigenous origin, the classification

of induced cases will assume importance in the third year of

the consolidation phase prior to entry into the maintenance

Phase

:

VI. Other investigations and remedial measures

1. Radical treatment of the positive cases, date of commencement

and the number of days treatment given by Health Inspector:

2. Result of monthly follow up of the cases treated for 12 months:

Follow up SmearDate of CollectionREsultFollow up SmearDate of CollectionResult

IVII

IIVIII

IIIIX

IVX

VXI

VIXII

3. If contact smear taken, No. and result

:4. Mass Survey

:

No. of Mass SurveyDate of SurveyNo. of blood smear collectedResult

5. Action taken, if any found positive

:6. Focal spray

:

7. No. of houses sprayed

:

8. Time lag between detection of case / cases and

insecticide application

:

9. If classified relapse

:

10. Whether previous records available

:

11. Date of completion of RT

:

12. If imported, whether notified (date)

:

CHART - I

Month / SeasonNo. of attacks of fever in months or seasonDate of onset of present feverDate of blood smear collection

Past illnessPresent illness

Bouts of fever may be depicted in the chart as

1. Details of present illness

:

2. Details of past illness

:

3. Clinical examination

:

CHART -II

For recording the movement of patient outside PHC area / also for entries of new comers to the PHC area3 Weeks2 Weeks1 Week10 DaysDate of onset of present feverDate of blood smear collection

Details of movement and places visited with dates

:

Signature

Designation