what is the strength of this paper Because the serum samples that the National Public Health Laboratory (NPHL) received were not tested until the departure of the team, the team revised the symptomatology and clinical presentations of the reported cases from the clinic registers (Nertiti rural hospital and Nyala). We have interviewed the health care providers who attended the reported patients (medical assistants, nurses and medical doctors) in each hospital. According to the documented descriptions, the investigation team suggested the following deferential diagnoses: • Crimean Congo Hemorrhagic Fever CCHF; • Rift Valley Fever RVF; • Yellow Fever YF; • Complicated Malaria; • Dengue, Zika virus infection and other VHFs; • Viral Hepatitis disease, particularly Hepatitis A (HAV), Hepatitis B (HBV), Hepatitis C (HCV) and Hepatitis E (HEV). We ranked these differential diagnoses because the majority of cases were reporting fever and bleeding. In addition, the area had just experienced a very heavy rainy season. Most of the community members are farmers and animal pastoralists and have close, direct contact with their animals. Due to the fact that few patients were reporting jaundice, we ranked CCHF and RVF first. We ranked YF third because few patients had reported jaundice. However, we considered the sylvatic cycle of YF transmission because the area that had reported the index cases is very close to the jungle. Wild monkeys inhabit the jungle, and people usually go there with their animals for rearing. The team conducted field entomological studies, collected additional blood samples and shipped them to the NPHL in Khartoum for confirmation and demarcating out between the possible diagnosis

What admit patient with fever, what information cannot help to identify the source of infection? Recent traveling history Recent hospitalization history Recent dietary intake history Recent medication history

criticize the paper Summary Introduction: Sudan is subject to repeated outbreaks, including Viral Hemorrhagic Fever (VHF), is considered to be a very serious illness. Yellow Fever (YF) outbreaks in Sudan have been reported from the 1940s through 2005. In 2012, a new outbreak of YF occurred in the Darfur region. Objective: To identify the potential for an outbreak, to diagnose the disease, and to be able to recognize its cause among the initial reported cases. Methodology: >This is a descriptive and investigative field study that applies standard communicable disease outbreak investigation steps. The study involved clinical, serological, entomological and environmental surveys. Results: The field investigation confirmed the outbreak and identified its cause to be YF. Conclusion: National surveillance systems should be strong enough to detect VHFs in a timely manner. Local health facilities should be prepared to promptly treat the initial cases because the case fatality ratios (CFRs) are usually very high among the index cases.

find the strength of this paper Hypothesis generation Before laboratory confirmation of the collected blood samples, the investigators generated three hypotheses based on the available descriptions for the reported cases and the surrounding environment, in addition to information from previous outbreaks. Figure 2 (a) Because the majority of the cases were young adults, most cases presented with fever and massive bleeding, and most patients were involved with animal rearing activities. When combined with the high case fatality rate, we assumed that these events could be explained by an outbreak of CCHF or RVF. (b) The majority of the cases were young adults and were involved in animal rearing. Additionally, the index cases reported were from the Khour Ramla and Fukodoko areas, which are very close to the forest, which is inhabited by wild monkeys. Young men will often take their animals into the forest. We assume that this behavior could explain an outbreak of sylvatic cycle transmission Yellow Fever. (c) The area is endemic to malaria. Additionally, the preliminary results indicated that a vast majority of the cases were Malaria ICT-positive and had a history of taking anti-malarial medications. Considering the natural history of the disease, we thought that this case might be an outbreak of complicated malaria

find the strength and weakness of this paper Case definition When the team reached the field, we made a very broad case definition as a method to include as many diseased cases as possible for blood sample collection for testing and confirmation. Our field case definition was any patient who developed a sudden high-grade fever ≥38 ◦C with or without bleeding, jaundice, vomiting or prostration after October 1. We used this case definition to guide our hospital visits, to facilitate active household case searching and to assist with clinical records revision.

criticize Preparation to investigate Immediately after the construction of the investigation team, the team conducted a brief meeting and distributed the responsibilities and the field tasks between them. The head of the investigation team opened the contact channels with the Central and South Darfur states and shared the main objectives of the mission. The head of the team also secured the required field tools and commitments. The team members conducted a thorough literature review of the basic concepts of hemorrhagic fevers, their epidemiology, transmission and ways to investigate the outbreak. The team revised all records of similar problems reported to the FMOH during the last several years, particularly from areas with similar geography and demographics.