criticize Verification of the diagnosis and confirmation of the outbreak 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 diagnoses.

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

criticize Steps of the outbreak investigation 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. Verification of the diagnosis and confirmation of the outbreak 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 diagnoses. 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 facilitat

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.

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

critically appraise the article, Yellow Fever Outbreak in Darfur, Sudan in October 2012; the Initial Outbreak Investigation Report using the steps of outbreak report