Addressing Reemergence of Diphtheria among Adolescents through Program Integration in India

We report a diphtheria outbreak mostly among children (median 12 years; range 4–26 years) of a religious minority in urban India. Case-fatality rate (15%, 19/124) was higher among unimmunized patients (relative risk 4.1, 95% CI 1.5–11.7). We recommend mandating and integrating immunization into school health programs to prevent reemergence.

An outbreak of acute skin and soft tissue infections including necrotizing fasciitis in Kalwala village, India, 2018: Public health implications for the lymphatic filariasis elimination program

BACKGROUND

A cluster of 15 acute skin and soft tissue infections (SSTIs), including two cases of necrotizing fasciitis, reported in July 2018 from Kalwala village, led us to investigate and describe their epidemiology and to provide recommendations.

METHODS

Cases, defined as localized painful swelling and redness in Kalwala residents from 1 December 2017 to 20 August 2018, were identified from hospital records and house-to-house surveys. We conducted an unmatched case-control study to identify risk factors for severity. We cultured wound samples and environmental samples from wound-dressing stations.

RESULTS

We identified 36 cases (median age: 55 [range 17-80] y; 78% male), village attack rate 1% (36/4337) and no deaths. In 34 cases (94%), lower limbs were involved. Lymphatic filariasis (LF) was a common predisposing condition (67%). Comorbidities (diabetes or hypertension) (OR=9; 95% CI 2.0 to 41.1), poor limb hygiene (OR=16; 95% CI 2.8 to 95.3) and poor health-seeking behavior (OR=5; 95% CI 1.6 to 30.8) were associated with severity. All seven wound samples and 8/11 samples from wound-dressing stations showed atypical polymicrobial growth (Pseudomonas, Proteus, Klebsiella, Escherichia coli and Clostridium).

CONCLUSION

The outbreak of SSTIs among older males with LF was due to secondary bacterial infections and severity was associated with comorbidities, poor hygiene and health-seeking behavior, and likely contamination during wound-dressing. The LF elimination program managers was alerted, programmatic interventions were scaled up, home/facility-based morbidity and comorbidity management was facilitated and the outbreak was rapidly contained.

Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience

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At Kumbh Mela 2019, disease surveillance was established for 22 acute diseases and syndromes.

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Among the reported illnesses, 95% were communicable diseases such as acute respiratory illness (35%), acute fever (28%), and skin infections (18%).

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The incident command centre generated 12 early warning signals from indicator-based and event-based surveillance: acute diarrheal diseases (n = 8, 66%), vector-borne diseases (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%).

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There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

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Implementation of disease surveillance facilitated early outbreak detection and response.

Background

Mass gathering (MG) events are associated with public health risks. During the period January 14 to March 4, 2019, Kumbh Mela in Prayagraj, India was attended by an estimated 120 million visitors. An onsite disease surveillance was established to identify and respond to disease outbreaks.

Methods

A health coordination committee was established for planning. Disease surveillance was prioritized and risk assessment was done to identify diseases/conditions based on epidemic potential, severity of illness, and reporting requirement under the International Health Regulations (IHR) of 2005. A daily indicator and event-based disease surveillance was planned. The indicator-based surveillance (IBS) manually and electronically recorded data from patient hospital visits and collected MG area water testing data to assess trends. The event-based surveillance (EBS) helped identify outbreak signals based on pre-identified event triggers from the media, private health facilities, and the food safety department. Epidemic intelligence was used to analyse the data and events to detect signals, verify alerts, and initiate the response.

Results

At Kumbh Mela, disease surveillance was established for 22 acute diseases/syndromes. Sixty-five health facilities reported 156 154 illnesses (21% of a total 738 526 hospital encounters). Among the reported illnesses, 95% (n = 148 834) were communicable diseases such as acute respiratory illness (n = 52 504, 5%), acute fever (n = 41 957, 28%), and skin infections (n = 27 094, 18%). The remaining 5% (n = 7300) were non-communicable diseases (injuries n = 6601, 90%; hypothermia n = 224, 3%; burns n = 210, 3%). Water samples tested inadequate for residual chlorine in 20% of samples (102/521). The incident command centre generated 12 early warning signals from IBS and EBS: acute diarrheal disease (n = 8, 66%), vector-borne disease (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled.

Conclusions

This onsite disease surveillance imparted a public health legacy by successfully implementing an epidemic intelligence enabled system for early disease detection and response to monitor public health risks. Acute respiratory illnesses emerged as a leading cause of morbidity among visitors. Future MG events should include disease surveillance as part of planning and augment capacity for acute respiratory illness diagnosis and management.

A community-wide acute diarrheal disease outbreak associated with drinking contaminated water from shallow bore-wells in a tribal village, India, 2017

Background

In 2016, India reported 709 acute diarrheal disease (ADD) outbreaks (> 25% of all outbreaks). Tribal populations are at higher risk with 27% not having accessibility to safe drinking water and 75% households not having toilets. On June 26, 2017 Pedda-Gujjul-Thanda, a tribal village reported an acute diarrheal disease (ADD) outbreak. We investigated to describe the epidemiology, identify risk factors, and provide evidence-based recommendations.

Methods

We defined a case as ≥3 loose stools within 24 h in Pedda-Gujjul-Thanda residents from June 24–30, 2017. We identified cases by reviewing hospital records and house-to-house survey. We conducted a retrospective cohort study and collected stool samples for culture. We assessed drinking water supply and sanitation practices and tested water samples for faecal-contamination.

Results

We identified 191 cases (65% females) with median age 36 years (range 4–80 years) and no deaths. The attack-rate (AR) was 37% (191/512). Downhill colonies (located on slope of hilly terrains of the village) reported higher ARs (56%[136/243], p < 0.001) than others (20%[55/269]). Symptoms included diarrhea (100%), fever (17%), vomiting (16%) and abdominal pain (13%). Drinking water from five shallow bore-wells located in downhill colonies was significantly associated with illness (RR = 4.6, 95%CI = 3.4–6.1 and population attributable fraction 61%). In multi-variate analysis, drinking water from the shallow bore-wells located in downhill colonies (aOR = 7.9, [95% CI =4.7–13.2]), illiteracy (aOR =6, [95% CI = 3.6–10.1]), good hand-washing practice (aOR = 0.4, [95%CI = 0.2–0.7]) and household water treatment (aOR = 0.3, [95%CI = 0.2–0.5]) were significantly associated with illness. Two stool cultures were negative for Vibrio cholerae. Heavy rainfall was reported from June 22–24. Five of six water samples collected from shallow bore-wells located in downhill colonies were positive for faecal contamination.

Conclusion

An ADD outbreak with high attack rate in a remote tribal village was associated with drinking water from shallow downhill bore-wells, likely contaminated via runoff from open defecation areas after heavy rains. Based on our recommendations, immediate public health actions including repair of leakages at contaminated water sources and alternative supply of purified canned drinking water to families, and as long-term public health measures construction of house-hold latrines and piped-water supply initiated.