Download - PreliminaryReport On Acute Gastro-Intestinal Illness

Preliminary Report Acute Gastrointestinal Illness (outbreak)

Deptsang _____________________________________________________________________________

Tashi Pheljay1, Kencho Chopel,2 Tshering Jamtsho,3 and Tenzin4

1. LPS Lauri Geog, 2. Gup of Serthig, 3. HA Mingjiwong BHU and ADHO

____________________________________________________________________________

Contents

Back Ground ................................................................................................................................... 1

Objectives ....................................................................................................................................... 3

Methodology ................................................................................................................................... 3

a. Descriptive study ......................................................................................................................... 3

b. Laboratory study ......................................................................................................................... 3

c. Environmental Assessment ......................................................................................................... 4

d. Environmental Intervention ........................................................................................................ 4

d. Data analysis ............................................................................................................................... 4

e. Result........................................................................................................................................... 4

1. Graph showing the No. of cases reported at Jomotsangkha BHU and their onset of Illness ...... 5

Conclusion ...................................................................................................................................... 8

Acknowledgement .......................................................................................................................... 9

Reference ........................................................................................................................................ 9

Preliminary Report Gastrointestinal Illness (Outbreak) ____________________________________________________________________________________

Page 1 of 11

Back Ground

Deptsang village, under Serthig Gewog is situated at an altitude of 1298 meters from the sea

level, which is approximately 15 Km drive from Gewog Centre and 38 Km from Jomotsangkha

Dungkhag. The Lauri Gewog Centre (GC) Road bypasses this village and has 33 Household

(HH) with 99 total populations, out of that 53 were male and 46 were female (AHH survey,

2016).

Communities are busy

especially at this time of the

season not only for farming

activities, but also for their

labor contribution in

constructing community

Temple (Lhakhang) fig.1.

During the investigation, we

found that 79% of the

household were engaged in this construction and it represents 73% who consumed the carcasses

meat; the source of outbreak and 63 % of them were victims.

On 26 May 2016, the teams comprising the Gup of Serthig Gewog, Live Stock officer of Lauri

Gewog, Health Assistant of Mingjiwong BHU and the Dungkhag health sector have visited the

site to do comprehensive investigation. The investigation has extended to the place of carcass in

the forest above one and half

hours uphill walk. During this

investigation, the team did

not suspect the death as a

case of Anthrax as there were

other animals that mingles

around, but till date no such

dead was reported anywhere

in the locality nor any

symptom were reported. Moreover, the team has observed huge plastic sack (potato packing

Fig.(1). Temple under construction

Fig.(2). Collecting Information


Page 2 of 11

sack) with the remaining of stomach contains (waste product) which indicates that the cow might

be sick due to this in the stomach causing her to sudden death (Figure.3). On further assessment,

the team has found a trace of bear feaces, who supposedly has chomp through the carcass and

left out. No one is sure for the carcass being left there, even our team failed to ascertain the

number of days passed by, but the meat really has unpleasantly smelling even at 500 meters.

It was only on May 21, 2016

(Saturday), the owner of the cow

has claimed not only dead, but

also found devoured from anal

part into the internal organs

including the reproductive

system. It was the only cow for

the owners and he did not think

of anything else, rather than to

take the remaining carcass at

home for consumption. As

though and planned, He (owner)

once again spotted to the site next day (Sunday), with few of his neighbor to carried out the

leftover carcass towards the temple for consumption during the ongoing construction and rest

were divided amongst themselves for home consumption.

As above, they had prepared meat for lunch at the temple construction on 22/05/16 (Sunday),

were 28 of them has had it and 36 of them had at their home during their dinner. As a result, 33

of them have developed symptoms and were ambulated to Jomotshangkha BHU-I, all were with

similar symptom of Nausea/vomiting, Headache, Fever, Abdominal discomfort/Cramps and

some with dehydration status. However, other 30 people who consumed the carcass meat did not

illustrate any symptoms and our finding from this investigation reveals that the meat was prepare

after thoroughly washing and properly cooked.

The Outbreak Control Team (OCT) with fore mention member have then carried out the

comprehensive investigation with effect from May 26, 2016.

Fig.(3). Waste product of cow with presence of plastic sack

Red & blue color plastic sack


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Objectives 1. To determine the etiological agent causing the Outbreak

2. To indentify the risk group

3. To identify the source of outbreak

4. To establish the control and preventive Measure

Methodology

a. Descriptive study

It was a veiled case control studies and defined the cases as, “any person, at any age, who

engaged in handling, or consumed meat at the temple, either at home, or exposed to the carcass

meat, Who later developed Nausea/vomiting, Headache, Fever, Abdominal discomfort and

Abdominal Cramps.” Control was any person within the locality who did not eat or consumed

the meat at temple, nor at home.

Trough this Dungkhag Administration, the team informed all the community of Deptsang village

to gathered at Temple and obtained their name list, personal contact history and meal history

(Fig. 2). Assessed for further active cases in the community or looked for any new cases. No new

cases were reported and those who were ambulated the day before to the BHU –I were also being

discharge with appropriate treatment and advised by the clinician. The three standard

epidemiological parameter of outbreak (People, Place and Time) is used for determine causal

relationship.

b. Laboratory study Stool sample from the active cases were collected for laboratory examination at Jomotsangkha

BHU and the same stool sample were send to Public Health Laboratory, Sarbithang for further

confirmation of result after CS examination.


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c. Environmental Assessment

On visiting the site on 26/05/16, the OCT has first assessed the Temple kitchen and found

cleaned. The tap stands, is within the vicinity of the kitchen and has continuous water supply.

They use firewood while preparing the meal for the labor, but no evidence of contaminations

observed. Although they did not have designated person as cook, but one who delegated as cook

by the community is healthy prior to this occurrence. We are also privilege to trip to respective

household, all the same did not observed any contributing factor in this episode, rather than from

the carcass meat that was flood almost in every household (26/33 HH) in the village.

d. Environmental Intervention In order to prevent from new

occurrences, we made to collects all

the remaining meat from every

household who had been stored as

dry meat (Shakams). Approximately

20 -25kg of carcass meat (Recall

product or seize product) burnt in

the open pit and then buried. The

containers and baskets were disinfected with Potassium permanganate solution (1ml: 1000ml)

and still were unpleasant smelling. The waste product at the site also collected, burnt, and then

disinfected with chlorine solution. Health education regarding the food safety and hygiene had

also communicated to the communities. They were repeatedly reinstated the important of

refraining from consuming such carcass meat of any kind in future.

d. Data analysis The collected data were analyzed, using the Microsoft excel and statistics we used were

frequency, Mean, Median, , Percentage, Rate, Odd ratio and relative risk.

e. Result Out of 99 total populations at Deptsang village, 33 people reported to have developed symptom

after ingestion of carcass meat on 22/5/16. Among them 64 % of the cases were male dominance

Fig.(4). Dry meat stored at home


Page 5 of 11

and rest 36% were female representative. It has grossly extend to the entire household 79%

(26/33 HH) and majorities were among the age bracket of 21 years to 50 years (51%) male and

(30%) female. Mean duration of illness was 2 + 0.1 SD. and overall attack rate due to

consumption of meat was 60% (30/50) all met our case definition.

According to CDC-EIS, (2003): Compendium of Acute food borne and Waterborne Diseases;

this typical outbreak met the food characteristic of the disease causing agent Escherichia coli,

which can cause Gastroenteritis. The clinical syndrome and incubation period is also very likely

of this (Deptsang) outbreak. However, we could not confine to probable causes of this outbreak,

due to lack of laboratory, facilities and expertise at this BHU, but this part will be confirmed

later from the PHL as have already been send the samples.

Nevertheless, the basic laboratory test from this BHU, have reported to have Entamoeba

Histolytica in 5 of the sample (71%) out of 7 samples tested. Ancyclostoma duodenale and

tapeworm eggs were other etiological agent found in the samples collected from those admitted

in the wards on 25/5/16. Entamoeba Histolytica is etiological agent of Protozoa causes

Amoebiasis (Amoebic dysentry), with similar symptoms of Deptsang outbreak, and is one of the

features of food borne disease causing Gastrointestinal Illness outbreaks in the communities

(WHO, 2008).

For that reason, the OCT discloses this outbreak as gastrointestinal illness due to presence of

Entamoeba Histolytica in the stool examination.

1. No. of cases reported at Jomotsangkha BHU and their onset of Illness


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2. Clinical manifestation of Acute Gastrointestinal illness in Percentage (%)

Table 1. (a). No. of People who had carcass meat at Temple only

Incidence of Exposure (Ie) to meat = a = 21 = 0. 9 (a+b) = 23 Incidence of unexposure (Iu) to meat = c = 5 = 0. 2 (c+d) = 26 Therefore, Relative Risk (RR) of ILL due to meat consumption is- Ie = 0.9 = 4.5 Iu = 0.2

31

22

13 11 9 4 2 2 2

0

5

10

15

20

25

30

35

Perc

enta

ge (%

)

Clinical Presentation

Clinical Minifestation of Acute Gastrointestinal Illness among the cases reported to BHU


Page 7 of 11

Table. 1. (b) No of People who had carcass meat at Home

Incidence of Exposure (Ie) to meat= a = 9 = 0. 3 (a+b) = 27 Incidence of unexposed (Iu) to meat== c = 1 = 0. 02 (c+d) = 36 Therefore, Relative Risk (RR) of ILL due to meat consumption is- Ie = 0.3 = 15 Iu = 0.02 Those people who ate meat at the temple are 4.5 times higher at risk of getting ILL than those who did not ate meat at the temple. Similarly, People who consumed meat at home are 15 times at higher risk of getting the Illness, than those who did not take meat. This clearly illustrates that the carcass meat was the only source of this outbreak. Table. 1. (c) Total No. of who consumed carcass meat (Temple & Home)

Incidence of Exposure (Ie) to meat= a = 30 = 0. 6 (a+b) = 50 Incidence of unexposed (Iu) to meat== c = 6 = 0. 4 (c+d) = 14 Therefore, Relative Risk (RR) of Illness due to meat consumption is- Ie = 0.6 = 1.5 Iu = 0.4

Those who ate meat during the meal are 1.5 times higher at risk of acquiring this ILL than those who have not taken the meat. Meat found to be the attributing factor (20%) in this outbreak, with additional attributable fraction of 33.3%, indicating that the incidence of this illness would have reduced by 33.3% if meats were not served.


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Table 2. Two-by two tables for consumption of meat (Case Control)

Those who have not eaten meat neither at the temple, or at home were considered as control groups and those who have taken meats were considered as cases irrespective of their place of meal.

Odd ratio (OR) = (30x8) = 3.5 (23x3) Therefore, the odd ratio of 3.5 for the food (meat) can be interpreted as: the odds of having been exposed

to the contaminated food (meat) in those who developed the illness was 3.5 times that of people who did

not ate meat. This odds ratio means that there is strong association between being the case and

consumption of meat.

Conclusion

The communities of Deptsang village had suffered with gastrointestinal illness after consuming

the carcass meat of their neighbor. Out of 99 total populations, 33 of them had been reported

with similar syndrome and 15 were admitted. One among them was referred to CRRH, Gelephu

and rest were discharge the following day and no new cases were observed thereafter.

The stool examination at the Jomotsangkha BHU reveals the presence of Entamoeba Histolytica

that can cause gastrointestinal illness and outbreak. Carcass meat significantly found to be the

point source of this outbreak and the recall products burnt, then buried after disinfecting with

chlorine solution. Food safety handling and sanitation awareness were given to the gathering

during the outbreak investigation at Deptsang.


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Acknowledgement

The team would like to sincerely, thank Dasho Dungpa, Dungkhag administration Jomotsangkha

for support and rendering us the pool vehicle, without which this investigations would not

completed on time. The credit also goes to the People of Deptsang and Geog administration for

their crucial supports provided during the investigation.

Lastly but not the least, we express our gratitude to Dzongkhag Health Office Samdrup

Jongkhar, the GDMO and all staff who involved during this Outbreak for continue support,

which is indispensable part of an outbreak investigation and control measure.

Reference

1. CDC, (2003), Oswego- An outbreak of Gastrointestinal Illness following a Church Super; U.S

Department of Health and Human Services: Public Health Services.

2. WHO, (2008), Food borne Disease Outbreaks; Guidelines for investigation and Control;

World Health Organization,France.

Download - PreliminaryReport On Acute Gastro-Intestinal Illness

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