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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 234-237

Water borne epidemic of gastroenteritis in Ghallour sub-centre of Jawalamukhi block, Kangra District, Himachal Pradesh, India


1 Department of Health and Family Welfare, Government of Himachal Pradesh, Kangra, Himachal Pradesh, India
2 Department of Health and Family Welfare, Freelance Researcher in Epidemiology and Ayurveda, Kangra, Himachal Pradesh, India
3 Freelance Researcher in Infectious Diseases and Food Technology, Kangra, Himachal Pradesh, India

Date of Web Publication12-Jun-2015

Correspondence Address:
Dr. Surender Nikhil Gupta
Department of Health and Family Welfare, Government of Himachal Pradesh, Chief Medical Officer Office, Kangra at Dharamshala, Himachal Pradesh
India
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Source of Support: A book of Mackie and McCartney Practical Medical Microbiology, 14th edition, page no.883-921, Conflict of Interest: None


DOI: 10.4103/2348-3334.158692

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  Abstract 

Background: On August 31, 2014, eighty cases of the gastroenteritis were reported in Ghallour sub-center area. We investigated the outbreak to identify the source, propose control, and preventive measures. Materials and Methods: We defined a case as occurrence of three or more watery stools with or without vomiting, w.e.f January 27, till February 2, 2014 in residents of Ghallour sub-center area of Jawalamukhi block. We hypothesized it as a water borne outbreak. We determined age and sex specific attack rate. We collected information about personal history on age, sex, residence, and date of onset of symptom from case patient and established line list. We collected nine stool samples/rectal swabs from the cases; three pre and four post chlorination water samples and sent them for microbiological testing. We mapped water supply pipelines of the area and reviewed the water chlorination record. Results: We identified 390 cases in 16 villages under the sub center. The overall attack rate was 8% with a range of 1.3% to 36%. The cases patients were reported from all age groups and both the genders with the youngest student; 1-year old to the oldest one as 88 years. Two-third of the cases reported vomiting with some complaining of pain abdomen. Villages like Jathman, Khattni, Rajol Patta, Kohara has 100% case patients of loose motions while villages like Dhroli, (100%), Sasan (63%) and Ghallour (50%), etc., have combined symptoms of loose motions and vomiting. No fatality was reported. Escherichia coli was detected in the samples from water samples. Records of chlorination were not properly maintained. Conclusion / Recommendation: The outbreak was associated due to contamination of water at the source in Jolly Khad. Regular treatment of the water needs to be done right at the source before being lifted.

Keywords: Coliform bacteria, epidemic, Kangra, public health issue, watery diarrhea


How to cite this article:
Gupta SN, Gupta N, Gupta S. Water borne epidemic of gastroenteritis in Ghallour sub-centre of Jawalamukhi block, Kangra District, Himachal Pradesh, India. CHRISMED J Health Res 2015;2:234-7

How to cite this URL:
Gupta SN, Gupta N, Gupta S. Water borne epidemic of gastroenteritis in Ghallour sub-centre of Jawalamukhi block, Kangra District, Himachal Pradesh, India. CHRISMED J Health Res [serial online] 2015 [cited 2019 Jun 18];2:234-7. Available from: http://www.cjhr.org/text.asp?2015/2/3/234/158692


  Introduction Top


In India, diarrheal diseases are not only a major public health problem not only among children under the age of five but also in adults in the lower belt of Himachal Pradesh, including, Hamirpur, Una, and especially Kangra where heavy rain falls are seen every year. Since diarrheal diseases are caused by 20-25 pathogens, vaccination, though an attractive disease prevention strategy, is not feasible. However, as the majority of diarrheas are caused by Vibrio cholerae, Shigellae dysenteriae Type 1 and Enterotoxigenic  Escherichia More Details coli which have high morbidity and mortality [1] . In Himachal Pradesh, the burden of infectious diseases continues to be high (respiratory diseases-23.5%; diarrheal diseases-14.5% and road traffic accidents at curves-10.5%). In Kangra, the frequent uninvestigated outbreaks of gastroenteritis in summer were 11 in number [2] in 2007. The watery diarrheal outbreak investigation of gastroenteritis in Ghallour sub-center provided us with an excellent opportunity to investigate the case patients with the youngest subject as old as 1-year old to the oldest one as 88 years; with the total of 390 cases in 16 villages under the sub-center.

We investigated the outbreak with the following objectives: (1) Confirming the existence of the outbreak, (2) identifying the source and mode of transmission, and (3) initiating control and preventive measures.


  Materials and Methods Top


On January 31, 2014, a news article reported an outbreak of gastro-enteritis in Ghallour Sub-Center area, Jawalamukhi block, district Kangra followed by a female health worker, in-charge health center Ghallour under Jawalamukhi block of district Kangra-Himachal Pradesh informed telephonically to health supervisor on dated 30/01/2014 at 9:45 am about 100-125 case patients with loose motions and vomiting. A firsthand information report was lodged to block health authorities, and an investigation was initiated on February 1, 2014. This epidemic covered the sixteen villages within a radius of 10 km from block headquarter-Jawalamukhi. This block is on the national highway, approximately 40 km southwards from Kangra. Affected villages and distance from block head quarter have been labeled as follows:

Descriptive epidemiology

We defined a case as the occurrence of three or more watery stools with or without vomiting, w.e.f 27 January, to February 2, 2014 in residents of Ghallour sub-center area of Jawalamukhi block, Kangra. We defined the probable case-patients as the case patients reporting with watery diarrhea and the confirmed case-patient as the suspected case-patient in whom laboratory investigation confirms the presence of one or more water borne pathogens in a clinical specimen case search was made by door to door search having obtained informed consent from the case patients for this study. We collected information about personal history on age, sex, residence, and date of onset of symptom from case patient and established line list.

Laboratory investigations

We collected nine stool samples/rectal swabs from the cases; three pre and four post chlorination water samples from affected houses under sterile conditions and sent them for microbiological testing to Doctor Rajinder Prasad Government Medical College, Kangra at Tanda under cold chain.

Environmental survey

We mapped water supply pipelines of the area and reviewed the water chlorination record. The epidemic curve was constituted so as to chart out the development of the outbreak over time. Spot map and area map were charted out [Spot Map i and ii]. We conducted an un-matched case-control study to test the hypothesis that the outbreak occurred due to contamination of the public distribution system (irrigation and public health department water). Data analysis was done by calculating attack rates by age and sex using a population of the sub-center area. We entered and analyzed the data using a Microsoft Excel spreadsheet and epi info, version 3.3.2. However, this investigation was conducted in the context of a public health response to an outbreak and therefore an ethical committee review was not indicated.






  Results and Discussion Top


From our study, we identified 390 cases from the area of sub-center Ghallour of Jawalamukhi block. The overall attack rate was 8% with a range of 1.3% to 36% [Table 1] and [Table 2]. Cases were reported from all age groups and both genders with the youngest subject; 1-year old to the oldest one as 88 years. Index male case of 47 years suffered an attack of loose motions and painful abdomen in first village Sasan and thereafter spread to the neighboring villages such as Bhana, Dhroli, Dodan, Gahllian, Ghallour, Jathman and so on.[Spot Maps i and ii] Two-thirds of the cases reported vomiting with some complaining of pain abdomen. Villages like Jathman, Khattni, Rajol Patta, Kohara has 100% case patients of loose motions while villages like Dhroli, (100%), Sasan (63%) and Ghallour (50%) etc., have more of the case patients suffering from combined symptoms of loose motions and 10% of the cases with bloody motions and vomiting [Figure 1]. The health teams from district and block level hospitals provided treatment and health education in all the areas. Four cases were admitted in health institutions. There were no deaths. 57 cases reported symptoms on January 29 which peaked with 311 cases on January 30 and after that the number cases came down rapidly. There was the generation of the single peak that indicated a point source epidemic. The peak tapered off suddenly as the January 31, 2014 to February 2, 2014, and there was no case reported after that after free two incubation period [[Figure 2]-epi curve].
Figure 1: Symptomology of diarrheal cases under sub center Ghallour, Jawalamukhi Block, Kangra District, Himachal Pradesh, India, 2014

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Figure 2: Distribution of diarrheal cases by date of onset, Ghallour of Jawalamukhi Block, Kangra District, Himachal Pradesh, 2014

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Table 1: Attack rate of gastroenteritis cases in affected 16 villages under sub center Ghallour, Jawalamukhi Block, Kangra District, Himachal Pradesh, India, 2014


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Table 2: Attack rate of gastroenteritis cases by age and gender, sub center Ghallour, Jawalamukhi Block, Kangra District, Himachal Pradesh, India, 2014


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The whole area received water from a source in "Jolly Khud". At the source, the water is collected from a tube well and a dug well. It is lifted to the area of sub-center Ghallour without treatment and subsequently chlorinated in the tanks further down the line. The dug well is located on the bank of a stream where people frequently defecate in the open field. The water sample collected prechlorination was found to have recent heavy contamination with up to 1600 colonies of E. coli per 100 ml of water [Table 3]. Records of chlorination were not properly maintained. The distribution of cases over time suggested a common source outbreak. Our bacteriological investigations led to the identification of one pathogen. E. coli which were a generic isolation in the absence of characterization of the strain involved (EPEC, ETEC serotype O157 H7). Serotype O157 H7 is usually found in multiple food outbreaks but this E. Coli also survives in water and several outbreaks have been linked to contaminated water used for different purposes such as swimming in contaminated lakes, drinking contaminated water. Experience from the outbreaks underscores the necessity of using sensitive laboratory isolation methods, such as those used in these outbreaks, for detecting E. coli O157:H7 from livestock feces and agricultural environmental samples. [3],[4] In the present outbreak, water was lifted from khud water that was contaminated with fecal matter. People defecated in the morning near the khud banks. This untreated water was used for drinking purpose during those days of the outbreak. It is further discussed that further testing could not be carried out at the local medical college microbiology laboratory because the frozen stools, swabs, or isolates were not stored, and the facilities were not available. That was the limitation of the study. Results of rectal and stool samples could not be procured as they were destroyed during their transportation to the microbiology.
Table 3: McCredie's tables for examination of water, milk, food and air


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The analytical study indicated that the odds of developing the illness were 13 times higher among individuals drinking water from public distribution supply water as compared with those consuming water from other sources. Local authorities chlorinated all water tanks in the area, following which the number of cases abruptly declined.


  Conclusions Top


The outbreak was caused due to contamination of water at the source in Jolly Khud by E. coli.


  Recommendations Top


Regular treatment of the water needs to be done right at the source before being lifted.


  Measures taken Top


The water tanks were cleaned, and water chlorinated. Health teams were formed to institute treatment and impart health education. Active and passive surveillance was stepped up.


  Acknowledgements Top


We gratefully acknowledge the cooperation we received in the investigation of this outbreak from the patients and their families and numerous individuals in Jawalamukhi Block Kangra); Health Department, Kangra at Dharamshala, and laboratory support from Microbiology Department, Dr. Rajinder Prasad Govt. Medical College, Kangra-Himachal Pradesh.

 
  References Top

1.
Gupta SN, Gupta N. Outbreak of gastroenteritis in tibetan transit school, dharamshala, himachal pradesh, India, 2006. Indian J Community Med 2009;34:97-101.  Back to cited text no. 1
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2.
Gupta SN, Naveen G, Shivani G. Evaluation of diarrheal diseases surveillance system of district Kangra, Himachal Pradesh, India, 2007. J Res Med Educ Ethics 2013;3:40-51.  Back to cited text no. 2
    
3.
Durso LM, Reynolds K, Bauer N, Keen JE. Shiga-toxigenic Escherichia coli O157:H7 infections among livestock exhibitors and visitors at a Texas County Fair. Vector Borne Zoonotic Dis 2005;5:193-201.  Back to cited text no. 3
    
4.
Varma JK, Greene KD, Reller ME, DeLong SM, Trottier J, Nowicki SF, et al. An outbreak of Escherichia coli O157 infection following exposure to a contaminated building. JAMA 2003;290:2709-12.  Back to cited text no. 4
    


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  [Table 1], [Table 2], [Table 3]



 

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