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India EIS
ESCAIDE 2015, Stockholm, Sweden11th – 13th Nov 2015
Outbreak Investigation of Anthrax, Simdega, Jharkhand, India - 2014
Dr Priyakanta NayakEpidemic Intelligence Service (EIS) Officer
India EIS Programme National Centre for Disease Control, Delhi, India
E Mail ID: [email protected]
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India EIS
BACKGROUND
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India EIS
Zoonotic disease caused by Bacillus anthracis, an aerobic, gram-positive bacillus.
Humans infected only incidentally through contact with diseased animals
Cutaneous form accounts for 95% of anthrax worldwide Case fatality <1% if treated properly and can go up to 20 %
without treatment. Commonly affects people of lower socio economic status/tribal
community
Anthrax
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India EIS
Anthrax in India Limited documentation of Anthrax outbreaks from India 14th October 2014: a school teacher in Tungritoli hamlet of
Kuruchdega village, Simdega district, Jharkhand reported 5 deaths 15th October 2014: Investigation by District Rapid Response Team
(RRT) 18th – 19th October 2014: Active surveillance by state RRT 26th October 2014: Two EIS officers deployed to investigate the
outbreak
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India EIS
Objectives To study the epidemiological characteristics of the outbreak
To determine potential risk factors associated with the outbreak
To propose recommendations for prevention and control of the outbreak
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India EIS
METHODS
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India EIS
Case Definition Probable Case: Painless skin lesions e.g., papule, vesicle, eschar
in a person residing in Bano block, Simdega district with onset of illness between 1st August -31st October 2014
Confirmed Case: Probable case with culture confirmation from skin lesion for Bacillus anthracis
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India EIS
Case Finding Enhance passive Surveillance
Patients with cutaneous lesion will report to health facility Review of medical records of all patients from Bano block and
District hospital, Simdega Active Surveillance :
House to House Survey in Kuruchdega and 5 neighbourhood villages
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India EIS
Case Control Study Study population: Residents of Tungritoli Hamlet, Kuruchdega
Village Study Design: 1:2 un-matched case control study Control Selection: Neighbourhood contacts of the probable case
without any painless skin lesions e.g., papule, vesicle, eschar between 1st August -31st October 2014
Data collection: By principal investigators through semi structured questionnaire
Variables: Demographic and Risk factors e.g., Handling Meat Data analysis: Data analysed with Epi Info 7.1.4
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India EIS
Laboratory Investigations Specimen: Venous blood and wound swab of cutaneous lesion
from three clinical cases Laboratory: Department of Microbiology, Rajendra Institute of
Medical Science, Ranchi, Jharkhand Evaluation: Gram staining and culture for Bacillus anthracis
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India EIS
Animal/Environmental Investigations
Animal Livestock census & vaccination status Livestock death in Bano block
Laboratory: Random blood samples from 50 livestock (bull & cow) collected Soil particle collected from slaughter site Processed for Gram staining & Culture at Centre for Animal Disease
Research and Diagnostic Centre (CADRAD), Ranchi.
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India EIS
RESULTSDESCRIPTIVE EPIDEMIOLOGY
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India EIS
Descriptive Epidemiology 13 cases; Probable 10 & Confirmed 3 100 % Male Case fatality rate: 38% (5/13) Median age: 30 years (Range 18 to 58 years) Attack rate: 11% (13/118) in Tungritoli hamlet (Sub-village)
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India EIS
Number of cases by illness Onset Date
13th -19th Aug
20th -26th Aug
27th Aug- 2nd Sept
3rd- 9th Sept
10th - 16th Sept
17th -23rd Sept
24th -30th Sept
1st -7th Oct
8th- 14th Oct
15th -21st Oct
22nd- 28th Oct
29th Oct -4th Nov
0
1
2
3
4
5
6
7
Cases DeathsN
umbe
r of
Cas
es
Date of Onset
Bull/Calf Death
Investigation Started
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India EIS
Distribution of Cases in Tungritoli Hamlet
BANO BLOCK
SIMDEGA DISTRICT, JHARKAHND
INDIA
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India EIS
Clinical Presentation Cutaneous lesions in the upper extremities One patient had bleeding from mouth during the onset of symptoms
Clinical Features Number (N= 13) %
Eschar/Ulcer 100
Malaise 77
Fever 77
Lymphadenopathy 46
Shortness of Breath 31
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India EIS
RESULTS CASE CONTROL STUDY
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India EIS
Socio-demographic CharacteristicVariable Type Number (N=13)
% Education Illiterate 15
Primary 31Secondary 54
Religion Hindu 69Christian 31
Occupation Agriculture 100Housing Earthen Floor 100
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India EIS
Risk Factors Associated with Illness
Variable Case (N=13)
Control (N=26) OR 95% CI
Male 13 7 35.0 3.9 – 312.2
Illiterate 2 15 0.13 0.02 – 0.72
Agriculture Occupation 13 11 18.66 2.14 – 162.25
Consumption of Cooked Meat 13 19 5.6 0.62 – 49.94
Chopping / handling dead bull 13 0 378 21.95 – 6508.8
Slaughtered dead bull 10 0 90 8.35 – 969.21
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India EIS
Laboratory InvestigationSpecimen Laboratory Procedure Results
Blood Culture Staphylococcus aureus
Wound Swab Gram Staining Spore forming, non-motile, gram positive bacilli, with bamboo stick appearance in one sample in favour of Bacillus anthracis
Culture Non-haemolytic colony on Blood Agar in one sample suggestive of Bacillus anthracis
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India EIS
Animal/Environmental Investigations
Specimen Laboratory Procedure Results Blood sample from Livestock Gram Staining & Culture No organism found
Soil particle Culture No organism found
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India EIS
Livestock Vaccination 29th October 2014: First round livestock vaccination in
Kuruchdega village Seven teams deputed to vaccinate all livestock's including cattle,
sheep and goat with-in 5 kms around the Kuruchdega village Vaccination Coverage : 64% (4900/7600) livestock vaccinated
as of 7th November 2014
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India EIS
Conclusion Outbreak in Tungritoli hamlet of Kuruchdega village is likely caused
by Anthrax All cases were from low socio economic status and predominantly
tribal Being male and in agricultural occupation were at more risk of
getting anthrax as compared to labourers Slaughtering and handling or chopping dead bull meat were
significantly associated with the illness
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India EIS
Recommendation Sensitize health workers and animal health department for
early identification of anthrax disease among human and livestock
Increase community awareness about appropriate precautions and practices to prevent anthrax infection
Practicing personal protective measure during handling infected raw animal meat and bones
Vaccinate livestock annually in Bano block Enhance inter-sectorial coordination for early preparedness in
identifying & controlling the outbreak
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India EIS
Acknowledgement Dr Achelal R Pasi: Co-investigator & EISO, NCDC, Delhi, India CDC:
Dr Kayla Laserson, Country Director, CDC, India Dr Samir V Sodha, Resident Advisor, India EIS Program, CDC, India Dr Shah Hossain, Public Health Specialist, CDC, India
NCDC: Dr Srinivas R Venkatesh, Director, NCDC, Delhi, India Dr Anil Kumar, HOD, Epidemiology, NCDC, Delhi, India Dr Aakash Shrivastava, Joint Director, Epidemiology, NCDC, Delhi, India Dr Pradeep Khasnobis, CMO, IDSP, NCDC, Delhi, India
IDSP, Jharkhand: Dr Ramesh Prasad, State Surveillance Officer, IDSP, Jharkhand, India Dr Adhyayan Sharan, District Epidemiologist, Simdega, Jharkhand, India
Thank You