Epidemic Investigation of the Jaundice Outbreaki n Girdharnagar, Ahmedabad, Gujarat, India, 2008

Department of Community Medicine, BJ Medical College, Ahmedabad, Gujarat, India.
Indian Journal of Community Medicine 04/2010; 35(2):294-297. DOI: 10.4103/0970-0218.66864


Background: Since 1976, seven outbreaks of hepatitis E occurred in Ahmedabad. Clusters of jaundice cases were reported on
June 19, 2008, by a civic center, Girdharnagar ward, Ahmedabad. Objectives: The objectives were as follows: (1) to identify the
etiological agent, source of outbreak, and mode of transmission; (2) to propose a control measure based on the outbreak investigation.
Materials and Method: We defined a case as an acute illness with (a) a discrete onset of symptoms and (b) jaundice or elevated
serum aminotransferase levels, from March to September 2008 in the households of the Girdharnagar ward. We collected data
through a door-to-door survey and hospital records. We described the outbreak in terms of time, place, and person. We collected
laboratory investigation reports of case patients admitted to the civil hospital. To test our hypothesis we conducted a retrospective
cohort study to find out the relative risk for hepatitis. We conducted environment investigation to find out the source of
contamination of water supply. Results: A total 233 case patients of hepatitis were identified with the attack rate of 10.9/1000
population. Cases were reported in all the age groups with a higher attack rate in the age group of 20–29 years (18.5/1000). Out of
17 case patients, 16 were positive for the hepatitis E IgM antibody. The attack rate was two times more among those who were
exposed to the leaking pipeline than the non-exposed (RR=2.3, 95% CI 1.76, 2.98). Environmental investigation also confirmed
the sewage contamination of drinking water in the distribution system. Conclusion: The outbreak was due to hepatitis E virus.
We recommended a temporary alternative water supply, repair of the leakages, and water quality surveillance.


Available from: Naresh Chauhan
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    • "Studies show that hepatitis outbreaks are an indicator of poor water supply and degraded environmental sanitation. A study done in Ahmadabad, Gujarat, India, in 2008 showed the cause of hepatitis E was sewage contamination and higher attack rate was found in 20-29 years of age group [4].Another study on acute hepatitis carried out in Lalkuan of Nainital district of India surveyed 2,785 people and finds 240 positive. "
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    ABSTRACT: This is a review article on jaundice outbreak occurred in Biratnagar during April-July 2014. The study reviewed the reports on hepatitis outbreak presented by District Public Health Officer Morang during a seminar organized by Nepal Health Research Council (NHRC), District Disaster Management Committee (DDMC) meetings and HMIS (Health Management Information System) database. District Public Health Office (DPHO) recorded 2,789 Jaundice patients in Morang district including Biratnagar city. Most of the patients (80.67%) recorded from Biratnagar. In the outbreak sex ratio of female to male was 0.56:1. Hepatitis infection was highest among 15-29 age groups and noticed remarkable among 15 to 54 years age groups. District Disaster Management Committee declared the outbreak in Biratnagar on April 28 when 95 jaundice patients recorded in the hospitals. The number reached at peak level 176 patients on May 6 and the trend came downward to normal level on July 8, 2014. Total 12 deaths recorded in the outbreak. Of them 8 deaths recorded from Biratnagar, 3 deaths from Morang district and 1 death from Saptari district. In Biratnagar ward No. 11 listed 5 deaths, ward No. 8 listed 2 deaths and ward No. 3 listed 1 death. Case fatality rate in the Biratnagar outbreak calculated as 0.43%. The causes of hepatitis infection were hepatitis viruses E and A. The transmission of infection in Biratnagar was due to sewage contamination through leaking pipes in water distribution. The level of community awareness on taking safe water observed in the Biratnagar. Before the outbreak, people used to drink tap water without treatment. After the outbreak, people changed their behavior to boil or filter water to drink in houses. Many people started to purchase mineral water in jars and bottles from the market. However, government water supply system in Biratnagar is poor which demands an upgrade to meet WHO standard of drinking water.
    • "Attack rate of acute viral hepatitis ranging from 1.9 to 17% have been reported from various studies from India.(891011121314) The overall attack rate in the present study was 8.61%, comparable with the other studies.(9) "
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    ABSTRACT: Background:In March 2013, cases of acute hepatitis were reported from Lalkuan, Nainital district. We investigated the outbreak to identify the source of infection and to facilitate control measures.Objectives:To study the distribution of hepatitis cases, to find the source of infection, and to initiate the control measures in the affected area.Materials and Methods:We defined a case of acute hepatitis as those cases that had jaundice with at least one of the following symptoms: Dark urine, fever, pain in abdomen, vomiting, and loss of appetite in the affected area between January and March 2013. Door-to-door survey was carried out. Thirteen blood samples were randomly collected from jaundice cases for immunoglobulin M (IgM) antibody for hepatitis A virus (HAV) and hepatitis E virus (HEV). Water samples were collected to test residual chlorine.Results:Total 2,785 individuals were surveyed; of which 240 were suffering from acute viral hepatitis (attack rate (AR) = 8.61%). Out of 13 serum samples, 10 were found positive for HEV IgM antibodies and three cases had IgM antibodies for both HAV and HEV, which confirmed a hepatitis E outbreak. The difference in attack rate of hepatitis of both the sexes was statistically significant (P < 0.001). The attack rate was significantly higher in age groups >12 years of age (P < 0.001). Environmental investigation also confirmed the sewage contamination of drinking water in the distribution system. The attack rate was much higher (29.4%) among those who were exposed to the leaking pipeline than the nonexposed (χ2 = 574.26, P < 0.01).Conclusion:HEV was confirmed as the major etiological agent in this outbreak that was transmitted by contaminated drinking water. The recognition of early warning signals, timely investigation, and application of specific control measures can contain the outbreak.
    Indian Journal of Community Medicine 04/2014; 39(2):94-7. DOI:10.4103/0970-0218.132725
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    ABSTRACT: Space-time clustering of people who fall acutely ill with jaundice, then slip into coma and death, is an alarming phenomenon, more markedly so when the victims are mostly or exclusively pregnant. Documentation of the peculiar, fatal predisposition of pregnant women during outbreaks of jaundice identifies hepatitis E and enables construction of its epidemic history. Between the last decade of the 18th century and the early decades of the 20th century, hepatitis E-like outbreaks were reported mainly from Western Europe and several of its colonies. During the latter half of the 20th century, reports of these epidemics, including those that became serologically confirmed as hepatitis E, emanated from, first, the eastern and southern Mediterranean littoral and, thereafter, Southern and Central Asia, Eastern Europe, and the rest of Africa. The dispersal has been accompanied by a trend towards more frequent and larger-scale occurrences. Epidemic and endemic hepatitis E still beset people inhabiting Asia and Africa, especially pregnant women and their fetuses and infants. Their relief necessitates not only accelerated access to potable water and sanitation but also vaccination against hepatitis E.
    Epidemiology and Infection 01/2012; 140(5):767-87. DOI:10.1017/S0950268811002925 · 2.54 Impact Factor
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