Washing Hands Before Meals Becomes A Protective Factor In An Outbreak Of Typhoid Fever (ICD 10 Code: A01.0) In Village Darnu, Near Dharamsala, District Kangra, Himachal Pradesh, India

Rajesh K. Sood; Omesh K. Bharti; Vidya Ramachandran

Volume : V, Issue : II, February - 2015

Washing Hands Before Meals Becomes A Protective Factor In An Outbreak Of Typhoid Fever (ICD 10 Code: A01.0) In Village Darnu, Near Dharamsala, District Kangra, Himachal Pradesh, India

Rajesh K. Sood, Omesh K. Bharti, Vidya Ramachandran

Abstract :

Introduction: Each year 1.6 million children die from diarrhoea, more than malaria, measles and HIV/AIDS combined. The WHO estimates that 88%, or 1.4 million, of these deaths are caused by poor sanitation combined with unsafe drinking water . WHO estimates the annual incidence of typhoid at 21.6 million cases worldwide (2000). Typhoid fever occurs in all parts of the world where water supplies and sanitation are poor and incidence in south Asia is >100/100,000. In 2006, India reported 0.7 million cases of typhoid of which 26,327 (3.6%) were from the hill sate of Himachal Pradesh On 13/9/07 the local health workers informed the block Medical Officer and District Surveillance Officer about recent increase in fever cases in the Village Darnu, which is located 5 km from the district headquarter Dharmasala. The cases presented with fever, chills, sweating and headache and/or generalized pains. On 14/09/07 the District Surveillance Officer directed the author to look into and investigate the problem and suggest preventive measures. Method: We collected Baseline fever data from outpatient reports of health sub centre Darnu since 2002 and analyzed for seasonal trends and seasonal averages. We looked into any recent change in case definition of enteric fever, surveillance system or population migration. We defined a case as occurrence of fever for more than one week in a resident of village Darnu from 20th Aug to 5th Oct 2007, and conducted a house to house search on 17/9/07 using a structured Performa and prepared line list of fever cases with date of onset, age, sex, address, clinical descriptions, number of household members, and serial number of households affected, laboratory investigation results and outcome and enumerated village population. During the active case search, we informed all people that cases should report at sub centre. We sent blood samples for culture and serum samples for WIDAL, Weil Felix to Department of Microbiology, RPG Medical College, Kangra. We studied the water supply and distribution system in the village. A map was prepared and correlated with spot map. We collected three water samples and sent to medical college and to lab of irrigation and public health department for coliform count to check for evidence of fecal contamination. Results: We identified 124 cases from between 22/7/07 and 2/10/07. Baseline fever cases for the village were 8 for the month of September and standard deviation was 3. The reported 28 cases (and present 124 cases) are thus in excess of the expected frequency by more than 2 standard deviations. All cases had fever with chills, 96% had headache and 95% complained of generalized body aches and fatigue. The first case was on 22/7/7 and the number peaked in the week of 10–16 September and then declined. The geographic distribution shows that Marthan, Barthan Mogu, Batarha, Barsain 2 and Harijan localities in the village were more affected and there were negligible cases in colony/ sippy/ dhiman basti. The attack rate was 12 % overall, higher in females (15%) than males (10%). People of age 5–14 were most affected with attack rates of 17 %, followed by 15–29 (17%) and 0–4 yrs (15%). The blood culture lab reports showed 7 samples positive for Salmonella typhi. CRI Kasuali lab confirmed 5 lab isolates as Serotype Salmonella typhi, antigenic structure 9,12,Vi:d:–. Phage type of 5 samples was Ei and one of phage type was DegVi. A total of 22 cases were positive by either blood culture or WIDAL titer of 1:160 There was no common meal. Eating outside– some cases had fast food / food from street vendor. –There was no household level purification of the water prior to the outeak, though chlorine tablets were being used by many the outeak Report of water samples showed that the water was contaminated with coliforms and the coliform count in 2 samples was > 1800 and > 1600 respectively. The coliform count of the hand pump sample was 1000. There were 2 sources– hand pump (underground) and stream. The water supply in the village is daily but intermittent, twice daily. Another water supply is from a natural source (untreated) for a part of the village. Case control study revealed that the hand pump B was associate with significant risk of outeak and hand washing was protective against the disease. Action taken : We prepared a spot map and with overlay technique of water supply pipe map, was able to identify the source of the contamination and did analytical analysis. The lab confirmed the hypothesis. We closed the shallow handpump which led to the containment of the outeak.