OUT BREAK INVESTIGANTON AND PREPARING REPORT

ABOUT OUTBREAK INVESTIGATION

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Frontline Epidemiology
Viral Hepatitis Outbreak
Investigation in Haldwani (urban),
Nainital, Uttarakhand, July-2021
Investigators: Dr. Balbir Singh - DSO
N K Kandpal -
Epidemiologist

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•Hepatitis A/E : inflammation of the liver that can cause mild to
severe illness.
•HA/EV transmitted through ingestion of contaminated food and
water or through direct contact with an infectious person.
•Case fatality is very low in case of Hepatitis AE
•The risk of hepatitis A/E infection is associated with a lack of safe
water and poor sanitation and hygiene (such as contaminated
and dirty hands).
•Incubation period of hepatitis A/E : 14 –28 days.
Background

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296 million people worldwide are living with
hepatitis A/E.
HAV infection is common in the less-developed
nations of Africa, Asia, and Central and South
America.
Background

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Hepatitis A virus (HAV) and hepatitis E virus
(HEV), both enterically transmitted, are highly
endemic in India.
 HEV has been responsible for most of these
epidemics.
HAV is responsible for 10-30% of acute hepatitis.
HEV is responsible for 5-15% of acute hepatitis. .
Viral hepatitis A/E scenario in India

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SDH & G.M.C.(STGH) Haldwani has reported in “P” form suspected
cases of Viral Hepatitis.
–Time: First information received by weekly report 22 (8
th
July
2021) 08 suspected cases.
–Last case (1) was reported by week 30 (1
st
August 2021).
Timeline of outbreak

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Need for investigation:
To describe the epidemiology of viral hepatitis (A/E)
cases.
Analysis of public utilities.
Potential benefits:
•To prevent future outbreak..
•To allocate resources as per need.
Objectives

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oConfirmation of outbreak :
•There was no outbreak in previous years.
•Increasing no. of cases were an alarming
situation.
oCase definition:
Acute illness with discreet onset of at least two of
the following sign & symptoms-
Fever, malaise, Abdominal discomfort, loss of
appetite, nausea, jaundice or dark urine.
Methods

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Suspected case:
Discrete onset of an acute illness with signs / symptoms
of acute infectious illness (e.g. fever, malaise, fatigue)
associated with:
-Clinical signs of liver damage: anorexia, nausea,
jaundice, dark urine, right upper quadrant tenderness; -
Raised alanine aminotransferase (ALT) levels more than
ten times the upper limit of normal laboratory levels).
Confirm case :
A suspected case with:
-Laboratory confirmation: Immunoglobulin M (IgM) anti-
HA/EV (hepatitis A/E virus) positive.
-An epidemiological link with a confirmed case.

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oCase search:
House to house active case search by “Red
Cross Volunteers” through developed forms in
Kathgodam, Polysheet, Tedipuliya &
Damuwadhunga.
oTime period and setting :
Day1 (14
th
August 2021) - 2 hours training
organized for active case search. Distributed
active case search forms.
Day 2 & 3 ( 14-15
th
August 2021)- Active case
search. 85 cases found.

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Data Collection :
oHouse to house survey.
Interviews : All active cases were interviewed for
ADLs.
Review of records : All interviews were recorded.
oData analysis : Data were analyzed on VA/EH
parameters.

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–Place: Kathgodam (33), Polysheet (23) &
Damuwadhunga (16).
–64% people (29 – 43 years) of local
–Residential communities were most affected.
–Male (89%) were affected.
Result

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Descriptive epidemiology:
–Total cases: 91. (02 IPD, 04 OPD & 85 Active
case search)
– Median age : 34.5 years.
–Range : 12 – 52 years
– Attack rate: 39.56
–Time: June & July 2021.
– Place : Haldwani Urban (Kathgodam,
Polysheet & Damuwadhunga).
– Person distribution: Male : 81, Female : 10
Results

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Lab Investigation:
From active case search
samples were sent to
VRDL (GMC Haldwani).
25% samples were found
positive for VEH.
Environmental
investigation:
03 months chlorination
record was checked of
Jalsansthan & Municipality.
Irregularities were found.
O2 tests conducted at 28
places and found chlorination
level below 0.1 ppm.
H2S tests were conducted at
17 places, 05 samples found
positive.
Lab confirmation

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Interviews have confirmed that during afternoon
this age group people visits roadside fast-food
vendors.
Who collects unsafe drinking water from nearby
canal.
During June – July 2021 there was heavy rainfall
in hills.
Which may be having faecal contamination.
Interview or other key findings

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 The most affected age group is 29 – 43 years
(42%).
Males are most affected (89%).
Most residential colonies people are affected
(79%).
Conclusions

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Recommendations
 Improve food hygiene and sanitation facilities, such as
access to safe drinking water, consumption of hygienically
cooked fresh food.
 Proper disposal of excreta particularly from persons with
viral hepatitis. These measures have the potential to
greatly reduce the disease burden due to HAV and HEV
infection.
Legislation and enforcement of guidelines related to
preparation, packaging and sale of various food items may
also be monitored by Food Inspector.
IEC through ASHAs and channels must encourage.
Joint committee for water testing (Jal Sansthan,
Municipality and Deptt.of Medical Health & Family Welfare.

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Acknowledgments
We are highly grateful to –
-Mentor: Dr. Anupama Arya, Associate Professor GDMC.
-Executive Engineer Jal Sansthan Haldwani-Kathgodam.
-Senior Health Officer Municipality Haldwani.
-Chairperson Indian Red Cross Society, Local Branch.
-Volunteers who helped us.
-CMO Nainital: for valuable time.
-Dr. Vinita Rawat (P.I.) - VRDL, GMC Haldwani.
-Local residents of affected colonies.
-NCDC for various support.
-SSU/ DG office members.
-WHO & other websites.

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Thanks

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