Developing public health capacities of Frontline Public Health Workforce in Uttarakhand

Recent COVID-19 pandemic has highlighted the importance of increase in the ability of public health workforce to detect and respond to the public health threats. For timely implementation of an adequate response and mitigation measure, the standardized and sustainable capacity building programme for frontline public health workforce is the need of hour. National Center for Disease Control (NCDC), Ministry of Health and Family Welfare, in partnership with U.S. Centers for Disease Control and Prevention (CDC), developed a three-month in-service Basic Epidemiology Training programme. This is a tailor-made programme for frontline public health workforce to strengthen epidemiological skills. This training was a practical interactive approach to field epidemiology for three months on the job training for frontline public health workforce that addressed the critical skills needed to conduct surveillance effectively at the local level while focusing on improving disease detection, reporting and feedback. The training also demonstrated the role of learning model in form of interaction between the mentor and the mentees. The importance of handhold support given by the mentors to the mentees in quality outbreak investigations and documentation.

Detection of Contagious Caprine Pleuropneumonia and Concurrent Diseases in Outbreaks Presenting with Respiratory Signs in Small Ruminants in Tanzania

Aims: To establish the prevalence and concurrent diseases in outbreaks presenting with respiratory signs, major associated clinical signs and postmortem lesions and proportions of those diseases in clinically and autopsied small ruminants for a proper diagnosis and control strategies.Study Design: Purposive outbreaks investigation.Place and Duration of Study: Department of Global Health, School of Life Science and Bio Engineering (LiSBE), Nelson Mandela Institution of Science and Technology (NM-AIST) between September 2016 and December 2018.Methodology:We included investigations of outbreaks of diseases presenting with respiratory signs in small ruminants reported from five agro-ecological zones in Tanzania. Small ruminats with clinical signs or postmortem lesions suggestive of respiratory involvement were subjected to clinical or postmortem examination. Samples from all examined animals were tested in the laboratory using conventional polymerase chain reaction (PCR) to confirm the tentative diagnosis.Results: A total of 205 small ruminats were examined and tested, of these 72.2% and 20.8% were goats and sheep respectively. In goats, 79.1% (117/148) and sheep, 28.1% (16/57) were confirmed to have concurrent infections, and pneumonic pasteurellosis and peste des petits ruminants (PPR) for goats, and PPR for sheep being mostly involved diseases. Contagious caprine pleuropneumonia (CCPP) was detected in 16.1% (n=205) of the animals, and was significantly high in goats (p=0.003, OR=7.3) than sheep. Pneumonic mannheimiosis (prevalence = 9.3%) was less likely toaffect goats than sheep (p=0.047, OR=0.38). In goats (n=148), detection of all diseases was significantly (p<0.05) low in clinically examined animals except pneumonic pasteurellosis and PPR, (p =0.056, OR=2.1) and (p=0.096, OR=2.15) respectively, though the difference was not significant. In sheep (n=57), CCPP was significantly (p=0.005, OR=0.17) more likely to be detected in clinically examined animals.Conclusion: In investigations of outbreaks presenting with respiratory signs in small ruminants, it is important to consider concurrent infections in the interventions and control strategies to be deployed, which may include development and use of multivalent vaccines.

Outbreak investigation of acid fly attack among residential students in a tertiary care centre in South India

Paederus dermatitis is the skin irritation resulting from contact with the haemolymph of certain rove beetles, a group that is comprised by the genus Paederus. In May 2018, there was an increase in the number of residential students reporting with burning skin lesions. In this context, an outbreak investigation was conducted. A team of public health specialists visited these residential buildings and premises. The inmates who were affected were interviewed and examined. Suspected insects were collected and entomologically evaluated by the Zoological Survey of India. On examination of the affected individuals, it was observed that the rashes were very much suggestive of acid fly toxin induced lesions. Inspection of the premises, revealed small heaps of dried leaves with moisture at two sites which could have served as a suitable environment for acid fly multiplication. Our study concluded that Paederus fuscipes as the causative agent. Top storeys of buildings, illuminated at night, facing potentially wet areas were considered to be the potential risk factor. Fly proofing of the building, cleaning the institution premises and chemical treatment was suggested as appropriate control measures.

Investigation of acute diarrhoea outbreak at Narasapura, Kolar

Background: Greatest risk of acute diarrhea outbreaks occurs in over-populated communities & refugee settings characterized by poor sanitation, unsafe drinking-water and increased person to person transmission. Because the incubation period is very short, number of cases can rise extremely quickly and it calls for a prompt and thorough investigation. There were reports of cases of acute diarrhoea and based on the preliminary field work, the existence of an outbreak was confirmed. Hence it was decided to investigate the outbreak with objectives to determine the causes and source of acute diarrhoea outbreak at Narasapura village in Kolar and to suggest control measures.Methods: The cross sectional study was conducted in Narasapura village of Kolar which is a fast growing industrial area. All the households and migratory settlements of the affected area were included. Attack rates of the disease were computed, epidemic curve drawn and the results were analyzed to draw conclusions. Control measures were applied simultaneously.Results: The diarrhoea attack rate at AD colony was 10%. Males (65%) were more affected compared to females (35%). 15.4% stool samples were positive for Vibrio cholera and 18% of the water samples was found to be non-portable. Vibrio cholerae O1 biotype El Tor serotype Ogawa strain was implicated as the cause for present outbreak.Conclusions: Cholera continues to be a public health problem in migratory settings, causing disease outbreaks. Environmental risk factors and lack of awareness are the contributory factors which need to be addressed.

Current strategy for local- to global-level molecular epidemiological characterisation of global antimicrobial resistance surveillance system pathogens

The prime goal of molecular epidemiology is to identify the origin and evolution of pathogens, which can potentially influence the public health worldwide. Traditional methods provide limited information which is not sufficient for outbreak investigation and studying transmission dynamics. The recent advancement of next-generation sequencing had a major impact on molecular epidemiological studies. Currently, whole-genome sequencing (WGS) has become the gold standard typing method, especially for clinically significant pathogens. Here, we aimed to describe the application of appropriate molecular typing methods for global antimicrobial resistance surveillance system pathogens based on the level of discrimination and epidemiological settings. This shows that sequence-based methods such as multi-locus sequence typing (MLST) are widely used due to cost-effectiveness and database accessibility. However, WGS is the only method of choice for studying Escherichia coli and Shigella spp. WGS is shown to have higher discrimination than other methods in typing Klebsiella pneumoniae, Acinetobacter baumannii and Salmonella spp. due to its changing accessory genome content. For Gram positives such as Streptococcus pneumoniae, WGS would be preferable to understand the evolution of the strains. Similarly, for Staphylococcus aureus, combination of MLST, staphylococcal protein A or SCCmec typing along with WGS could be the choice for epidemiological typing of hospital- and community-acquired strains. This review highlights that combinations of different typing methods should be used to get complete information since no one standalone method is sufficient to study the varying genome diversity.

An enterohaemorrhagic Escherichia coli outbreak spread through the environment at an institute for people with intellectual disabilities in Japan in 2005

Objective@#An enterohaemorrhagic Escherichia coli (EHEC) outbreak at an institute with multiple facilities for children and adults with intellectual disabilities was investigated to characterize the cases and identify risk factors for infection.@*Methods@#A case was defined as a resident, a staff member or a visitor at the institute from 16 May through 30 June 2005 testing positive for type 2 Vero toxin-producing EHEC O157:H7 (confirmed case) or exhibiting bloody diarrhoea for two or more days (probable case). We collected and analysed demographic, clinical, laboratory and individual behaviour data to identify possible risk factors for infection and infection routes.@*Results@#We recorded 58 confirmed cases, of which 13 were symptomatic. One probable case was also found. The median age of the patients was 37 years (range: 6–59 years). Thirty-six patients (61%) were male. Thirteen patients (93%) had diarrhoea and six (43%) had abdominal pain. Two developed haemolytic-uraemic syndrome but recovered. All the patients were treated with antibiotics and tested negative after treatment. Some residents had problems with personal hygiene. The residents of one of the facilities who cleaned a particular restroom had 18.0 times higher odds of being infected with EHEC (95% confidence interval: 4.0–102.4) than those who did not.@*Discussion@#The source of the outbreak could not be identified; however, the infection may have spread through environmental sources contaminated with EHEC. We recommend that institutional settings, particularly those that accommodate people with intellectual disabilities, clean restrooms as often as possible to reduce possible infection from contact with infected surfaces.

An investigation of a measles outbreak in Japan and Taiwan, China, March–May 2018

Objective@#To investigate a measles outbreak that spread to Japan and Taiwan, China during March–May 2018, exploring the characteristics of the super-spreading event.@*Methods@#A contact investigation of the index case and reconstruction of the epidemiological dynamics of measles transmission were conducted. Employing a mathematical model, the effective reproduction number was estimated for each generation of cases.@*Results and discussion@#A single index case gave rise to a total of 38 secondary cases, 33 in Japan and five in Taiwan, China. Subsequent chains of transmission were observed in highly vaccinated populations in both Japan and Taiwan, China. The effective reproduction number of the second generation was >1 for both Japan and Taiwan, China. In Japan, the reproduction number was estimated to be <1 during the third generation. Vaccination of susceptible individuals is essential to prevent secondary and tertiary transmission events.

A Salmonella Typhimurium outbreak linked to Vietnamese bread rolls in South Western Sydney, Australia, 2015

Introduction: In September 2015, the South Western Sydney (SWS) Public Health Unit was notified of a cluster of Salmonella Typhimurium (STm) cases with a common multiple-locus variable-number tandem repeats analysis (MLVA) pattern. An investigation was conducted to identify a source and contain the outbreak. Methods: The cluster was initially identified through routine geographic information system cluster scanning applied to the New South Wales Notifiable Conditions Management System. Additional cases were identified through a complaint to local council about a bakery. The bakery was inspected and 48 environmental and food swabs were collected for analysis. Results: A total of 26 suspected cases were identified, of which 14 were interviewed. STm MLVA type 3-16-9-11-523 was identified in 19 of 26 case stool specimens. Most cases (12/14) consumed bread rolls containing pork or chicken with chicken liver pâté and raw egg mayonnaise filling. Five cases identified a common bakery exposure. Environmental and food samples from the bakery isolated STm with an identical MLVA pattern. Discussion: An STm cluster in SWS was investigated and found to be linked to Vietnamese bread rolls containing pork or chicken with chicken liver pâté and raw egg mayonnaise filling. Confirmation of a distinct MLVA pattern among STm isolates from clinical, food and environmental samples provided evidence to establish an epidemiological link between the cases and the implicated premises and informed public health action to contain the outbreak.

An investigation on an outbreak of fluoropolymer fume fever caused by incineration of solid waste / 预防医学

Objective To investigate the cause of an outbreak that with fever,chest tightness,cough as the main symptoms in a production enterprise of solar cells,and to provide suggestrons for the on -site disposal and preventing of re -issued. Methods Clinical features and epidemiological characteristics of the cases were analyzed.The workplaces and treatment of industrial wastes were investigated.Legionella in the throat swab sample and residual water during the processes were detected.Simulation test for poisonous gas from waste incineration was performed using a portable GC -MS detector. Results 52 cases were found and the attack rate was 42.76%.The case distribution was consistent with the characteristics of the outbreak of a homologous exposure.Legionella test result was negative.Clinical symptoms of patients were similar to those of fume fever.In the 1 2 jobs,the higher the amount of compressed air used in the job,the higher the incidence rate was,and there were statistical correlation between the two (P <0.01 ).A large number of fluorine -containing solid waste was burned in the evening before the onset of the disease.The compressed air station was downwind from the location of waste incineration,and the simulation test showed that the concentrations of fluobenzene and two -fluobenzene were 435 and 51 3 mg/m3 ,respectively.Conclusion The toxic smoke produced by illegal incineration of fluorine -containing solid waste,from the compressed air station into the workshop,causing the workers exposed to organic fluoride poisoning,and then the fluoropolymer fume fever outbreak.Fortunately,we disposed it timely and effectively,and all cases quickly recovered and no secondary occurred.

An epidemiological investigation on a dengue fever outbreak / 预防医学

Objective To analyze the epidemiological characteristics of dengue fever outbreak in Shaoxing City,and to provide a scientific basis for the prevention and control.Methods A retrospective epidemiological investigation was conducted to search the patients by given definition.Enzyme linked immunosorbent assay (ELISA)was used for detecting the anti -dengue virus antibodies.The serum samples from patients were collected for dengue virus isolation and the positive samples were identified by RT -PCR.Breteau Index was carried out to monitor the density of mosquito larva. Results A total of 42 cases were found with no death reported.The symptoms mainly included fever (1 00%),fatigue (59. 52%),arthralgia(50. 00%),headache (47. 62%)and rash (38. 1 0%).The outbreak lasted for 71 days with the first case occurred in July 1 5 and the last in September 23.The peak was from August 30 to September 5. Thirty seven cases were located in Keqiao District and 5 cases were in Yuecheng District.The male/female ratio was 1 . 33∶1 .The age of cases ranged from 1 0 to 79 years old with the 40 -(1 9. 05%)and 50 -(1 9. 05%)age group making the largest proportion.The outbreak also showed family aggregation.IgM antibody and nucleic acid of dengue virus were detected from serum samples of 1 2 patients.The sequence of the isolation indicated that this outbreak was caused by dengue virus typeⅡ.Conclusion The imported cases,high density of mosquito vector and missed diagnosis might contribute to this outbreak.Developing a practical scheme for mosquito elimination,improving diagnostic capacity of medical staff and their consciousness of reporting could be important ways to control dengue fever.

A Q fever cluster among workers at an abattoir in south-western Sydney, Australia, 2015

Background: In September 2015, the Public Health Unit of the South Western Sydney Local Health District was notified of two possible Q fever cases. Case investigation identified that both cases were employed at an abattoir, and both cases advised that co-workers had experienced similar symptoms. Public Health Unit staff also recalled interviewing in late 2014 at least one other Q fever case who worked at the same abattoir. This prompted an outbreak investigation. Methods: The investigation incorporated active case finding, microbiological analysis, field investigation and a risk factor survey. Included cases were laboratory definitive or suspected cases occurring from October 2014 to October 2015, residing or working in south-western Sydney. A suspected case had clinically compatible illness, high-risk exposure and was epidemiologically linked to another confirmed case. A confirmed case included laboratory detection of C. burnetii. Results: Eight cases met the case definition with seven confirmed (including a deceased case) and one suspected. The eight cases were all males who had been employed at an abattoir in south-western Sydney during their incubation period; symptom onset dates ranged from November 2014 to September 2015. Field investigation identified multiple potential risk factors at the abattoir, and the majority (75%) of employees were not vaccinated against Q fever despite this high-risk setting. Conclusion: This cluster of Q fever in a single abattoir confirms the significance of this zoonotic disease as an occupational hazard among persons working in high-risk environments. Implementation of Q fever vaccination programmes should eliminate Q fever in high-risk occupational settings.

An outbreak investigation of scrub typhus in Western Province, Solomon Islands, 2014

OBJECTIVE: To identify the etiology and risk factors of undifferentiated fever in a cluster of patients in Western Province, Solomon Islands, May 2014. METHODS: An outbreak investigation with a case control study was conducted. A case was defined as an inpatient in one hospital in Western Province, Solomon Islands with high fever (> 38.5 °C) and a negative malaria microscopy test admitted between 1 and 31 May 2014. Asymptomatic controls matched with the cases residentially were recruited in a ratio of 1:2. Serum samples from the subjects were tested for rickettsial infections using indirect micro-immunofluorescence assay. RESULTS: Nine cases met the outbreak case definition. All cases were male. An eschar was noted in five cases (55%), and one developed pneumonitis. We did not identify any environmental factors associated with illness. Serum samples of all five follow-up cases (100%) had strong-positive IgG responses to scrub typhus. All but one control (10%) had a moderate response against scrub typhus. Four controls had low levels of antibodies against spotted fever group rickettsia, and only one had a low-level response to typhus group rickettsia. DISCUSSION: This outbreak represents the first laboratory-confirmed outbreak of scrub typhus in the Western Province of Solomon Islands. The results suggest that rickettsial infections are more common than currently recognized as a cause of an acute febrile illness. A revised clinical case definition for rickettsial infections and treatment guidelines were developed and shared with provincial health staff for better surveillance and response to future outbreaks of a similar kind.

Suspected anthrax outbreak: Investigation in a rural block of west Bengal and public health response.

Anthrax is one of the top 10 diseases reported in India and also one of the major causes of death in livestock. This study was conducted to confirm the outbreak of suspected anthrax, determine the transmission mechanism, and implement control measures in Bhatar block of Burdwan district, West Bengal, India. A cross-sectional descriptive study was conducted through house-to-house visits in Oregram and Kathaldanga villages during the period from May 30, 2013 to June 8, 2013. Out of the 93 persons exposed to anthrax, 11 persons had history of slaughtering, while 82 consumed the meat. All of the 7 cases of suspected anthrax were male (mean age 41.14 ± 10.04 years) and involved in slaughtering the animal. Most cases presented with papule and vesicle over the upper extremity and the trunk. One patient among the suspected cases died. The outbreak was labeled as a suspected anthrax outbreak. A health awareness camp was organized to improve awareness of anthrax among villagers.

Mass Chemoprophylaxis in Control of Pneumococcal Pneumonia Outbreak in a Military Training Centre.

Background: Outbreaks of streptococcal pneumonia among young recruits in military training centers are welldocumented. A signifi cant outbreak of pneumonia occurred between November 19, 2011 and February 4, 2012 among the young recruits of a large training center located in Southern India. Objectives: The objective of this investigation was to identify the cause of the outbreak, to control the outbreak at the earliest, and to provide future strategies for containing such an outbreak. Materials and Methods: The outbreak was investigated using standard epidemiological methods so as to describe its epidemiology, to identify the causative organism, to guide the outbreak control efforts, and to provide future strategies for containing such an outbreak. Results: Over 2 months, 58 cases of pneumonia occurred among the recruits of the center, giving an attack rate of 4.81 cases per 1,000 person-months. Radiological positivity was found in 72.4% of the cases. Streptococcus pneumoniae (S. pneumoniae) was grown in all the three bronchoalveolar lavage (BAL) samples. The outbreak rapidly ended following prophylaxis with oral azithromycin. Conclusions: This outbreak of pneumococcal disease occurred in the setting of intense military training and a crowded environment. Oral azithromycin was found to be the suitable strategy for control of the outbreak.

An Outbreak of Rubella in Chandigarh, India.

Objective: To investigate an outbreak of fever with rash in an urbanized village in Chandigarh, India. Methods: Active case search was performed by house-to-house survey. The etiological agent of the outbreak was confirmed by serology. Spot map was done using Geographical Information System (GIS) technology. Results: Out of 7742 persons screened, 12 were serologically confirmed rubella cases and 83 were epidemiologically linked cases. Overall attack rate was 1.1, more among the age group 1-4 years (4.9). Conclusion: An outbreak mimicking measles was investigated only to be confirmed as rubella.

Introducing Combined Measles, Mumps and Rubella Vaccine in Chandigarh, India: Issues and Concerns.

Cyclical outbreaks of mumps have been noticed across Chandigarh city during winter months. Chandigarh does not provide measles, mumps and rubella (MMR) vaccination in the State immunization schedule. Epidemiological shift in age at diagnosis of mumps was noticed with higher incidence in older children and adults. Increased occurrence of complications can be predicted with this age shift. Silent burden of rubella with serious outcomes in newborns further strengthen the case for MMR vaccine inclusion in routine immunization program of Chandigarh.

Pertussis in the central-west region of Brazil: one decade study

In many parts of the world, numerous outbreaks of pertussis have been described despite high vaccination coverage. In this article we report the epidemiological characteristics of pertussis in Brazil using a Surveillance Worksheet. Secondary data of pertussis case investigations reported from January 1999 to December 2008 recorded in the Information System for Notifiable Diseases (SINAN) and the Central Laboratory for Public Health (LACEN-MS) were utilized. The total of 561 suspected cases were reported and 238 (42.4%) of these were confirmed, mainly in children under six months (61.8%) and with incomplete immunization (56.3%). Two outbreaks were detected. Mortality rate ranged from 2.56% to 11.11%. The occurrence of outbreaks and the poor performance of cultures for confirming diagnosis are problems which need to be addressed. High vaccination coverage is certainly a good strategy to reduce the number of cases and to reduce the impact of the disease in children younger than six months.

An outbreak of syphilis in Darkhan-Uul, Mongolia, January to March 2012

BACKGROUND: Fifty-eight syphilis cases were notified from Darkhan-Uul Province in the first three months of 2012, which is double that of the same period in 2011. The objective of this investigation was to confirm the existence of the outbreak, examine the risk factors of cases and develop recommendations to prevent further spread. METHODS: We conducted a descriptive study of cases notified to the national surveillance system diagnosed with syphilis between 1 January and 20 March 2012 in Darkhan-Uul Province. Additional data were collected from doctors’ record books and outpatient cards. We compared outbreak cases to non-outbreak cases notified in Darkhan-Uul Province in 2011. RESULTS: The total notification rate was 62.3 per 100 000. The notification rate was highest among 20–29 year olds, and 38 (65.5%) were females. More males than females were detected through contact tracing (45% compared with 10.5%). Only 10% of cases reported using condoms during their last sexual encounter, with 65.5% reporting having had casual sex or multiple sex partners. There were no homosexual cases. Compared to the non-outbreak cases, outbreak cases had a significantly higher proportion of detection through contact tracing (22.4% compared with 0.7%) but a lower proportion of detection through prevention (3.5% compared with 26.5%). There was also a higher proportion of primary syphilis in outbreak cases (62.1% compared with 41.7%). CONCLUSION: The syphilis outbreak in Darkhan-Uul Province was confirmed. We recommended effective contact tracing followed by timely diagnosis and treatment. Health promotion activities targeted to high school, college and university students on syphilis infection and prevention as well as condom usage were recommended for future prevention.

Fifteen Years After the Gozan-Dong Glass Fiber Outbreak, Incheon in 1995 / 예방의학회지

OBJECTIVES: In 1995, an outbreak survey in Gozan-dong concluded that an association between fiberglass exposure in drinking water and cancer outbreak cannot be established. This study follows the subjects from a study in 1995 using a data linkage method to examine whether an association existed. The authors will address the potential benefits and methodological issues following outbreak surveys using data linkage, particularly when informed consent is absent. METHODS: This is a follow-up study of 697 (30 exposed) individuals out of the original 888 (31 exposed) participants (78.5%) from 1995 to 2007 assessing the cancer outcomes and deaths of these individuals. The National Cancer Registry (KNCR) and death certificate data were linked using the ID numbers of the participants. The standardized incidence ratio (SIR) and standardized mortality ratio (SMR) from cancers were calculated by the KNCR. RESULTS: The SIR values for all cancer or gastrointestinal cancer (GI) occurrences were the lowest in the exposed group (SIR, 0.73; 95% CI, 0.10 to 5.21; 0.00 for GI), while the two control groups (control 1: external, control 2: internal) showed slight increases in their SIR values (SIR, 1.18 and 1.27 for all cancers; 1.62 and 1.46 for GI). All lacked statistical significance. All-cause mortality levels for the three groups showed the same pattern (SMR 0.37, 1.29, and 1.11). CONCLUSIONS: This study did not refute a finding of non-association with a 13-year follow-up. Considering that many outbreak surveys are associated with a small sample size and a cross-sectional design, follow-up studies that utilize data linkage should become standard procedure.

Contact tracing of in-flight measles exposures: lessons from an outbreak investigation and case series, Australia, 2010

OBJECTIVE: To describe a 2010 outbreak of nine cases of measles in Australia possibly linked to an index case who travelled on an international flight from South Africa while infectious. METHODS: Three Australian state health departments, Victoria, Queensland and New South Wales, were responsible for the investigation and management of this outbreak, following Australian public health guidelines. Results: An outbreak of measles occurred in Australia after an infectious case arrived on a 12-hour flight from South Africa. Only one of four cases in the first generation exposed to the index case en route was sitting within the two rows recommended for contact tracing in Australian and other guidelines. The remaining four cases in subsequent generations, including two health care workers, were acquired in health care settings. Seven cases were young adults. Delays in diagnosis and notification hampered disease control and contact tracing efforts. CONCLUSION: Review of current contact tracing guidelines following in-flight exposure to an infectious measles case is required. Alternative strategies could include expanding routine contact tracing beyond the two rows on either side of the case’s row or expansion on a case-by-case basis depending on cabin layout and case and contact movements in flight. Releasing information about the incident by press release or providing generic information to everyone on the flight using e-mail or text messaging information obtained from the relevant airline, may also be worthy of consideration. Disease importation, inadequately vaccinated young adults and health care-related transmission remain challenges for measles control in an elimination era.