Small contribution towards prevention

1. Report on Suspected post streptococcal Acute Glomerulonephritis
outbreak at Buli Middle Secondary School
Namkha Dorji1
Sangay Tenzin2
1. Medical Officer In-Charge of Zhemgang BHU-I
2. Assistant District Health Officer, District Administration, Zhemgang
1. Background Information
The In-Charge of Buli BHU informed the office of Dzongkhag Health Sector on 19 June
2012 about an unusual trend of cases reporting from the Buli Middle Secondary School.
There were several students with infected rashes in the bilateral upper and lower limbs.
The rashes developed as a result of bite by insects which caused intense pruritus and
scratching. The first case was a male student who was referred to Yebilaptsha hospital on
9th
June 2012. He was then referred to Central Regional Referral Hospital and treated as a
case of Post streptococcal Glomerulonephritis. Following him, two students were
admitted. One of them (11 year old female student) was then referred to Yebilaptsa
District Hospital and other one (14 year old male student) was undergoing treatment at
the BHU only.
2. Short Meeting
Immediately after receiving the information, a short meeting was arranged in the
presence Dasho Dzongda and other relevant sector heads to plan how to go on to manage
the emergency situation.
3. Activities
On 20st
June, 2012- a team from Dzongkhag health and education sectors comprising of
Medical Officer and Laboratory Technician from Zhemgang BHU-I, District Education

2. Officer and Assistant District Health Officer left to Buli for educating, screening,
investigating, treating patients and coming up with relevant preventive measures.
3.1. Activities carried out include:
3.1.1. On the afternoon of 20th
June, 2012- the team arrived at the Buli BHU II. The
team had a discussion with the BHU staff about the disease pattern, number of
cases, severity and what immediate measures were taken by them. The first case
was reported on 9th
June, 2012. He was 15 year old male student with the
complaints of generalized body swelling and difficulty in breathing. He had
several bites by insects in his lower and upper limbs with secondary bacterial
infections. He was found to be dyspnoiec, having periorbital oedema and bilateral
ankle oedema. His blood pressure was high. After consulting with ACO
(Assistant Clinical Officer) of Yebilaptsa Hospital, he was referred to the
Yebilaptsa Hospital. The main indication for referral was suspected Nephrotic
Syndrome with uncontrolled hypertension. On 16th
June, 2012- a 11 year old
female student was admitted with similar symptoms and signs. She was then
referred to Yebilaptsa Hospital. On 19th
June- he reported the issue to the District
Health Officer over telephonic conversation Third case was a 14 year old male
student who was admitted on 20th
June, 2012 and started treating as for
Glomerulonephritis. On our visit, he was still in ward receiving treatment.
3.1.2. On 20th
June, 2012 morning, BHW visited the Buli Middle Secondary School saw
students with infected lower limbs. There were a total of 28 male students and 7
female students. He has seen those students having infected skin lesion onlyOn
21st
June, 2012- we could not carry on the activities in the morning session as the
students were busy writing their examinations. In the afternoon session, the team
visited Buli MSS. All the teachers and students were gathered in the multipurpose
hall of the school for IEC by the visiting team.

3. Firstly, Mr Sangay Chophel, District
Education Officer Zhemgang
Dzongkhag) made an introductory
speech. He highlighted on the
purpose of our visit and about the
current unusual trend of sickness
amongst students.
Dr Namkha Dorji Medical Officer of
Zhemgang BHU -I gave health talk on
the following topics.
Firstly the talk was on the post streptococcal
acute glomerulonephritis. He emphasized on
the squeal of skin sepsis which causes
glomerulonephritis. The symptoms of facial and
limbs swelling were shared. On the preventive
aspects, students were told to protect
themselves from insects bite, wound care and
Photo 2.Medical Officer educating students
Photo 1.. District Education Officer made a key note address on
the issues
Photo.3.Photo of infected skin on lower limb

4. early medical attention. Also the importance of promoting sanitation and personal
hygiene were stressed.
Secondly, the talk was on nutritional peripheral neuropathy which is an emerging
problem of the country. He talked briefly about the epidemiological background of
the disease in Bhutan. The symptoms of peripheral neuropathy such as tingling
sensation, pain and weakness were emphasized. He told those patients are usually
alcoholics but no one is immune to the illness. Majority of students suffering from
this disease is due to inadequate nutrition. It is commonly seen among boarder
students. We can prevent by improving school diet menu, proper cooking techniques
and regular intake of meals. He also discouraged students especially female from
consuming junk foods and neglecting the meal provided by the school authority.
4. Case Investigation.
On 22nd
and 23rd
June 2012- all the students with skin infection including those 35
students who were line listed by the BHU staff were asked to come to the BHU for
detailed clinical examinations and laboratory investigations. Medical officer
examined a total of 50 students. Besides looking for skin sepsis, facial and limbs
oedema and checking blood pressure, their nutritional status and heart conditions
were examined. All the students were found to have normal range blood pressure.
There were no facial or limbs oedema. There were 2 students with evidence of throat
infections and one with fungal infection of scrotum in addition to the skin sepsis.
Medical officer ausculted heart to detect undiagnosed and asymptomatic congenital
heart diseases with murmur. There was not a single student with audible murmur.
There were two students with pallor and they were advised to check their hemoglobin
levels.
Urine routine examinations were performed for all the students directed to detect red
cells and albumin were all normal.

5. 5. Treatment
As per the telephonic conversation
with Dr Dorji Wangchuck, Officiating
Secretary of Ministry of Health, he
advised medical officer, Dr Namkha
Dorji to give Injection Procaine
penicillin to all the patients
prophylactically. After examination
and investigation of all the cases, and
considering the practical difficulty of
providing injection, it was felt that
giving injection was not really
practical and needed. Medical officer discussed the matter with Dr Dorji Wangchuck
and decided to go with oral antibiotic. Since the only available antibiotic was tablet
Amoxicillin, all the students with skin sepsis were prescribed Tablet Amoxicillin for
duration of ten days in addition to the local application of Gentian Voilet (GV) paint.
The health staff of Buli BHU will be responsible to follow up those cases.
6. Epidemiological investigations
Case Definition: any student with facial and limbs oedema, raised blood pressure,
and breathlessness with history of preceding skin sepsis or ongoing skin sepsis
Table 1: Case classification
Cases classified No. of cases
Suspected Not applicable
Probable Not applicable
Confirmed
3 ( two referred to Yebilaptsha Hospital and one
admitted at Buli BHU(through laboratory
confirmation).
Photo.4.Medical Officer examining the student

6. Table : 1 Epi-curve
Table: 2. Age breakdown of cases
7. Conclusion
A total of 3 confirmed cases of post streptococcal acute glomerulonephritis. All were
initiated proper treatment at proper time and are in stable condition. However, the first
case continued to have hypertension despite antihypertensive and he is advised to consult
physician at JDWNRH during his midterm vacation. The one at Yebilaptsa hospital is in
0
5
Noofcases
Date
Trends of student visited to BHU
No. fo cases No. of positive
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Age 11
years
Age 12
years
Age 13
years
Age 14
years
Age 16
Years
Age 17
years
1 1
2
1 11 1
No.ofyears
Age
Male
Female

7. stable condition and continuing treatment there. The one at Buli BHU is improving. At
present the outbreak was totally contained and control due to prompt and proactive
actions taken by our BHU staff.
The teachers and the students were fully sensitized about the illness and few
recommendations were discussed to avert such events in future. The total of 50 students
were screened and was found no positive result, however antibiotic prophylaxis was
given as directed.
8. Interventions Undertaken
8.1. The teachers and the students were briefed
on the diseases
8.2. The total of 50 students with skin sepsis
were screened through clinical examination
and laboratory test (50 students)
8.3. Students were advised to practice personal
hygiene and sanitation
8.4. All 50 students screened were
administered blanket antibiotic prophylaxis for
10 days duration.
Photo 5.Screening of students
Photo: 7. Urine test facilities set up at BHU
Photo: 6. looking for infected wounds

8. 9. Suggestions
9.1. Insects bite (? midge) in the exposed part of the body was found to be the primary
cause of the current problems. As per the school rule, students are supposed to wear
slipper during the summer from June-August, exposing to the insects bite. We
recommended on reinstating the use of long sock with school shoe even during the
summer season in order to prevent from insect bites.
9.2. Students with such insect bites to seek early health care services to prevent from
infection and further complication through adequate wound care at initial stage.
9.3. Not only in Buli is such cases prevalent, there are such cases in other parts of
Zhemgang. However, they did not develop such complications. We would recommend
ministry of health to properly study the insects, its habitat, any diseases spread by it, etc.
9.4 Ministry of health to identify the bacteria responsible for this secondary infection as
they have developed extensive pustules. We use antibiotics blindly and this might result
in antibiotic resistance. If the organism is identified by doing pus culture and antibiotic
sensitivity, we can use specific antibiotic and prevent from development of antibiotic
resistance.