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Journal Club presentation on Outbreak Investigation Study

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The following presentation is based on: Concurrent Multiple Outbreaks of Varicella, Rubeola,
German Measles Outbreak in Unvaccinated Children of
Co-Educational Mount Carmel Senior Secondary School,
Thakurdwara Palampur of Northern Himachal, India

Published in: Health & Medicine
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Journal Club presentation on Outbreak Investigation Study

  1. 1. Journal Club Article Presentation Presented by: Dr. Kunal Guided by: Dr. Abhay Mudey 6/19/2016 1
  2. 2. • Title: Concurrent Multiple Outbreaks of Varicella, Rubeola, German Measles Outbreak in Unvaccinated Children of Co- Educational Mount Carmel Senior Secondary School, Thakurdwara Palampur of Northern Himachal, India • Authors: Gupta SN, Gupta N , Gupta S • Published In : Journal of Family Medicine & Primary Care • Year: 2015 I Volume: 4 I Issue: 1 I Page: 117-23 6/19/2016 2
  3. 3. Background of the study • In April, 2009, in a co-education school, we investigated suspected triple outbreak; varicella first and then with chance detection of rubeola and rubella. 6/19/2016 3
  4. 4. Objective • To confirm diagnosis and recommend remedial measures to prevent further outbreaks. 6/19/2016 4
  5. 5. Previous work done which has lead up to the study • Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med 2005;352:450-8. • Lopez AS, Guris D, Zimmerman L, Gladden L, Moore T,Haselow DT, et al. One dose of varicella vaccine does not prevent school outbreaks: Is it time for a second dose? Pediatrics 2006;117:e1070-7. 6/19/2016 5
  6. 6. Continued…. • Gupta SN, Gupta N, Neki NS. A of Rubeola-Rubella in District Kangra of Northern India; European Scientific Conference on Applied Infectious Disease Epidemiology, Stockholm, Sweden, between 06-08th November 2011. • Guris D, Jumaan AO, Mascola L, Watson BM, Zhang JX, Chaves SS, et al. Changing varicella epidemiology in active surveillance sites--United States, 1995-2005. J Infect Dis 2008;197(Suppl 2):S71-5. 6/19/2016 6
  7. 7. Continued…. • Gupta SN, Gupta N, Neki NS, Chaudhary S, Bansal P, Gupta MK; Epidemiological Investigation of Mixed Outbreaks of Measles/Varicella in Hilly Villages of District Kangra, Himachal Pradesh, India, 2007; European Scientific Conference on Applied Infectious Disease Epidemiology, Stockholm, Sweden, between 06- 08th November 2011. • Gupta SN, Gupta N, Neki NS, Swain P, Gupta S. Two in one outbreak of rubeola-rubella in tobacco affected Maan Vajreshwari Nagarkot Dham-District Kangra of Northern Himanchal. American J of Epid and Infect Disease2013;1:47-52.6/19/2016 7
  8. 8. Continued…. • Gupta SN, Gupta N, Gupta S. A mixed outbreak of rubeola-rubella in district Kangra of Northern India. J Fam Med Primary Care 2013;2:354-9. 6/19/2016 8
  9. 9. Materials & Methods • Study Area : Khalet & Roady villages of Gopalpur medical block of Kangra Himachal Pradesh, India • Study Duration : March 23rd to October 14th • Study Design : The study design was cross sectional. The sampling method was Random Sampling. • Study Sample : 505 cases of mixed outbreaks of Varicella, Measles & German measles. 6/19/2016 9
  10. 10. Continued…. • Inclusion Criteria : 1) A case that meet clinical case definition & which was epidemiologically linked. 2) A case that gives consent to do study on. • Exclusion Criteria : the random samples were taken from those who were willing while the reluctant and refusing populations were dropped. 6/19/2016 10
  11. 11. Statistical analysis • MS-excel sheet using Epi info version 3.3.2 6/19/2016 11
  12. 12. Data Collection • Active case search was initiated by visiting class to class of school & adjoining villages to identify case definition in affected villages. • For this two teams of health workers were formed. • Each team has two health workers: 1 male & 1 female (supervised by 1male supervisor) 6/19/2016 12
  13. 13. Continued…. • They interviewed mothers of each case patient or the next elder available member in the family with the semi structured questionnaire in Hindi language. • As this team was not oriented carrying out outbreak investigation previously, 2 senior medical officers trained & supervised previously 2 senior medical officers trained & supervised the whole team. 6/19/2016 13
  14. 14. Continued…. • In ongoing outbreak , rapid response team was collected 1) Ten randomly collected 5 ml of blood for each specimen observing universal safety precautions. 2) Four samples of nasopharyngeal swabs in virus transport media (VTM) for virus isolation and genotyping of the strain. 6/19/2016 14
  15. 15. Continued…. • They also collected information about age, sex, symptomatology & date of onset of illness, treatment taken, travel history; any outsiders or foreigner visiting the place; pregnancy status; immunization status of case patients and susceptible population by mothers interviews, assessment of reverse cold chain system. 6/19/2016 15
  16. 16. Result 6/19/2016 16
  17. 17. Continued…. 6/19/2016 17
  18. 18. Continued…. 6/19/2016 18
  19. 19. Continued…. 6/19/2016 19
  20. 20. Significance of Result • 505 case patients from mixed outbreaks of varicella, measles, and german measles (30/505 clinically, 467/505 epidemiologically linked and 8/505 laboratory confimed case patients from a study population of 3,280 which covered the affected age group of 0–45 years under the villages of subcenter Khalet and mainly from Mount Carmel School, Thakurdwara from Gopalpur block. 6/19/2016 20
  21. 21. Continued…. • The index male student case from fist standard contracted infection from Chandigarh while travelling in the bus with infected children. • It was identified and reported on 2nd April, 2009. The outbreak started in the class and then gradually spread to other class mates and school mates. 6/19/2016 21
  22. 22. Disscussion • Three in one simultaneous multiple outbreaks of varicella/rubeola/german measles outbreak in unvaccinated children derived its origin from the index male student case from fist standard who contracted infection from Chandigarh while travelling in the bus with infected children. • This outbreak covered mostly the school children with the highest AR in the fist category; (56%) in Nursery up to 4th standard with index case in fist standard. Sex specific AR was (23%) more in boys. 6/19/2016 22
  23. 23. • Important finding to pin point here is that 17% of the cases went for traditional treatment Vs modern medicine. • the sensitivity of the health care facilities is more or less nil and so is weakness of the existing surveillance system. 6/19/2016 23
  24. 24. Limitations • Sero-surveillance in the study area could not be carried out due to funds and time constraints. • As there was lack of trained Health Assitants the investigation took longer time. 6/19/2016 24
  25. 25. Recommendations • 1. Vaccinate MMRV to the susceptible. • 2. Ensure IEC activities aggressively at all the fronts, especially for adolescents, school children and the susceptible. • 3. Identify outreach strategies to cover slum and remote villages. • 4. Strengthen surveillance system and other logistics for specimen collection and transportation. 6/19/2016 25
  26. 26. • Thank You 6/19/2016 26

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