The document presents a journal club article on concurrent outbreaks of varicella, rubeola, and german measles in unvaccinated children at Mount Carmel Senior Secondary School in Himachal Pradesh, India. The study, conducted from March to October 2009, involved 505 cases identified through active case searches and highlighted significant weaknesses in local health surveillance systems. Recommendations for future prevention include vaccination, improved public health education, and better surveillance logistics.

1. Journal Club
Article Presentation
Presented by: Dr. Kunal
Guided by: Dr. Abhay Mudey
6/19/2016 1

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
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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.
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4. Objective
• To confirm diagnosis and recommend remedial
measures to prevent further outbreaks.
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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.
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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.
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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
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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.
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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.
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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.
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11. Statistical analysis
• MS-excel sheet using Epi info version 3.3.2
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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)
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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.
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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.
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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.
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16. Result
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17. Continued….
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18. Continued….
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19. Continued….
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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.
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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.
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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.
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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.
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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.
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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.
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26. • Thank You
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