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ESCAIDE 2015, Stockholm, Sweden11th – 13th Nov 2015

Outbreak Investigation of Anthrax, Simdega, Jharkhand, India - 2014

Dr Priyakanta NayakEpidemic Intelligence Service (EIS) Officer

India EIS Programme National Centre for Disease Control, Delhi, India

E Mail ID: pikoo.2007@gmail.com

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BACKGROUND

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Zoonotic disease caused by Bacillus anthracis, an aerobic, gram-positive bacillus.

Humans infected only incidentally through contact with diseased animals

Cutaneous form accounts for 95% of anthrax worldwide Case fatality <1% if treated properly and can go up to 20 %

without treatment. Commonly affects people of lower socio economic status/tribal

community

Anthrax

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Anthrax in India Limited documentation of Anthrax outbreaks from India 14th October 2014: a school teacher in Tungritoli hamlet of

Kuruchdega village, Simdega district, Jharkhand reported 5 deaths 15th October 2014: Investigation by District Rapid Response Team

(RRT) 18th – 19th October 2014: Active surveillance by state RRT 26th October 2014: Two EIS officers deployed to investigate the

outbreak

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Objectives To study the epidemiological characteristics of the outbreak

To determine potential risk factors associated with the outbreak

To propose recommendations for prevention and control of the outbreak

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METHODS

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Case Definition Probable Case: Painless skin lesions e.g., papule, vesicle, eschar

in a person residing in Bano block, Simdega district with onset of illness between 1st August -31st October 2014

Confirmed Case: Probable case with culture confirmation from skin lesion for Bacillus anthracis

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Case Finding Enhance passive Surveillance

Patients with cutaneous lesion will report to health facility Review of medical records of all patients from Bano block and

District hospital, Simdega Active Surveillance :

House to House Survey in Kuruchdega and 5 neighbourhood villages

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Case Control Study Study population: Residents of Tungritoli Hamlet, Kuruchdega

Village Study Design: 1:2 un-matched case control study Control Selection: Neighbourhood contacts of the probable case

without any painless skin lesions e.g., papule, vesicle, eschar between 1st August -31st October 2014

Data collection: By principal investigators through semi structured questionnaire

Variables: Demographic and Risk factors e.g., Handling Meat Data analysis: Data analysed with Epi Info 7.1.4

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Laboratory Investigations Specimen: Venous blood and wound swab of cutaneous lesion

from three clinical cases Laboratory: Department of Microbiology, Rajendra Institute of

Medical Science, Ranchi, Jharkhand Evaluation: Gram staining and culture for Bacillus anthracis

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Animal/Environmental Investigations

Animal Livestock census & vaccination status Livestock death in Bano block

Laboratory: Random blood samples from 50 livestock (bull & cow) collected Soil particle collected from slaughter site Processed for Gram staining & Culture at Centre for Animal Disease

Research and Diagnostic Centre (CADRAD), Ranchi.

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RESULTSDESCRIPTIVE EPIDEMIOLOGY

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Descriptive Epidemiology 13 cases; Probable 10 & Confirmed 3 100 % Male Case fatality rate: 38% (5/13) Median age: 30 years (Range 18 to 58 years) Attack rate: 11% (13/118) in Tungritoli hamlet (Sub-village)

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Number of cases by illness Onset Date

13th -19th Aug

20th -26th Aug

27th Aug- 2nd Sept

3rd- 9th Sept

10th - 16th Sept

17th -23rd Sept

24th -30th Sept

1st -7th Oct

8th- 14th Oct

15th -21st Oct

22nd- 28th Oct

29th Oct -4th Nov

0

1

2

3

4

5

6

7

Cases DeathsN

umbe

r of

Cas

es

Date of Onset

Bull/Calf Death

Investigation Started

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Distribution of Cases in Tungritoli Hamlet

BANO BLOCK

SIMDEGA DISTRICT, JHARKAHND

INDIA

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Clinical Presentation Cutaneous lesions in the upper extremities One patient had bleeding from mouth during the onset of symptoms

Clinical Features Number (N= 13) %

Eschar/Ulcer 100

Malaise 77

Fever 77

Lymphadenopathy 46

Shortness of Breath 31

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RESULTS CASE CONTROL STUDY

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Socio-demographic CharacteristicVariable Type Number (N=13)

% Education Illiterate 15

Primary 31Secondary 54

Religion Hindu 69Christian 31

Occupation Agriculture 100Housing Earthen Floor 100

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Risk Factors Associated with Illness

Variable Case (N=13)

Control (N=26) OR 95% CI

Male 13 7 35.0 3.9 – 312.2

Illiterate 2 15 0.13 0.02 – 0.72

Agriculture Occupation 13 11 18.66 2.14 – 162.25

Consumption of Cooked Meat 13 19 5.6 0.62 – 49.94

Chopping / handling dead bull 13 0 378 21.95 – 6508.8

Slaughtered dead bull 10 0 90 8.35 – 969.21

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Laboratory InvestigationSpecimen Laboratory Procedure Results

Blood Culture Staphylococcus aureus

Wound Swab Gram Staining Spore forming, non-motile, gram positive bacilli, with bamboo stick appearance in one sample in favour of Bacillus anthracis

Culture Non-haemolytic colony on Blood Agar in one sample suggestive of Bacillus anthracis

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Animal/Environmental Investigations

Specimen Laboratory Procedure Results Blood sample from Livestock Gram Staining & Culture No organism found

Soil particle Culture No organism found

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Livestock Vaccination 29th October 2014: First round livestock vaccination in

Kuruchdega village Seven teams deputed to vaccinate all livestock's including cattle,

sheep and goat with-in 5 kms around the Kuruchdega village Vaccination Coverage : 64% (4900/7600) livestock vaccinated

as of 7th November 2014

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Conclusion Outbreak in Tungritoli hamlet of Kuruchdega village is likely caused

by Anthrax All cases were from low socio economic status and predominantly

tribal Being male and in agricultural occupation were at more risk of

getting anthrax as compared to labourers Slaughtering and handling or chopping dead bull meat were

significantly associated with the illness

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Recommendation Sensitize health workers and animal health department for

early identification of anthrax disease among human and livestock

Increase community awareness about appropriate precautions and practices to prevent anthrax infection

Practicing personal protective measure during handling infected raw animal meat and bones

Vaccinate livestock annually in Bano block Enhance inter-sectorial coordination for early preparedness in

identifying & controlling the outbreak

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Acknowledgement Dr Achelal R Pasi: Co-investigator & EISO, NCDC, Delhi, India CDC:

Dr Kayla Laserson, Country Director, CDC, India Dr Samir V Sodha, Resident Advisor, India EIS Program, CDC, India Dr Shah Hossain, Public Health Specialist, CDC, India

NCDC: Dr Srinivas R Venkatesh, Director, NCDC, Delhi, India Dr Anil Kumar, HOD, Epidemiology, NCDC, Delhi, India Dr Aakash Shrivastava, Joint Director, Epidemiology, NCDC, Delhi, India Dr Pradeep Khasnobis, CMO, IDSP, NCDC, Delhi, India

IDSP, Jharkhand: Dr Ramesh Prasad, State Surveillance Officer, IDSP, Jharkhand, India Dr Adhyayan Sharan, District Epidemiologist, Simdega, Jharkhand, India

Thank You