State Surveillance Unit, Punjab Parivar Kalyan Bhawan ...pbhealth.gov.in/Annual Report 2014...

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State Surveillance Unit, PunjabParivar Kalyan Bhawan,

Sector 34- A, Chandigarh.Tel. No. [email protected]

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IndexS no Contents Page

1 Introduction 1

2 Laboratory segment 16

3 Case Definitions 33

4 Disease outbreak 50

5 Communicable Diseases 54

6 Newly Identified Outbreaks 87

7 Bacteriological status of Drinking water 107

8 H1N1 (Swine flu) 112

9 Ebola 126

10 Bird Flu 134

11 Brucellosis 140

12 Silicosis 146

13 Fluorosis 153

14 Arsenicosis 211

15 EIS Programme 215

16 Poster presentation and Studies 218

17 Way Forward 247

Compiled by: Dr Satish KumarEr. Nitin Kondal

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Integrated Disease Surveillance Programme

Introduction

Disease surveillance is an epidemiological practice by which the spread

of disease is monitored in order to establish patterns of progression. The main

role of disease surveillance is to predict, observe, and minimize the harm

caused by outbreak, epidemic, and pandemic situations, as well as increase

knowledge about which factors contribute to such circumstances. A key part of

modern disease surveillance is the practice of disease case reporting.

In modern times, reporting incidences of disease outbreaks has been

transformed from manual record keeping to instant worldwide internet

communication. The number of cases could be gathered from hospitals - which

would be expected to see most of the occurrences - collated, and eventually

made public. With the advent of modern communication technology, this has

changed dramatically. Organizations like the World Health

Organization (WHO) and the Centers for Disease Control now can report cases

and deaths from significant diseases within days, sometimes within hours of the

occurrence.

The concept of integrated infectious disease surveillance emerged in late 1990s

and it was put into practice by a number of countries since then. In 2003, the

World Health Organization (WHO) Regional Office for South-East Asia

(SEARO) developed a regional Integrated Disease Surveillance (IDS) strategic

plan in promoting an integrated approach to communicable and non-

communicable diseases (NCD) surveillance. After the plan was issued, SEARO

supported a comprehensive assessment of the national surveillance and

response systems in a number of member countries in the Region. Government

of India initiated a decentralized State based Integrated Disease Surveillance

Project in the country in response to a long felt need expressed by various

expert committees. Integrated Disease Surveillance Project (IDSP) was

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launched with World Bank assistance in November 2004 to detect and respond

to disease outbreaks quickly. The project design was based on the experience of

implementation of a WHO supported National Surveillance Project for

Communicable Diseases (1998-2003). The project was extended for 2 years in

March 2010. From April 2010 to March 2012, World Bank funds were

available for Central Surveillance Unit (CSU) at NCDC & 9 identified states

(Uttarakhand, Rajasthan, Punjab, Maharashtra, Gujarat, Tamil Nadu,

Karnataka, Andhra Pradesh and West Bengal) and the rest 26 states/UTs were

funded from domestic budget Programme continues during 12th Plan under

NRHM with outlay of Rs. 640 Crore from domestic budget only.

The State of Punjab had piloted disease surveillance program under the State

Health Project supported by the World Bank whereas the State was included in

the Phase III of the project in 2006-2007 and by now has experience of 7 years

in implementation. As per the guidelines provided by Govt. of India, IDSP is

being implemented in all districts of state which was formally launched on 12th

June, 2007 by Hon’ble, Health & Family Welfare Minister, at Bhawanigarh,

District Sangrur.

The State has designated Surveillance Units in all 22 districts to detect the early

causes of disease outbreak by involving health personnel at various levels like

Medical Officers, Lab. Technicians and Health Workers, who have been trained

in phases. Water Borne Diseases are major cause of outbreaks and there have

been reports of heavy metals in drinking water leading to various water related

health problems. A provision has been made in the State Public Health Lab to

do heavy metal testing in drinking water. All the districts are reporting

surveillance data on weekly basis as well as all the outbreaks, whenever they

occur. It is intended to detect early warning signals of impending outbreaks and

help initiate an effective response in a timely manner.

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Major Components of the Project

Early detection, confirmation and management of the

communicable diseases

Community based and hospital based surveillance

Integration and decentralization of surveillance activities

Strengthening of public health laboratories

Human Resource Development – Training of State Surveillance

Officers, District Surveillance Officers, Rapid Response Team,

other medical and paramedical staff as Pharmacists and health

workers.

Use of Information Technology for collection, collation,

compilation, analysis and dissemination of data.

For Project implementation, Surveillance Units have been set up

at State and District level.

Surveillance Committees at National, State and District levels are

monitoring the Project.

Linkages have been established with all State Head Quarters,

District Head Quarters and all Government Medical Colleges on

a Satellite Broadband Hybrid Network. This network enables

enhanced Speedy Data Transfer, Video Conferencing,

Discussions, Training, Communication and in future e-learning

for outbreaks and program monitoring under IDSP.

Information is sent to the respective District Surveillance Units

on internet and mobile networks for verification and initiating

appropriate actions wherever required.

Under IDSP data is collected on a weekly (Monday–Sunday)

basis. The information is collected on three specified reporting

formats, namely “S” (suspected cases), “P” (presumptive cases)

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and “L” (Laboratory confirmed cases) filled by Health Workers,

Clinician and Clinical Laboratory staff. The weekly data gives

the time trends whenever there is a rising trend of illnesses in any

area, it investigated by the Medical Officers/Rapid Response

Teams (RRT) to diagnose and control the outbreak.

Reporting of Weekly Surveillance data on “IDSP Online

Data Entry Portal” being entered online by districts since

April, 2008.

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Demography

10

Demography

10

Demography

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Demographic Data of Punjab

2011 census, Population of Punjab is 2,77,43,338.

13.89% increase from the population in 2001.

Decadal growth rate is lowest since 1961.

As per figures of 2011, the male population is 1,46,34,819 and

female population is 1,30,69,417.

Male/Female ratio in Punjab is 893 which is much lower than the

national ratio of 940.

Demographic Map of the Districts of Punjab

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11










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Table Showing District wise Distribution of the Number of HealthInstitutions in Punjab

Total Population(2011) 2,77,43,338

Total No. of districts 22

Total Divisions 5

Total Hospitals (Govt) Hospitals 21

CHC 129

Medical Colleges 8

SDH 36

No. of PHC’s 396

SHC 1196

Sub Centers 2950

Total Medical Colleges (Govt.) 3

Total Medical Colleges(Private) 5

State Training Institutes (SIHFW) 1

No. of State Training Institutes for

Paramedical

2

The data is collected from the reporting units in S (Syndromic

Surveillance), P (Presumptive Surveillance) and L (Lab Confirmation)

forms. There are 2972 reporting units for Syndromic surveillance form,

1633 for Presumptive surveillance form and 528 units for Laboratory

confirmation.

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District Wise Reporting Units of Punjab, 2014

S.NO. DISTRICTS RU In Form-S RU In Form-P RU In Form-L

1 AMRITSAR 190 138 50

2 BARNALA 67 52 11

3 BATHINDA 143 13 13

4 FIROZEPUR 125 62 15

5 FAZILKA 109 52 10

6 FARIDKOT 64 38 12

7 F. SAHIB 73 52 18

8 GURDASPUR 180 139 49

9 HOSHIARPUR 244 143 50

10 JALANDHAR 211 179 58

11 KAPURTHALA 88 56 15

12 LUDHIANA 287 104 32

13 MANSA 103 23 13

14 MOGA 124 85 17

15 MUKTSAR 109 69 9

16 NAWANSHAHR 96 29 11

17 PATIALA 57 41 16

18 PATHANKOT 192 118 35

19 RUPNAGAR 85 49 19

20 SASNAGAR 78 79 21

21 SANGRUR 194 16 16

22 TARN TARAN 153 96 38

Total 2972 1633 528

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Adminstrative Set Up of Health Department, Punjab

1 Sh Surjit Kumar Jiyani - Honourable Health Minister, Punjab

2 Dr. Navjot Kaur Sidhu – Chief Parliamentary Secretary (Health), Punjab

Smt Vini

Mahajan, IAS

Principal Secretary, Govt. of Punjab,

Deptt of Health & Family Welfare

0172-2743442

Mr.Hussan lal,

IAS

Secretary Health and Mission Director,

NHM, Punjab

0172-4012011/12

Dr. Karanjit

Singh

Director Health and Family welfare,

Punjab

0172-2600455

Dr. Jatinder

Kaur

Director Family Welfare (DFW), Punjab 0172-2646811,

09814055996

Dr. Deepak

Bhatia

Project Coordinator cum State

Surveillance Officer , IDSP

0172-2621506

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Constitution of State and District Surveillance Committees:-

State Surveillance Committee under the Chairmanship of Principal Secretary

Health & Family Welfare has been formed, as per guidelines issued under

IDSP.

Principal Secretary Health & Family Welfare Chairman

Director Health Services Co-ChairmanProgramme Officer of PH, TB, Malaria, HIV,Polio

Member

Director Research and Medical Education(DRME)

-do-

Representative from Department of Environment& Home

-do-

Coordinating member from State MedicalCollege Surveillance Team

-do-

Representative from the State Unit of the IndianMedical Association

-do-

NGO representative -do-

Head of State Public Health Laboratory -do-

State Surveillance Officer Member Secretary

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Diseases / Conditions Under Surveillance Programme

(i) Regular Surveillance:

Vector Borne Disease

Water Borne Disease

Diarrheal Disease (Cholera):

Respiratory Diseases

Vaccine Preventable Diseases

Diseases under eradication

Other Conditions

Road Traffic Accidents

(Linkup with police computers)

Other International commitments:

Plague

Unusual clinical syndromes .

Menigoencephalitis / Respiratory

(Causing death / hospitalization)

Distress Hemorrhagic fevers, other undiagnosed conditions

(ii) Sentinel Surveillance

Sexually transmitted diseases/Blood borne

HIV/HBV, HCV

Other Conditions :

Water Quality

Outdoor Air Quality

(Large Urban centers)

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(iii) Regular / periodic surveys.

IDSP Online Portal Reporting in 2014

The information from the peripheral health institutions is received by the

district surveillance unit (DSU) through S, P and L forms. The district in turn

sent the reports to the state. The states sent their reports through the IDSP

portals to the central surveillance unit (CSU). CSU receive the reports from all

over the country.

Diagram Showing the Flow of Information in IDSP

In Punjab, IDSP portal has above 90% (overall) reporting throughout the year

2014 in S and L forms. Only the month oh May had shown a slight decrease in

reporting. In case of the P forms, January had reported above 90% reporting

while it was below 90% throughout the year. Regarding Form P, reporting was

less than 80% from February to October 2014.

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Table Showing the %age of Reporting on IDSP Online Portal of VariousDistricts of Punjab in 2014

Month Form-S Form-P Form-L

January, 2014 96.87 95.63 95.80

February, 2014 91.69 77.12 93.59

March, 2014 95.04 75.61 94.80

April, 2014 90.62 73.55 89.62

May, 2014 88.04 71.23 85.19

June, 2014 95.43 78.79 90.51

July, 2014 93.96 77.99 93.26

August, 2014 93.48 78.23 93.29

September, 2014 93.89 79.02 94.02

October, 2014 91.51 77.66 93.64

November, 2014 95.86 80.54 96.83

December, 2014 93.95 79.90 93.34

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Graph Showing the %age of Reporting on IDSP Portal by Various

Districts of Punjab, 2014

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

%age Reporting on IDSP Online Portal-2014

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19




Form-SForm-PForm-L

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Manpower Under IDSP

Post No of postsanctioned

In place Remarks

StateEpidemiologist

1 1 -----

DistrictEpidemiologists

22 15 IDSP

12 PCMS

Recruitment underprocess. There is at leastone Epid. posted at eachdistrict, either underIDSP or regular inPCMS except Barnala,Hoshiarpur and Sangrur.districts

StateMicrobiologist

1 1 -----

State Entomologist 1 1 -----Microbiologist atDistrict Priority lab

1 1 -----

Data manager atState

1 1 -----

Data manager atDistricts

22 20 -----

Data entryoperators at state

1 1 -----

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Status of the Laboratory Services In Punjab Under IDSP

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Status of the Laboratory Services In Punjab Under IDSP

Laboratory is the backbone of the IDSP network. It has a major role in disease

surveillance at the peripheral level and the existing infrastructure is planned to

be improved for detection of communicable diseases to confirm and diagnose

outbreaks/ epidemics.

List of Functional Equipments Made Available at Reference Laboratories

1. Autoclave

2. Incubator

3. Binocular microscope

4. ELISA reader and washer

5. Refrigerator

6. Deep Freezer (-20°C)/any other

7. Shredder/ Needle destroyer

8. Centrifuge

9. Micro pipettes

10 Water bath

Documents Available In Reference Laboratories-

1. Waste management guidelines

2. Records of patient information and results of samples processed in lab

3. Standard SOPs

4. IDSP reporting formats.

List of Tests for Public Health Surveillance Under IDSP

1. Cholera culture and sensitivity

2. Typhoid: Typhoid and Culture and sensitivity

3. Meningococcal meningitis-latex agglutination

4. Hepatitis A-IgM ELISA

5. Hepatitis E-IgM ELISA

6. Measles-IgM ELISA

7. Dengue- IgM ELISA

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8. Diphtheria-culture

9. Leptospirosis-Rapid dot test

10 Any other locally relevant epidemic prone disease.

Minimum Diagnostic Facilities Available at Referral Labs

ELISA facilities for HAV ,HEV

ELISA facilities for HbsAg, HCV

ELISA facilities for Dengue, Chikungunya, Leptospirosis, J.E

ELISA for Scrub Typhus

ELISA for Measles, Mumps

Gram staining for sputum, throat swab, CSF, pus

Blood Culture for Enteric Fever

Diphtheria smear examination and Culture and ELISA

Culture for Vibrio cholera

Antimicrobial sensitivity

Serotyping

Establishment of “Referral Lab Network” in the State for investigation and

confirmation of cause of outbreaks through human samples.

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Linkages of the Various Districts With Referral Labs

Lab. Identified Linked Districts

Med. College Amritsar Amritsar, Taran Taaran, Kapurthala, Gurdaspurand Jalandhar

Med. College Faridkot Faridkot, Firozepur, Bathinda, Muktsar and Moga.

Med. College Patiala Patiala, Sangrur, Mansa, Barnala and F.G Sahib

CMC , Ludhiana Ropar, Nawan Shahar (SBS Nagar), Ludhiana andHoshiarpur

District Priority Lab,Mohali

District Mohali (SAS Nagar) only

Services Provided by the Referral Laboratory:

Undertake culture and sensitivity tests for public health purposes and

support other microbiological testing for outbreak investigations and

in turn the confirmation of the outbreak

Provide support to the Rapid Response Teams of the linked districts

Participate in training of lab technicians of attached district

laboratories,

Play mentoring role for the linked districts,

Strengthen internal quality control following Standard Operating

Procedures

Share with SSU/DSU the data of routine surveillance of pathogens

causing syndromes like acute diarrhea among the users of the

hospitals where the lab is located.

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Funds Provided

1. SSO provides Rs 200,000 to the referral laboratories as annual grant.

2. Reimburse the referral laboratory every quarter based on reporting on the

number of tests carried out for public health purposes based on the

reimbursement rates for each test.

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Outbreaks Investigated/Confirmed by Referral Labs and Other State

Laboratories From 2012-2014

Year

Total

outbreaks

reported

No.

Outbreaks lab

accessed, out of

total

outbreaks

No. %

Outbreaks lab

confirmed, out of

total outbreaks

No. %

Outbreaks clinically

confirmed, out of

total outbreaks

No. %

2012 49 43 87 41 83 7 14

2013 39 34 87 34 87 5 12

2014 48 38 79 38 7910

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Outbreaks Lab Investigated/Confirmed by Referral Labs and OtherLabs During 2014

Name of Referral Lab/other labs No. of Outbreaks labaccessed

No. of Outbreaks labconfirmed

GMC, Amritsar 4 4

GMC, Faridkot 8 8GMC, Patiala 6 6

CMC, Ludhiana 10 10State Public Health Lab, Chd. 01 01

District Public Health Lab,Mohalli

6 6

District Public Health Lab,Fatehgarh Sahib

1 1

District Public Health Lab,Barnala

1 1

District Public Health Lab,Hoshiarpur

1 1

Total 38 38

0

10

20

30

40

50

60

Total outbreak Lab assessed Lab confirmed Clinicallyconfirmed

No ofOutbreak

Method of Outbreak Investigation

Graph Showing the Number of outbreaks andthe Methods of investigation from 2012-2014

2012

2013

2014

28

0

2

4

6

8

10

12

No ofOutbeaks

Name of the Referral and Public Health Laboratory

No. of Outbreaks Lab. Assessed and Lab. Confirmed byReferral and Public health Laboratories,Punjab, 2014

No. of Outbreaks labaccessed

No. of Outbreaks labconfirmed

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Hospital Based Surveillance under Reference Laboratories in Punjab,

2014

Out ot the total blood tests done in the reference laboratories, GMC, Amritsar,

GMC, Patiala, CMC, Ludhiana had performed 30% each while 11% blood tests

were carried out by GGSMC, Faridkot. 68% of the IgM ELISA for HAV and

HEV was performed by GMC, Amritsar.

Referral

Lab

HA

V,

HE

V

IgM

ELI

SA

IgM,

HBsA

g

ELIS

A

IgM,

HCV

ELIS

A

Cult

ure

for

V.

Cho

lrea

IgM

Mu

mps

Cult

ure

(Blo

od)

Cult

ure

Diph

theri

a

IgM

Mea

sles

Scru

b

Typh

us

IgM

Diph

theri

a

Total

GMC,Amritsar

446 66 66 78 0 0 0 0 0 0 656

GMC,Faridkot

0 20 203 0 0 0 16 9 0 0 248

GMC,Patiala

204 85` 154 84 5 5 22 19 0 137 630

CMC,Ludhiana

158 37 37 84 41 0 18 0 69 191 635

808 123 460 246 46 5 56 28 69 328 2169

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District Laboratories Under IDSP

14 District Public Health Labs (Barnala, Fatehgarh Sahib, Ferozepur,

Gurdaspur, Jalandhar, Kapurthala, Mansa, Mukatsar, Nawanshahr,

Ropar, SAS Nagar, Sangrur, Bathinda and Hoshiarpur) are strengthened

where all the investigations for epidemic prone diseases are being

conducted/ confirmed. Out of these 14 labs, three labs were started in

2013-2014 at Hoshiarpur, Bathinda and Sangrur.

List Of Functional Equipments Provided / To Be Provided In Three New

Laboratories

• Autoclave

• Bio- safety cabinet

• Binocular Microscopes

• Needle destroyer

• Refrigerator

050

100150200250300350400450500550600650700

No ofTests

Name of the Tests

Graph Showing the Various Tests Carried Out bythe Referral Laboratories in Punjab in 2014

GMC, Amritsar

GMC, Faridkot

GMC, Patiala

CMC,Ludhiana

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• Electronic Balance

• Water bath

• Incubator

• Hot Air Oven

• Deep Freezer

• Computer with printer

Physical Infrastructure In Laboratories

• Sample collection area

• Sample storage facility

• Working area of laboratories

• Sterilization & Disinfection area

• Media Preparation room

• Continuous Water Supply

Distribution of the staff, work management and the pattern of the staff

employed is given in the table below.

Work distribution Bacteriology, Serology, Mycology

Staffing pattern Microbiologist, Lab Assistant, Cleaner

Working hours 24 hours

Work management Emergency Services round the clock and extraduties during outbreak

EQAS Not done

Minimal Diagnostic Services to be Provided in District Labs

Gram Stain Smears of clinical specimen like throat swab, sputum, CSF etc.

Smear examination of malaria.

Culture blood, sputum, CSF etc. or bacterial pathogens and perform

antimicrobial susceptibility testing on the isolates.

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Culture of stool specimen for Vibrio Cholera and other common bacterial

enteropathogens.

IgM ELISA for Viral Hepatitis A & E.

IgM ELISA for Dengue/ Chickengunya

IgM ELISA for Measles

Diphtheria Smear examination and culture

Rapid latex agglutination test for meningococci ( during suspected

outbreaks)

Sputum for AFB

Other tests relevant for locally prevalent epidemic prone disease i.e. ELISA

for Leptospirosis, rapid diagnostic tests for Kalaazar, IgM ELISA for JE.

Present Status of the Tests Conducted by the Priority Labs

Procurement of kits/Equipments: - In Medical college referral labs, the

equipment and kits are already in place and in District priority lab the

necessary equipment and kits have been already procured and are being

utilized. Recently DPL Mohali has purchased new kits for HEV and HAV.

Guidelines have been issued to Civil Surgeon Mohali to completely utilize

the testing facilities available at District Priority Lab which is located in

Civil Hospital, Mohali.

EQAS: - The first round of EQAS is in process. Samples provided for

EQAS by NCDC, New Delhi have been processed and reports have been

submitted by all the Referral Labs and District Priority Lab, Mohali directly

to NCDC. The results of those samples for EQAS are yet to be conveyed by

NCDC.

Sensitization of Medical Officers/ Epidemiologists/ Microbiologist lab

technicians: Sensitization regarding the sample collection and

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transportation during the outbreaks and early processing of the samples

needs to be stressed under IDSP.

Outbreaks Assessed & Confirmed by District Public Health Laboratories

In 2014

Name of District public health

labs

No. of Outbreaks lab

accessed

No. of Outbreaks lab

confirmed

District public health lab Mohalii 6 6

Barnala 1 1

Fatehgarh Sahib 1 1

Hoshiarpur 1 1

Total 9 9

Performance Of District Public Health Labs Under IDSP

The district public health laboratories carried out the culture of urine, pus,

blood as well as stool. 22% of the urine samples cultures were carried out by

the district public health laboratory SAS Nagar followed by 10% by SBS

Nagar and 1% in Muktsar. 17% of the pus culture was done by SBS Nagar

while it was 3% in Kapurtahala and Jalandhar. 39% of blood culture by

Hoshairpur while it was minimum (<1%) in Kapurthala.

Overall performance of the SBS Nagar was 26% (maximum) while it was

2% by Fatehgarh Sahib (minimum)

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Name ofDistrict

UrineCulture

Pus swabCulture Stool

BloodCulture

ThroatSwab

Other(OT

Swabs)

GrandTotal

SAS Nagar 1535 167 151 508 5 598 2964SBS Nagar 684 113 14 47 3 38 899

Ropar 526 62 8 74 7 77 754Kapurthala 339 31 6 6 0 34 416

Mansa 655 55 15 197 2 29 953Gurdaspur 599 51 44 86 0 13 793Ferozepur 464 50 63 50 6 44 677Hoshiarpur 648 81 79 720 0 59 1587Jalandhar 132 31 199 21 0 51 454Barnala 377 44 14 19 0 4 458Sangrur 357 107 36 59 66 100 725

F.G Sahib 382 46 13 35 3 25 216Muktsar 95 88 7 28 11 96 325Bathinda 125 68 2 19 3 8 225Amritsar 297 58 - - - 639 911

Total 7215 1052 651 1869 106 1815 12357

State Public Health Laboratory System

Throughout the current decade, individual states have been working to develop

laboratory networks. The ultimate goal for such efforts is to create a

comprehensive system that can respond to all public health needs and threats.

In 2007, APHL defined an SPH Laboratory System as a network consisting of

all the participants in PHL testing, including those who initiate testing and those

who ultimately use the test results. This definition of the SPH Laboratory

System is consistent with the goals of the NLS. A successful NLS supports

voluntary, interdependent partnerships of public health, clinical, environmental,

agricultural, and veterinary laboratories through public-private collaboration for

assurance of quality laboratory services and public health surveillance.

The SPH Laboratory System should contribute to the assurance that:

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1. Public health threats are detected and intervention is timely,

2. Stakeholders are appropriately informed of potential threats,

3. Reportable conditions are monitored in a comprehensive statewide

system,

4. Specimens and isolates for public health testing are sufficient to provide

comprehensive public health surveillance and response, and

5. PHL data are transmitted to designated local, state, and federal agencies

responsible for disease prevention, surveillance, and control.

The state PHL has a leadership role in developing and promoting the SPH

Laboratory System through active collaboration with stakeholders, including

epidemiologists, public health program managers, first responders,

environmental and agricultural professionals, private clinical and

environmental laboratories, and local PHLs.

State public health laboratory, Mohalli was established in Civil Hospital,

SAS Nagar in Nov -2010 and works undertaken are diagnostics, public

health and teaching.

First lab of its kind in State Punjab to undertake culture and

sensitivity test activity for public health purposes and support other

microbiological testing for epidemic prone diseases in the district.

Diagnostic facilities made available at District Priority Lab

• ELISA facilities for HAV & HEV, Dengue

• Gram staining for sputum, throat swab, CSF, pus

• Blood Culture for Typhoid

• Diphtheria smears examination.

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Case Definitions Under IDSP

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Case Definitions Under IDSP

Acute Diarrhoeal Disease

Clinical case description:

Acute watery diarrhoea (passage of 3 or more loose or watery stools in the past

24 hours) with or without dehydration.

Laboratory criteria for diagnosis:

Not necessary

Case classification

Suspect case: As per clinical case description.

Probable case: Not applicable

Confirmed case: Not applicableC

Acute Bloody Diarrohea


Acute diarrhoea with visible blood in the stool.


Lab culture of stools maybe used to confirm possible outbreaks of specific

diarrhoea, such as S. dysenteriae type 1, but is not necessary.

Case classification

Suspect case: as per clinical case definition.


Confirmed case: Not applicableOLRA

Cholera


In an area where the disease is not known to be present:

Severe dehydration or death from acute watery diarrhoea in a patient aged 5

years or more

In an area where Cholera is endemic:

Acute watery diarrhoea, with or without vomiting in a patient aged 5 years or

more.

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In an area where there is a cholera epidemic:

Acute watery diarrhoea, with or without vomiting, in any patient.


Isolation of Vibrio cholera O1 or O139 from stools in any patient with

diarrhoea.

Case classification

Suspect case: A case that meets the clinical case definition.


Confirmed case: A suspected case that is laboratory-confirmed.

Dengue Fever

Clinical case definition:

An acute febrile illness of 2-7 days duration with 2 or more of the following:

♦ Headache,

♦ Retro-orbital pain,

♦ Myalgia,

♦ Arthralgia,

♦ Rash

♦ Haemorrhagic manifestations

♦ Leucopoenia

Laboratory Criteria for Diagnosis:

Any one or more of the following:

• Isolation of the dengue virus from serum, plasma, leukocytes, or autopsy

samples

• Demonstration of a fourfold or greater change in reciprocal IgG or IgM

antibody titres to one or more dengue virus antigens in paired serum samples

(depending on the diagnostic kit used)

• Demonstration of dengue virus antigen in autopsy tissue by

immunohistochemistry or immunofluorescence or in serum samples by EIA

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• Detection of viral genomic sequences in autopsy tissue, serum or CSF samples

by polymerise chain reaction (PCR)

Case classification

Suspected: A case compatible with the clinical description.

Probable: A case compatible with the clinical description with one or more of

the following:

• Supportive serology (reciprocal haemagglutination-inhibition

antibody titre, comparable IgG EIA titre or positive IgM antibody test

in late acute or convalescent-phase serum specimen).

• Epidemiologically linked with a confirmed case of dengue fever

(occurrence at same location and time as other confirmed cases of

dengue fever).

Confirmed: A case compatible with the clinical description and

laboratoryconfirmed.

Dengue Haemorragic FeverDengue (DHF)

A probable or confirmed case of dengue

1. And Haemorrhagic tendencies evidenced by one or more of the following:

• Positive tourniquet test

• Petechiae, ecchymoses or purpura

• Bleeding: mucosa, gastrointestinal tract, injection sites or other

• Haematemesis or melaena

2. And thrombocytopenia (100,000 platelets or less per mm3)

3. And evidence of plasma leakage due to increased vascular permeability,

manifested by one or more of the following:

• >_20% rise in average haematocrit for age and sex

• >_20% drop in haematocrit following volume replacement treatment

compared to baseline

• Signs of plasma leakage (pleural effusion, ascites, hypoproteinaemia)

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Dengue Shock syndrome

All the above criteria, plus evidence of circulatory failure manifested by rapid

and weak pulse, and narrow pulse pressure (<_20 mm Hg) or hypo-tension for

age, cold, clammy skin and altered mental status.

Acute Viral Hepatitis


Acute illness typically including acute jaundice, dark urine, anorexia, malaise,

extreme fatigue, and right upper quadrant tenderness. Biological signs include

increased urine urobilonogen and >2.5 times the upper limit of serum alanine

aminotransferase2.


Hepatitis A: IgM anti HAV positive

Hepatitis B: Positive for HbsAg or IgM anti-HBc3

Hepatitis C: Positive for anti-HCV

Hepatitis D: Positive for HbsAg or IgM anti-HBc Plus anti-HDV

Hepatitis E: Positive for anti-HEV

Case classification

Suspect case: as per clinical case definition.


Confirmed case: A suspect case that is laboratory confirmed. For Hepatitis A, a

case compatible with the clinical description and with epidemiological link with

a lab confirmed case of Hepatitis A.

HIV infection


There is no clinical description; the diagnosis is based on lab criteria


HIV positive serology (ELISA)

Confirmation should be a second ELISA.L HEPATITIS

43

AIDS


WHO clinical case definition for AIDS in an adult or adolescents (>12 years of

age) when diagnostic resources are limited. For the purposes of AIDS

surveillance an adult or adolescent (>12 years of age) is considered to have

AIDS if at least 2 of the following major signs are present in combination with

at least 1 of the minor signs listed below, and if these signs are not known to be

related to a condition unrelated to HIV infection

Major signs (2 signs or more):

• Weight loss >_10% of body weight

• Chronic diarrhoea for >1 month

• Prolonged fever for >1 month (intermittent or constant)

Minor signs (1 or more):

• Persistent cough for >1 month

• Generalized pruritic dermatitis

• History of herpes zoster

• Oropharyngeal candidiasis


HIV positive serology (ELISA)

Confirmation should be a second ELISA.

Case classification


Confirmed case: A suspect case that is lab confirmed.

Japanese Encephilitis


A case of sudden onset of fever, chills and aches, including headaches and

sometimes meningismus, particularly in adults. In children, gastrointestinal pain

and dysfunction may dominate the initial stage of the disease and convulsions

are common. Although the disease is often mild, some cases rapidly progress to

44

severe encephalitis with mental disturbances, general or focal motor

abnormalities and progressive coma. The encephalitis cannot be distinguished

clinically from other central nervous system infections.


Presumptive: Detection of an acute phase anti-viral antibody response through

one of the following:

• Elevated and stable serum antibody titres to JE virus through ELISA,

haemagglutination-inhibition or virus neutralization assays or

• IgM antibody to the virus in the serum

Confirmed:

• Detection of the JE virus, antigen or genome in tissue, blood or other body

fluid by immunochemistry or immunofluorescence or PCR, or

• JE virus-specific IgM in the CSF, or

• Fourfold or greater rise in JE virus-specific antibody in paired sera (acute and

convalescent phases) through IgM / IgG, ELISA, haemagglutination inhibition

test or virus neutralization assay, in a patient with no history of recent yellow

fever vaccination and where cross-reactions to other flaviviruses have been

excluded

Note: JE infections are common and the majorities are asymptomatic.

JE infections may occur concurrently with other infections causing

central nervous system symptoms, and serological evidence of recent

JE viral infection may not be correct in indicating JE to be the cause

of the illness.

Case classification

Suspect Case: A case that is compatible with the clinical description

Probable Case: A suspect case with presumptive lab results

Confirmed Case: A suspect case with confirmatory lab results.

Malaria


45

A case of fever, may be accompanied with

• Headache, backache, chills, rigors, sweating, myalgia, nausea and vomiting

• Splenomegaly and anemia

• Generalized convulsions, coma, shock, spontaneous bleeding, pulmonary

edema, renal failure and death (untreated falciparum infection)

Laboratory definition of malaria:

Demonstration of malaria parasites in blood films

Case classification

Suspect case: as per the clinical case definition

Confirmed case: A suspect case with malaria parasites in blood films

Confirmed complicated/severe malaria: A confirmed case with

symptoms/signs of complicated/severe malaria (prostration, impaired

consciousness, respiratory distress (acidotic breathing), multiple

convulsions, circulatory collapse, pulmonary oedema (radiological),

abnormal bleeding, jaundice, haemoglobinuria, severe anemia, etc).

Confirmed malaria death: Death of a confirmed case.

Measles


Any person with:

• Fever and

• Maculopapular (non-vesicular) rash, and

• Cough, coryza (i.e. running nose) or conjunctivitis (i.e. red eyes).

Or any person in whom a clinician suspects measles infection.


• At least a fourfold increase in antibody titre or

• Isolation of measles virus or

• Presence of measles specific IgM antibodies.

46

Case classification



Confirmed case : A case that meets the clinical case definition and that is

laboratory-confirmed or linked epidemiologically to a lab-confirmed case.

Poliomyelitis


Any child under fifteen years of age with acute flaccid paralysis (AFP) or any

person with paralytic illness at any age when poliomyelitis is suspected.


• Isolation of the virus from stool samples

Case classification



Confirmed case: A suspect case that is lab confirmed

A case is said to be compatible with Polio, if the lab result is negative due to

inadequate specimen, but a National review committee feels that clinically there

is evidence to suspect polio based on review of medical documents, and

specialised tests like EMG and NCV.PLAGUE

Plague


Disease characterised by rapid onset of fever, chills, headache, severe malaise,

and prostration with

Bubonic form: extreme painful swelling of lymph nodes (buboes)

Pneumonic form: cough with blood-stained sputum, chest pain, difficult

breathing

Septicaemic form: toxic changes in the patient.

47

Case classification


Probable case: A suspect case with Y.pestis F1 antigen detected in clinical

materials by direct fluorescent antibody testing or by some other standardized

antigen detection method, or

Isolate from a clinical specimen demonstrates biochemical reactions consistent

with Y.pestis or PCR positivity, or

A single serum specimen is found positive for diagnostic levels of

antibodies to y.pestis F1 antigen, not explainable on the basis of prior

infection or immunization epidemiological link with a confirmed case.

Confirmed case: a suspected or probable case that is lab-confirmed

Isolate identified as Y. pestis by phage lysis or cultures; or

A significant (4-fold) change in antibody titre to the F1 antigen in paired serum

specimens.CULOSIS

Tuberculosis

Case Definition (According to site and bacteriology).

Pulmonary tuberculosis, sputum smear positive (PTB+)

• Tuberculosis in a patient with at least two initial sputum smear examinations

(direct smear microscopy) positive for Acid-Fast Bacilli (AFB), or

• Tuberculosis in a patient with one sputum examination positive for acid-fast

bacilli and radiographic abnormalities consistent with active pulmonary

tuberculosis as determined by the treating medical officer, or

• Tuberculosis in a patient with one sputum specimen positive for acid-fast

bacilli and at least one sputum that is culture positive for acid-fast bacilli.

Pulmonary tuberculosis, sputum smear negative (PTB-)

Tuberculosis in a patient with symptoms suggestive of tuberculosis with at least

three (3) sputum specimens negative for acid-fast bacilli, and any one of the

following:

48

• Radiographic abnormalities consistent with active Pulmonary TB (as

determined by a MO), or

• Culture is positive.

Extra-pulmonary tuberculosis (ETB)

• TB of organs other than lungs: pleura, lymph nodes, abdomen, genito-urinary

tract, skin, joints, bones, meninges etc.

• Diagnosis should be based on one culture positive specimen from an

extrapulmonary site, or histological or strong clinical evidence consistent with

active extra-pulmonary TB, followed by a decision by a MO to treat with a full

course of ATT.

Any patient diagnosed with both pulmonary and extra-pulmonary TB should be

classified as a case of pulmonary TB.TYPHOID

Typhoid (Enteric Fever)


Any person with an insidious onset of sustained fever, headache, malaise,

anorexia, relative bradycardia, constipation or diarrhoea, and non-productive

cough. Intestinal ulceration can produce intestinal haemorrhage or perforations.

However, many mild and atypical infections occur.


Isolation of S. typhi from blood, stool, or other clinical specimen

Case classification

Suspect case: A patient with fever of at least 38 degree C for 3 or more days.

Probable case: A clinically compatible case that is epidemiologically linked to a

confirmed case in an outbreak

Confirmed case: A suspect case with laboratory confirmed positive blood

culture.

Carrier: S.typhi organisms persisting in stools or urine for >1 year after onset of

disease.

49

Disease Modified Case Definition (for P-form only)

1. Diarrhoea

A Acute Diarrhoeal Disease

Acute watery diarrhoea (passage of 3 or more loose or watery stools in the past

24 hours) with or without dehydration. (Source: Medical Officers’ Manual,

IDSP, 2006)

B Cholera

• In an area where the disease is not known to be present: Severe

dehydration or death from acute watery diarrhoea in a patient aged 5 years or

more

• In an area where Cholera is endemic: Acute watery diarrhoea, with or

without vomiting in a patient aged 5 years or more.

• In an area where there is a cholera epidemic: Acute watery diarrhoea,

with or without vomiting, in any patient.(Source: Medical Officers’ Manual,

IDSP, 2006)

2. Bacillary Dysentery

Acute diarrhoea with visible blood in the stool. (Source: Medical Officers’

Manual, IDSP, 2006)

3. Acute Viral Hepatitis

Acute illness typically including acute jaundice, dark urine, anorexia, malaise,

extreme fatigue, and right upper quadrant tenderness. Biological signs include

increased urine urobilinogen and >2.5 times the upper limit of serum alanine

aminotransferase. (Source: WHO Recommended Surveillance Standards, 1999)

4. Enteric Fever Any patient with fever for more than one week and with any

two of the following:

• Toxic look

• Coated tongue

• Relative bradycardia

• Splenomegaly

50

• Exposure to confirmed case

• Clinical presentation with complications e.g. GI bleeding, perforation, etc.

(Source: Medical Officers’ Manual, IDSP, 2006)

5. Malaria A case of fever which may be accompanied with any of the

following:

• Headache, backache, chills, rigors, sweating, myalgia, nausea and vomiting

• Splenomegaly and anemia

• Generalized convulsions, coma, shock, spontaneous bleeding, pulmonary

edema, renal failure and death (untreated falciparum infection)

Any case of fever in an endemic area may be considered as malaria. (Source:

NVBDCP Guidelines)

6. Dengue

A. Dengue Fever An acute febrile illness of 2-7 days duration with two or more

of the following:

• headache,

• retro-orbital pain,

• myalgia,

• arthralgia,

• rash

• haemorrhagic manifestations

• leucopoenia

and with one or more of the following:

• Supportive serology (reciprocal haemagglutination-inhibition antibody titer,

comparable IgG EIA titre or positive IgM antibody test in late acute or

convalescent-phase serum specimen).

• Epidemiologically linked with a confirmed case of dengue fever (occurrence

at same location and time as other confirmed cases of dengue fever). (Source:

NVBDCP Guidelines)

51

B. Dengue Hemorrhagic Fever (DHF)

A probable or confirmed case of dengue with the following signs:

haemorrhagic tendencies evidenced by one or more of the following:

• positive tourniquet test

• petechiae, ecchymoses or purpura

• bleeding mucosa, gastrointestinal tract, injection sites or other haematemesis

or melaena

and thrombocytopenia (100,000 platelets or less per mm3)

and evidence of plasma leakage due to increased vascular permeability,

manifested by one or more of the following:

• 20% rise in average haematocrit for age and sex

• 20% drop in haematocrit following volume replacement treatment compared

to baseline

• signs of plasma leakage (pleural effusion, ascites, and hypoproteinaemia

(Source: NVBDCP Guidelines)

C. Dengue Shock Syndrome (DSS)

All the above criteria, plus evidence of circulatory failure manifested by rapid

and weak pulse, and narrow pulse pressure (< 20 mm Hg) or hypotension for

age, cold, clammy skin and altered mental status. (Source: NVBDCP

Guidelines)

7. Chikungunya An acute illness characterized by sudden onset of fever with

any of the symptoms like headache, backache, photophobia, severe arthralgia,

rash and positive serology (when single serum sample is obtained during acute

phase or during the convalescence) (Source: NVBDCP Guidelines)

8. Acute Encephalitis Syndrome

A person of any age with acute onset of fever and any of the following

• change in mental status (confusion, disorientation, coma, inability to talk)

• new onset of seizures (excluding simple febrile seizures).

52

• other early clinical findings like an increase in irritability, somnolence or

abnormal behavior greater than that seen with usual febrile illness.

Probable JE (Japanese Encephalitis): A suspected case that occurs in close

geographic and temporal relationship to a laboratory-confirmed case of JE, in

the context of an outbreak. (Source: NVBDCP Guidelines)

9. Meningitis

A. Meningococcal Disease

An illness with sudden onset of fever (>38.5°C rectal or >38.0°C axillary) and

one or more of the following:

• neck stiffness

• altered consciousness

• other meningeal sign or petechial or purpural rash

• Turbid CSF (with or without positive Gram stain) or

• ongoing epidemic and epidemiological link to a confirmed case In patients

<1 year, suspect meningitis when fever accompanied by bulging fontanelle.

(Source: WHO Recommended Surveillance Standards, 1999; /CD Alert, April

2005)

B. Viral Meningitis A case with fever > 38.5°C and one or more of the

following:

• neck stiffness, severe unexplained headache, neck pain

and 2 or more of the following

• photophobia, nausea, vomiting, abdominal pain, pharyngitis with exudates

For children <2 years of age, a case is defined as a child with fever > 38.5°C

and irritability or bulging fontanelle.

(Source: WHO Recommended Surveillance Standards, 1999)

10. Measles Any person with:

Fever and

• Maculopapular rash lasting for more than 3 days and

• Cough or coryza (i.e. running nose) or conjunctivitis (i.e. red eyes).

53

(Source: Immunization Handbook for Medical Officers, MOHFW)

11. Diphtheria An illness of the upper respiratory tract characterized by the

following:

• laryngitis or pharyngitis or tonsillitis,

• and adherent membranes of tonsils, pharynx and/or nose.


12. Pertussis A person with a cough lasting at least 2 weeks with at least one

of the following:

• paroxysms (i.e. fits) of coughing

• inspiratory whooping

• post-tussive vomiting (i.e. vomiting immediately after coughing) without

other apparent cause.


13. Chicken pox A febrile illness with acute onset of diffuse (generalized)

maculopapulovesicular rash without other apparent cause.

(Source: Manual for surveillance of Vaccine Preventable Diseases, 3rd Edition,

2002, CDC)

14. Fever of Unknown Origin (PUO)

Fever of more than 101°F (38.3°C), either continuous or intermittent, for at

least two weeks, or Fever above 101°F with no known cause even after

extensive diagnostic testing (Source: www.umm.edu/altmed/ articles/fever)

15. Acute Respiratory Illness (ARI) / Influenza Like Illness (ILI)

A person with sudden onset of fever of >38°C and cough or sore throat in the

absence of other diagnosis. (Source: WHO Recommended Surveillance

Standards, 1999)

16. Pneumonia Any case clinically diagnosed as pneumonia with symptoms of

fever and cough and/or difficult breathing + chest X-ray confirmation.

Or In a child -

Pneumonia: Cough or difficult breathing and

54

• breathing rate >50/minute for infant aged 2 months to <1year

• breathing rate>40/minute for child aged 1 to 5 years and no chest indrawing,

stridor or danger signs

Severe Pneumonia: Cough or difficult breathing + any general danger sign or

chest indrawing or stridor in a calm child.

(General danger signs: For children aged 2 months to 5 years, the four general

danger signs are unable to drink/breast feed, vomits everything, convulsions,

and lethargic/unconscious) (Source: WHO Recommended Surveillance

Standards, 1999; IMNCI)

17. Leptospirosis Acute febrile illness with headache, myalgia and prostration

associated with any of the following:

• conjunctival suffusion

• meningeal irritation

• anuria or oliguria and/or proteinuria

• jaundice

• haemorrhages (from the intestines, lung )

• cardiac arrhythmia or failure

• skin rash and a history of exposure to infected animals or an environment

contaminated with animal urine.

Other common symptoms include nausea, vomiting, abdominal pain, diarrhea

and arthralgia. (Source: WHO Recommended Surveillance Standards &

Zoonosis Division, NICD,2006)

18. Acute Flaccid Paralysis (<15 yrs of age)

A case of AFP is defined as any child aged <15 years who has acute onset of

flaccid paralysis for which no obvious cause (such as serve trauma or

electrolyte imbalance) is found and which is epidemiologically linked with a

case of polio. (Source: Immunization Handbook for Medical Officers,

MOHFW)

55

Disease Outbreak

56

Disease Outbreak

Definition of Outbreak : An outbreak or epidemic is defined as ‘’the

occurrence in a community of cases of an illness clearly in excess of expected

numbers.’’ While an outbreak is usually limited to a small focal area, an

epidemic covers large geographic areas and has more than one focal point.

There is yet another definition of an outbreak – ‘’occurrence of two or more

epidemiogically linked cases of a disease (e.g. measles, cholera, dengue, JE,

AFP etc).’’

Steps for Outbreak Investigation

1. Determine the existence of an outbreak

2. Confirm the diagnosis

3. Define a case

4. Search for cases

5. Generate hypothesis using descriptive findings

6. Test hypothesis based upon an analytical study

7. Draw conclusions

8. Compare the hypothesis with established facts

9. Communicate findings

10 Execute prevention measures

Comparative Data of Outbreaks in Punjab from 2012 - 2014

In Punjab, numbers of the outbreaks reported from Punjab were almost same in

202 and 2014 while number of outbreak reported in 2013 were less. In 2012,

62% of the reported outbreaks were of acute diarreal disease while it was 26%

in 2013 and 31% in 2014. Outbreaks of Diptheria, Tularemia and scrub typhus

had been reported in 2013.

57

Disease 2012 2013 2014

Measles 0 1 6

Chickenpox 6 3 9

Food Posioning 4 5 3

Hepatitis 8 5 6

ADD/Gastro/Cholera 30 10 15

Dengue 0 0 0

Viral Encephalitis 0 0 0

Mumps 1 3 6

Enteric Fever 0 3 0

Drug allergy 0 1 0

Tularemia 0 1 0

Diphtheria 0 5 3

Scrub Typhus 0 1 0Total 49 38 48

58

Trends of the Disease Outbreaks in Punjab in 2012, 2013, 2014

0

10

20

30

No ofCases

Graph Showing the Trends of the DifferentOutbreaks From 2012-2014 In Punjab

%age of all outbreak whereinvestigations conducted within 48 hrs

%age of outbreaks where appropriatehuman samples were sent for lab…

%age of outbreaks which wereetiologically confirmed

%age of outbreaks which were clinicallyconfirmed

%age of outbreaks had final outbreakreport made available

Outbreaks assessed based on competencyassessment tool in year 2014

58


Name of the Outbreaks


20

0 20 40 60

%age of all outbreak whereinvestigations conducted within 48 hrs

%age of outbreaks where appropriatehuman samples were sent for lab…

%age of outbreaks which wereetiologically confirmed

%age of outbreaks which were clinicallyconfirmed

%age of outbreaks had final outbreakreport made available


58



201220132014

100

79

79

72

80 100 120


59

Communicable Diseases Reported

60

Acute Diarrhoeal Diseases

61

Acute Diarrheal Disease

Diarrhea is defined as the passage of loose, liquid or watery stool. Stool is

usually passed more than three times a day. These are the diseases caused by

infectious agents that are shed in faeces and can contaminate food and water

sources. Transmission occurs primarily through direct or fecal oral contact with

an infected person. Diarrhoeal disease is the second leading cause of death in

children under five years old, and is responsible for killing around 760 000

children every year. Diarrhoea can last several days, and can leave the body

without the water and salts that are necessary for survival. Most people who die

from diarrhoea actually die from severe dehydration and fluid loss.

Interventions to prevent diarrhoea, including safe drinking-water, use of

improved sanitation and hand washing with soap can reduce disease risk.

Diarrhoea can be treated with a solution of clean water, sugar and salt, and with

zinc tablets.

Acute Diarrheal Disease is the major public health problem in India. The

Punjab state is also endemically affected with these infections .In 2014, 171904

cases of acute diarrhea had been reported from the Punjab. The district

Jalandhar reported maximum (30515) number of cases while district Mansa

reported the least number of cases (505).

62

Table Showing Cases of Acute Diarrohea through Passive Surveillance

under IDSP Punjab from 2012-2014

Name of District Year 2012 Year 2013 Year 2014

Amritsar 23662 19134 18694

Barnala 3515 2379 3130

Bathinda 3917 3406 2346

Faridkot 7335 5590 4210

F.G.Sahib 3232 2824 3691

Ferozepur 2792 2582 2842

Gurdaspur 27561 18161 16207

Hoshiarpur 11635 8937 7541

Jalandhar 43586 38311 30515

Kapurthala 16264 13888 14949

Ludhiana 23738 18861 9582

Mansa 1791 6728 505

Moga 6966 5203 3353

Muktsar 2839 2436 2266

N.Shahar 3552 3393 3256

Patiala 23529 18606 17967

Ropar 6059 3761 3177

Sangrur 17689 16003 16522

S.A.S. Nagar 8072 7621 8671

Tarn Taran 3558 5314 2480

Total 241292 203138 171904

63

64 confirmed cases of Cholera were reported in 2012 and 30 cases in 2014.

Table Showing Number of Cholera Cases ( Confirmed) in Punjab, 2012-

2014

S

No.Year No Districts

1 2012 64Amritsar-14,Ludhiana-18,Mohall

-16, Patiala- 13, Faridkot-3

2 2013 3 Faridkot-2, Mohalli-1

3 2014 30Hoshiarpur-20, Amritsar-8,

Patiala-2

0

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No ofCases

Name of Districts

Graph Showing the District wise Distribution of AcuteDiarroheal Cases from 2012-2014

Year 2014Year 2013Year 2012

64

Viral Hepatitis

65

Acute Viral Hepatitis

Acute viral hepatitis is an inflammatory disease of the liver due to a viral

infection and the most common cause is infection with one of 5 viruses called

hepatitis A, B, C, D, and E. Of these, only hepatitis A virus (HAV) and hepatitis

E virus (HEV) are enterically transmitted. They cause acute and generally self

limiting infections without any long term carrier state. However, they cause

significant morbidity and socio-economic loss in many parts of the world.

Hepatitis A caused by hepatitis A virus (HAV), a picornavirus transmitted by

the fecal-oral route often associated with ingestion of contaminated food. It

causes an acute form of hepatitis and does not have a chronic stage. The time

between the infection and the start of the illness averages 28 days (ranging from

15 to 50 days)

Hepatitis E virus (HEV) belongs to Hepeviridae family, produces symptoms

similar to hepatitis A, although it can take a fulminant course in some patients,

particularly pregnant women. Chronic infections may occur in immune-

compromised patients.

People with hepatitis A are advised rest, stay hydrated and avoid alcohol. A

vaccine is available that will prevent HAV infection for up to 10 years.

Strict personal hygiene and the avoidance of raw and unpeeled foods can help

prevent an infection. Infected people excrete HAV with their feces two weeks

before and one week after the appearance of jaundice.

In Punjab, In 2014, total 150 clinically diagnosed cases were reported to the

state IDSP which is half the number of cases reported in year 2013. District

Jalandhar and Sangrur had reported the maximum number of cases in 2014.

66

Table Showing Year Wise Distribution of Hepatitis A & E Cases in Punjab

from 2012-2014

Name of District Year 2012 Year 2013 Year 2014

Amritsar 37 13 0Barnala 0 0 0Bathinda 1 17 0Faridkot 0 4 0F.G.Sahib 0 3 0Ferozepur 0 0 0Gurdaspur 3 0 0

Hoshiarpur 0 0 0

Jalandhar 117 66 72Kapurthala 0 4 0Ludhiana 261 5 0Mansa 145 75 3Moga 0 2 0Muktsar 0 0 0N.Shahar 0 0 0Patiala 0 1 4Ropar 0 0 0Sangrur 31 29 67S.A.S. Nagar 3 84 4Tarn Taran 0 0 0Total 598 303 150

67

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Am

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.Sah

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.S. N

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Tarn

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an

No ofCases

Name of District

Graph Showing the Distribution of Hepatitis A& E in Punjab from 2012-2014

Year 2012

Year 2013

Year 2014

68

Hepatitis B and C

69

Hepatitis B and C

Hepatitis B is a potentially life-threatening liver infection caused by the

hepatitis B virus. It can cause chronic liver disease and chronic infection and

puts people at high risk of death from cirrhosis of the liver and liver cancer.

More than 240 million people have chronic (long-term) liver infections and

more than 780 000 people die every year due to the acute or chronic

consequences of hepatitis B.

Hepatitis C is a liver disease caused by the hepatitis C virus. The hepatitis C

virus is a blood borne virus and the most common modes of infection are

through unsafe injection practices; inadequate sterilization of medical

equipment in some health-care settings; and unscreened blood and blood

products.

Globally, 130–150 million people have chronic hepatitis C infection. A

significant number of those who are chronically infected will develop liver

cirrhosis or liver cancer. 350 000 to 500 000 people die each year from

hepatitis C-related liver diseases.

There have been reported a rising no of cases of Hepatitis B & C in State of

Punjab and the recent efforts being made by the Health Deptt in collaboration

with PGI for the study of Chronic Viral Hepatitis in The State of Punjab – The

Chip Study and to advocate prevention, control and management of the disease.

The duration of this study is one year for which period of nine month needed

for collecting the data and three months needed for analyzing the data.

A core group to assess the status of Hepatitis B and C in Punjab and to carry out

the load of disease in Punjab was formed committee was formed. Experts from

PGI, Chandigarh, CMC & DMC Ludhiana, GMC Patiala, Amritsar as well as

Faridkot worked under chairmanship of Dr YK Chawla, Director PGI.

70

Table Showing list of Experts to assess the Load of Hepatitis B & C in

Punjab

S No. Name Designation1 Dr. YK Chawla

Dr. Ajay DusejaPrincipal Investigators

2 Dr. JS Thakur, Prof. RK Ratho,Prof. RK Dhiman, Dr. Atul Sachdev

Co-PIs at Chandigarh

3 Dr. Ajit Sood, Dr. RS ChinnaDr. Shavinder Singh, Dr. DivyaDeodhar

Co – PIs at Ludhiana

4 Dr. H.K. Madan,,Dr. AshishBhagat, Dr. Paramjit Kaur

Co – PIs at Patiala

5 Dr. Santokh SinghDr. Sham Sunder Deepti

Co – PIs at Amritsar

7 Dr. Ravinder GargDr. Sanjay Gupta

Co – PIs at Faridkot

71

An advisory committee was formed regarding the study and the members of the

committee are as shown in the table below.

S. No Name Designation

1 Mrs. Vini Mahajan Principal Secretary, Health & FamilyWelfare, Punjab.

2 Dr Karanjit Singh Director, Health & Family WelfarePunjab.

3 Dr. SS Gill Vice Chancellor, BFUHS, Faridkot

4 Research and Medicaleducation, Punjab

Director

5 Dr Deepak Bhatia Project Coordinator, IDSP, Punjab

6 Dr Seema Aggarwal State Epidemiologist, Punjab

A survey was conducted in various districts of Punjab to assess the load of the

Hepatitis B and C in Punjab. 59 cases of Hepatitis B were positive and the

district reporting the more cases were Moga, Muktsar and Patiala.

At the same time, 514 cases of Hepatitis C were found positive. The districts

reporting more number of cases were Muktsar, Barnala and Faridkot.

72

Survey Based Compiled Cases of Hepatitis B & C for Punjab State (IDSP)

Sr.

No

.

Distt Village/PHC/CH

C

Hepatitis

B

Hepatitis

C

Referral

Lab from

where

confirmed

Month

/year

1 Moga VillageBaghapurana

5 28 GMC,Faridkot

10-May

2 Barnala Village Kalala,Chanawal,Chunniwal, andSehajwal

0 16 GMC,Patiala

Dec.'10

3 Barnala VillageDhangarh, CHCDhanaula

6 0 GMC,Patiala

Jan.' 11

4 Faridkot Cases fromdifferent distts

0 39 GGSMC,Faridkot

Aug.'12

5 Nawashehr Mallan Bedian,Mukandpur

0 3 CMC,Ludhiana

Sept.'12

6 Patiala Sayedkheri,,Kalomajra

3 15 GMC,Patiala

Oct.'12

7 Patiala Matouli, Shutrana 5 21 GMC,Patiala

12-May

8 Mansa Phoos Mandi 0 11 GMC,Patiala

12-Jun

9 Hoshiarpur Kang Mai 0 18 CMC,Ludhiana

12-Apr

10 Ferozepur Village laduka,Laduka mandiand ChandigarhBasti

0 35 GGSMC,Faridkot

5-Jul

11 Muktsar Jagat Singh Wala 5 55 GMC,Faridkot

Oct.12&April13

12 Hoshiarpur VillageChohan,Block Tanda

0 6 CMC,Ludhiana

13-Apr

13 Barnala Village Kubewal 0 13 GMC,Patiala

13-Apr

14 Muktsar Chak Sherwala 1 8 GMC,Faridkot

13-Mar

73

15 Muktsar VillageKaniyawali

2 5 GMC,Faridkot

13-Apr

16 Ferozepur VillageFerozeshah

0 19 GMC,Faridkot

May,2013

17 Barnala Village Kalala 0 78 GMC,Patiala

July,2013

18 Faridkot Village Dhilwankalan

7 12 GMC,Faridkot

July,2013

19 Amritsar Central jailinmates

7 9 GMCAmritsar

Aug,2013

20 Hoshiarpur Village JhonowalTeh MansowalGarhshankar

1 2 CMCLudhiana

Oct,2013

21 Sangrur VillageBukanwal, PHCPanjgrahian

2 29 DMCLudhiana,otherPrivateLabs

Feb,2014

22 Fazilka VPO DhaaniVishesharnath,CHC Khuikhera

0 14 GMC,Faridkot

June,2014

23 Muktsar Vill Balamgarh,CHC Chak SherWala

0 25 GMC,Faridkot

July,2014

24 Moga Vill MadiMustafa

10 36 District LabMoga

Nov,2014

25 Mansa VillBhagwanpura,PHC Sardoolgarh

5 6 GMCPatiala

Nov,2014

26 Muktsar Vill Ghagga,BlocK Dodha

0 11 GMC,Faridkot

Dec,2014

Total 59 514

74

Protocol for Confirmation of Diagnosis & Treatment of Hepatitis B and C

Under hepatitis protocol, all patients will be registered for Hepatitis B and C on

the basis of a questionarrie to detect the cause of the disease.

Patients of Hepatitis B and C will be confirmed through Lal path

collection centres as per terms of rate contract

Tests will be done at base line to confirm the diagnosis

Thereafter the test will be done at 4 weeks, 12 weeks and then at 24

weeks, at 48 weeks and at 3 months.

All tests will be done at free of cost

Inj. Peginterferona to be made available at subsidized contract rate at Jan

Aushidi stores along with free tablet of Ribaprinewith each Injection

For Hepatitis B, free testing will be done at SRL Religare lab identified

by Ranbaxy, the supplier of Hepatitis B medicine at rate contract to be

made vaialable at Jan aushidi centres

Three time investigation will be done free of cost to patients

Protocol for diagnosis of Hepatitis C

Process Flow of Diagnostic Tests

INTRODUCTION OFPROGRAM TO

PHYSICIANS

PHYSICIANS WILLPRESCRIBE THETESTS/DRUG TO

PATIENTS & BRIEFTHE PROGRAM

PTS CALL TO TOLL-FREE NUMBER

(18002099209) TOGET ENROLLED IN

THE PROGRAM

PTS GETSREGISTERED BY 3RD

PARTY ONCEDOCUMENTS ARE

VERIFIED

PTS SENDS(MAIL/FAX) THEDOCS (RX & ID

PROOF) TO THE 3RD

PARTY

UNIQUE IDCREATION

PCR E-COUPONGENERATION

MAIL TORESPECTIVECOLLECTIONCENTER & PT

LAB WILL PERFORMTHE TEST AS PERTHE E-COUPON

TESTSREPORTSWILL BEGIVENTO 3RD

PARTY &PTS

fax number: 022-61012126Email address:

[email protected]

75

From: [patient / doctor / lab email ID]To: [email protected]: E-coupon for [Patient Name]

Please generate the e-coupon for following patient and find attached Rx and IDcopy.

Name: [Patient name] [wife or / son of _______ ]Age – [Age]Phone no- [Patient’s mobile #]Test – [Test Name]Lab – [Collection center where e-coupon will be sent]Doctor – [Doctor Name]

• All the informationmentioned in the email ismandatory.

• Health Impetus will callon the mentioned phone# for verification.

• Rx must mention patientname and test name.

• The patient name mustmatch with what is inthe email and ID proof.

• It is better to writepatient mobile # on Rxalso.

• Name on the ID proofmust match the name onemail and Rx.

• Tests could be “HCV RNAQuant” or “HCVGenotype” or “HCV RNAQUAL”.

• “Pre-therapy” or “on-therapy” must bementioned.

78

The proforma for the Survey of Hepatitis B & C in English

79

Proforma for Survey of Hepatitis B & C in Punjabi

80

Survey based compiled cases of Hepatitis B & C Punjab ,(IDSP)

S.No.

DisttVillage/PHC/

CHCHepatitis

BHepatitis

C

Referral Labfrom whereconfirmed

Month/year

1 MogaVillage

Baghapurana5 28

GMC,Faridkot

10-May

2 Barnala

VillageKalala,

Chanawal,Chunniwal,an

d Sehajwal

0 16 GMC, Patiala Dec.' 10

3 Barnala

VillageDhangarh,

CHCDhanaula

6 0 GMC, Patiala Jan.' 11

4 FaridkotCases from

different distts0 39

GGSMC,Faridkot

Aug.'12

5Nawash

ehr

MallanBedian,

Mukandpur0 3

CMC,Ludhiana

Sept.'12

6 PatialaSayedkheri,Kalomajra

3 15 GMC, Patiala Oct.'12

7 PatialaMatouli,Shutrana

5 21 GMC, Patiala 12-May

8 Mansa Phoos Mandi 0 11 GMC, Patiala 12-Jun

9Hoshiar

purKang Mai 0 18

CMC,Ludhiana

12-Apr

10Ferozep

ur

Villageladuka,Ladukamandi,

ChandigarhBasti

0 35GGSMC,Faridkot

5-Jul

11 MuktsarJagat Singh

Wala5 55

GMC,Faridkot

Oct.' 12& April

2013

12Hoshiar

pur

VillageChohan,Tanda

0 6CMC,

Ludhiana13-Apr

13 Barnala Village 0 13 GMC,Patiala 13-Apr

81

Kubewal

14 MuktsarChak

Sherwala1 8

GMC,Faridkot

13-Mar

15 MuktsarVillage

Kaniyawali2 5

GMC,Faridkot

13-Apr

16Ferozep

urVillage

Ferozeshah0 19

GMC,Faridkot

May,2013

17 Barnala Village Kalala 0 78 GMC,PatialaJuly,2013

18 FaridkotVillage

Dhilwan kalan7 12

GMC,Faridkot

July,2013

19 AmritsarCentral jail

inmates7 9

GMCAmritsar

August,2013

20Hoshiar

pur

VillageJhonowal Teh

MansowalGarhshankar

1 2CMC

LudhianaOctober,

2013

21 SangrurBukanwal,PHCPanjgrahian

2 29DMC

Ludhiana andPrivate Labs

February, 2014

22 Fazilka

DhaaniVishesharnath,

CHCKhuikhera

0 14GMC,

FaridkotJune,2014

23 Muktsar

VillBalamgarh,CHC ChakSher Wala

0 25GMC,

FaridkotJuly,2014

24 MogaVill MadiMustafa

10 36District Lab

MogaNovember, 2014

25 MansaBhagwanpura,Sardoolgarh

5 6 GMC PatialaNovember, 2014

26 MuktsarVill Ghagga,BlocK Dodha

0 11GMC,

FaridkotDecember, 2014

Total Cases 59 514

82

HMIS Data of various Districts of Punjab, 2013

83

World Hepatitis Day

Every year on 28 July, WHO and partners mark World Hepatitis Day to

increase the awareness and understanding of viral hepatitis and the diseases

that it causes.

On World Hepatitis Day, 28 July 2014, WHO and partners will urge

policymakers, health workers and the public to 'Think again' about this silent

killer. 28 July was chosen for World Hepatitis Day in honour of the birthday

of Nobel Laureate Professor Baruch Samuel Blumberg, discoverer of the

hepatitis B virus. World Hepatitis Day provides an opportunity to focus on

specific actions, such as:

• Strengthening prevention, screening and control of viral hepatitis and its

related diseases.

• Increasing hepatitis B vaccine coverage and integration of the vaccine into

national immunization programmes.

As done last year in 2013, activities were done between 25th to 29th July to have

maximum coverage in terms of number of people to be sensitized at the

community level & number of institutions to be covered.

84

Message by the Chief Minister, Punjab:

85

IEC activities

Posters/ banners were put up at the State HQs for sensitization of the visitors

and the staff. Similar posters were displayed at Distt level through educative

material supplied from State.

86

School Assembly talks

Students were sensitized by District School Health Coordinators through State

Programme Officer, School Health Programme through morning assembly talks

in schools of respective area between 25th and 29th July.

Print media advertisement on the symptoms, needs of preventive steps by

general public etc were issued in identified news papers.

The specified medicines for Hepatitis-B & Hepatitis-C in different strengths are

also made available at concessional rates at Jan Aushadhi Stores.

Activities Undertaken in Various Districts of Punjab

89

Enteric Fever

90

Enteric Fever

Enteric / Typhoid fever is a septicaemia caused by Salmonella sp. In India, it is

caused mainly by Salmonella typhi and less frequently by Salmonella

paratyphiA. It manifests in the form of fever (step-ladder rise) accompanied

with other symptoms like abdominal pain, vomiting, headache, loss of appetite,

etc.In the year 2014, total 30060 clinically diagnosed cases were reported to the

state IDSP.

Table Showing Distribution of Cases of Enteric Fever in Punjab From

2012-2014

Amritsar 2238 1677 1656Barnala 196 99 78Bathinda 1489 1419 1371Faridkot 2194 749 1002F.G.Sahib 347 209 98Ferozepur 414 689 866Gurdaspur 4173 2719 2718Hoshiarpur 1834 1982 1354Jalandhar 6915 8314 7020Kapurthala 1787 1688 1838Ludhiana 3415 2844 1683Mansa 629 521 536Moga 1075 1139 1108Muktsar 480 429 403N.Shahar 465 492 517Patiala 1089 887 1082Ropar 465 423 263Sangrur 1011 733 628S.A.S. Nagar 1933 1634 743Tarn Taran 554 155 12

Total 32703 28802 24976

91

0

1000

2000

3000

4000

5000

6000

7000

8000

9000A

mrit

sar

Bar

nala

Bat

hind

aFa

ridko

tF.

G.S

ahib

Fero

zepu

rG

urda

spur

Hos

hiar

pur

Jala

ndha

rK

apur

thal

aLu

dhia

naM

ansa

Mog

aM

ukts

arN

.Sha

har

Pat

iala

Rop

arS

angr

urS

.A.S

. Nag

arTa

rn T

aran

No ofCases

Name of District

Graph Showing the Distribution of Enteric fever (L-form)Cases in Punjab From 2012-2014

Year 2012

Year 2013

Year 2014

92

Newly Identified Outbreaks in Punjab

A number of the different outbreaks had been identified in each year.49

outbreaks had been identified in 2012, 38 in 2013 while 48 outbreaks had been

identified in 2014. Outbreaks of acute diarroheal diseases and Hepatitis had

been reported commonly. In Punjab, in recent years, many newly identified

outbreaks such as Diphtheria, Scrub Typhus, Measles, Mumps, Tularaemia etc

had been reported from various districts. These are given below in detail:

93

Diphtheria (1)

94

Diphtheria

Diphtheria is an acute, toxin-mediated disease caused by the bacterium

Cornybacterium diphtheria. Diphtheria is primarily transmitted via airborne

respiratory droplets or by direct contact with secretions from infected

people.This disease primarily affects the mucous membranes of the respiratory

tract (respiratory diphtheria), although it may also affect the skin (Cutaneous

diphtheria) and lining tissues in the ear, eye, and the genital areas.Incubation

period is 2-5 days (range, 1-10 days) . With the use of antibiotics and vaccines,

diphtheria is not only treatable, but preventable as well. The vaccine for

diphtheria is given in a single shot (along with vaccines for pertussis and

tetanus) that is called DTaP. The DTaP vaccine is administered in a series at 2,

4, and 6 months of age, and then again at around 1 and 4 years of age. In

2013,five outbreaks of diphtheria had been reported while in 2014, three

outbreaks were reported.

Blood samples were collected from two villages in Fazilka district, two areas in

Ludhiana and one village of Patiala. Nearly 60% ( village Bapror, Patiala) and

47% (Tazpur road,Ludhiana) of the children from whom the samples were

taken require immunisation.The number of children who rquire immunisation

was 33% (Village Danewala, Fazilka) and 30% ( Village Bhagawala, Fazilka).

This status of immunisation was communicated to state immunisation wingof

the DHS for necessary follow up.

95

Districtwise Information for year 2013 is given below :

S.No Name ofDistrict

Totalsamplescollected(BloodSamples )

No. ofchildrenwho needbasicimmunization (Basicimmunizationrecommended)

No. of childrenwho needregular booster(Boostervaccinationrecommended)

No. ofchildrenwho needspecificbooster(To beimmunized in 5years/10yrs)

%requireimmunization

1 VillageDanewala,Fazilka

51 17 18 16 33%

2 VillageBhagawala,Fazilka

40 12 15 13 30%

3 Azad Nagar,KhannaLudhiana

40 13 20 7 26%

4 TajpurRoad,Ludhiana

40 19 13 8 47.5%

5 Vill Bapror, Patiala

55 40 25 2 59.7%

The following table shows the number of the throat swabs collected with

their results and the number of the houses surveyed from two villages of

Fazilka distict and one village of the Bhatinda district.

96

Districtwise Information for year 2014 is given below

S.no Name ofDistrict

Totalsamplescollected(ThroatSwabs)

Positivesamples

Housessurveyed

Population

1 VillageWazidpura,Block KhuiKhera, DisttFazilka

2 nil 300, 2 brickkiln, 3 schools 5000

2 Village DhabaKokerian,BlockSittoguna,Distt Fazilka

2 1 200 3200

3 Village JaiSingh Wala,block Sangat,DisttBathinda

18 1 250 5282

A total 4 throat swab samples collected from the village and sent to

Christian Medical College and Hospital Ludhiana. Out of 4, 1 was found

positive for Diphtheria.

97

Result of Four Throat Swabs collected from Village Dhaba Kokrian

& Wazidpura, District Fazilka, Punjab

SlNo.

Name and Address Age/Sex

Results Date ofreceipt ofsample

Date ofDeclarationof results

1.

Ekta Sharma D/ORam SwaroopSharma, VPO DhabaKokrian

18/F Negative 26.05.2014 28.05.14

2.Sandeep Kaur D/OGurjant Singh VPOWazidpura

10/F Negative 26.05.2014 28.05.14

3.

Satyadeep SharmaS/O RamswaroopSharma VPO DhabaKokrian

11/M Positive 26.05.2014 28.05.14

4.Gagandeep kaur D/OGurjant Singh VPOWazidpura

14/F Negative 26.05.2014 28.05.14

98

Tularemia (2)

99

Tularemia

Tularemia, also known as “rabbit fever,” is a disease caused by thebacterium Francisella Tularensis. Tularemia is typically found in animals,especially rodents, rabbits, and hares. People become infected throughthe bite of infected insects (most commonly, ticks and deerflies), byhandling infected sick or dead animals, by eating or drinkingcontaminated food or water, or by inhaling airborne bacteria.Possible symptoms of the disease include skin ulcers, swollen and painfullymph glands, inflamed eyes, sore throat, mouth sores, diarrhea orpneumonia.

Prevention and control of Tularemia

When hiking, camping or working outdoorsUse insect repellants containing 20% to 30% DEET.Wear long pants, long sleeves, and long socks to keep tick and deer fliesoff your skin.Remove attached ticks promptly with fine-tipped tweezers.Don’t drink untreated surface water.When mowing or landscapingDon’t mow over sick or dead animals.Consider using dust masks to reduce your risk of inhaling the bacteria.If you hunt, trap or skin animalsUse gloves when handling animals, especially rabbits, muskrats, prairiedogs, and other rodents.Cook game meat thoroughly before eating.In Punjab first case reported in Military camp Gurdaspur, DistrictPathankot. Sample found positive for Brucellosis . Lab investigationswere being carried out in Manipal, Bangalore for confirmation. (1st stageof Tularemia tested positive)

100

Scrub Typhus (3)

101

Scrub Typhus

It is distributed throughout the Asia Pacific rim, being endemic in Korea,

China, Taiwan, Japan, Pakistan, India, Thailand, Malaysia, and northern

portions of Australia.

Scrub typhus is a mite-borne infectious disease caused by Orientia

tsutsugamushi. Scrub typhus is transmitted by species of Trombiculid

mites (Chigger) which are found in areas of heavy scrub vegetation.

The bite of this mite leaves a characteristic black Escher that is useful to

the doctor for making the diagnosis.

Clinical presentation

• Fever

• Headache

• Muscle pain,

• Cough

• Gastrointestinal Infection.

• More virulent strains of O. tsutsugamushi can cause Hemorrhaging

and Intravascular Coagulation.

• Escher, Spleenomegaly and Lymphadenopathies are typical signs.

• Leucopenia and abnormal liver function tests are commonly seen

in the early phase of the illness.

• Pneumonitis , encephalitis and myocarditis occur in the late phase

of illness.

Prevention of Scrub Typhus

Early diagnosis and treatment can greatly reduce the chance of life

threatening complications and guide optimal therapy.

Health promotion.

102

Health education.

Environmental modification in the context of scrub typhus.

Advocacy, awareness and education activities should be targeted at

school children, teachers and women groups in endemic areas as well as

to all those at risk along with general population as a health education

measure.

Habitat modification can be done by good sanitation.

Wearing protective clothes.

Using insect repellents containing 5% emulsion of dimethylphthalate,

dibutylphthalate, benzyl benzoate diethyl toluamide.

Avoiding sitting or lying on bare ground or grass.

Clearing of vegetation and chemical treatment of grass

In 2013, Scrub Typhus Outbreak was reported from village Shekhupura, blockMukandpur, District SBS, Nagar, Punjab. A house to house survey wasconducted in the shekhupur village.The total population of the village is 2239.A medical camp was organized on 14.12.13 and total of 70.patients wereexamined. Five cases were found to be positive. Four positive cases were in theage group of 15-40 years

Table showing the list of patients tested for Scrub Typhus in 2013

S.no Date Name Age/Sex

Address Result

1. 12.12.13

Lalu 32Y/M Vpo Shekhupur,Mukandpur

Positive

2. 13.12.13

Bhanu 31Y/F Vpo Shekhupur,Mukandpur

Positive

3. 13.12.13

Kala 36Y/F Vposhekhupur,Mukandpur

Negative

4. 14.12.13

Halema 50Y/F Shekhupur, Mukandpur Negative

5. 14.12.13

Razia 14Y/F Shekhupur, Mukandpur Negative

6. 14.12.13

Jatoon 30Y/F Shekhupur, MukandpurPositive

103

7. 14.12.13

Rani 35Y/F Shekhupur, Mukandpur Negative

8. 14.12.13

Hazi TegAli

65Y/M Shekhupur, Mukandpur Negative

9. 14.12.13

Saido 36Y/F Shekhupur, Mukandpur Negative

10. 14.12.13

NoorAlam


11. 14.12.13

BaghHasan


12. 14.12.13

Soorajuddin


13. 14.12.13

Reshma 70Y/F Shekhupur, Mukandpur Negative

14. 14.12.13

Md.Saleem

----/M Shekhupur, Mukandpur Negative

15. 14.12.13

Pappi 24Y/M Shekhupur, Mukandpur Negative

16. 14.12.13

Shaffi 23Y/M Shekhupur, Mukandpur Negative

17. 14.12.13

Shamdeen


18. 14.12.13

Manna 3Y/F Shekhupur, Mukandpur Negative

19. 14.12.13

Farzana 15Y/F Shekhupur, Mukandpur Negative

20. 14.12.13

Hazra 35Y/F Shekhupur, Mukandpur Negative

21. 16.12.13

Roshandeep


22. 16.12.13

SadiqMd.


23. 16.12.13

Chano 70Y/F Shekhupur, Mukandpur Negative

24. 16.12.1 Shello 40Y/F Shekhupur, Mukandpur Negative

104

325. 16.12.1

3Harjinder 34Y/F Shekhupur, Mukandpur Negative

26. 16.12.13

HarbansKaur

55Y/F Shekhupur, Mukandpur Negative

27. 16.12.13

SurjitKaur


28. 16.12.13

Rano 40Y/F Shekhupur, Mukandpur Negative

29. 16.12.13

Simro 65Y/F Shekhupur, Mukandpur Positive

30. 16.12.13

Ravinder 50Y/F Shekhupur, Mukandpur Negative

31. 16.12.13

Bhoowam


32. 16.12.13

Rani 36Y/F Shekhupur, Mukandpur Negative

33. 16.12.13

Simro 60Y/F Shekhupur, Mukandpur Negative

34. 16.12.13

Amanjot 25Y/F Shekhupur, Mukandpur Negative

35. 16.12.13

Shelly 35Y/F Shekhupur, Mukandpur Negative

36. 16.12.13

Shivama 8Y/F Shekhupur, Mukandpur Negative

37. 16.12.13

Mano 35Y/F Shekhupur, Mukandpur Negative

38. 16.12.13

Jaitoon 25Y/F Shekhupur, Mukandpur Negative

39. 16.12.13

Jaswinder 25Y/F Shekhupur, Mukandpur Negative

40. 16.12.13

Rohan 50Y/M Shekhupur, Mukandpur Negative

41. 16.12.13

Pinky 28Y/F Shekhupur, Mukandpur Negative

42. 16.12.1 Md. Raffi 26Y/M Shekhupur, Mukandpur Negative

105

343. 16.12.1

3Mamta 40Y/F Shekhupur, Mukandpur Negative

44. 16.12.13

JiwanLata


45. 16.12.13

ManjitKAUR


46. 21.12.13

Anchal 20Y/F Shekhupur, Mukandpur Negative

47. 21.12.13

Jaspal 50Y/M Chc Mukandpur Negative

48. 24.12.13

Usha 24Y/F ,Shekhupur, Mukandpur Positive

49. 24.12.13

Manjit 19Y/F Shekhupur, Mukandpur Negative

50. 24.12.13

SuchaRam


51. 02.1.14 Arjan 50Y/M Shekhupur, Mukandpur Negative52. 02.1.14 Surjit 38Y/M Shekhupur, Mukandpur Negative53. 02.1.14 Promila 65Y/F Shekhupur, Mukandpur Negative54. 02.1.14 Krishan 62Y/M Shekhupur, Mukandpur Negative55. 02.1.14 Amro 72Y/F Shekhupur, Mukandpur Negative56. 02.1.14 Sunita 40Y/F Shekhupur, Mukandpur Negative57. 02.1.14 Maya 70Y/F Shekhupur, Mukandpur Negative58. 02.1.14 Kamla 55Y/F Shekhupur, Mukandpur Negative59. 02.1.14 Gurmit 40Y/F Shekhupur, Muklandpur Negative60. 02.1.14 Shiksha 52YF Shekhupur, Mukandpur Negative61. 02.1.14 Surjit 55Y/F Shekhupur, Mukandpur Negative62. 02.1.14 Jaswinder 19Y/F Shekhupur, Mukandpur Negative63. 02.1.14 Kulbir 35Y/F Shekhupur, Mukandpur Negative64. 02.1.14 Baby 45Y/F Shekhupur, Mukandpur Negative65. 02.1.14 Balvir

Kaur50Y/F Shekhupur, Mukandpur Negative

66. 02.1.14 Ram Piari 70Y/F Shekhupur, Mukandpur Negative67. 02.1.14 Md.

Bashir23Y/M . Shekhupur,

MukandpurNegative

106

68. 03.1.14 Lata Rani 25Y/F , Shekhupur,Mukandpur.

Negative

69. 8.01.14 Vishal 14/F Shekhupur, Mukandpur. Negative70. 10.1.14 Dev

Singh70/M Bidrowal Negative

107

Measles (4)

108

Measles

Measles is caused by a virus in the paramyxovirus family and it is normallypassed through direct contact and through the air. Measles is a humandisease and is not known to occur in animals.Accelerated immunization activities have had a major impact on reducingmeasles deaths. During 2000-2013, measles vaccination prevented anestimated 15.6 million deaths. Global measles deaths have decreased by75% from an estimated 544 200 in 2000 to 145 700 in 2013.The highly contagious virus is spread by coughing and sneezing, closepersonal contact or direct contact with infected nasal or throat secretions.

Signs and symptoms

The first sign of measles is usually a high fever, which begins about 10 to12 days after exposure to the virus, and lasts 4 to 7 days. A runny nose, acough, red and watery eyes, and small white spots inside the cheeks candevelop in the initial stage. After several days, a rash erupts, usually on theface and upper neck. Over about 3 days, the rash spreads, eventuallyreaching the hands and feet. The rash lasts for 5 to 6 days, and then fades.On average, the rash occurs 14 days after exposure to the virus (within arange of 7 to 18 days).Most measles-related deaths are caused by complications associated with thedisease.The most serious complications include blindness, encephalitis (aninfection that causes brain swelling), severe diarrhoea and relateddehydration, ear infections, or severe respiratory infections such aspneumonia. Severe measles is more likely among poorly nourished youngchildren, especially those with insufficient vitamin A, or whose immunesystems have been weakened by HIV/AIDS or other diseases.

Routine measles vaccination for children, combined with mass immunization

campaigns in countries with high case and death rates, are key public health

strategies to reduce global measles deaths. The measles vaccine has been in use

for 50 years. It is safe, effective and inexpensive. It costs approximately one US

dollar to immunize a child against measles.

In 2014, six outbreaks of measles had been reported from the Punjab

109

Table showing the Measles outbreaks in Punjab, 2014

Date District No of Blood

Samples

Result

21.1.14 Moga 1 1 positive

7.10.14 Ferozepur 8 7 positive

31.10.14 Hoshiarpur 2 2 equivalent

15.11.14 Hoshiarpur 2 2 positive

17.12.14 Bathinda 1 1 positive

31.12.14 Mukatsar 1 1 Positive

110

Mumps (5)

111

Mumps

Mumps (epidemic parotitis) is a highly infectious, self-limited viral

disease caused by the mumps virus. Mumps is highly contagious and is able to

spread rapidly among people living in close quarters. The virus is transmitted

by respiratory droplets, direct contact, or contaminated objects.

Symptoms typically occur usually 14 to 18 days after exposure and patients are

infectious a few days before the onset of symptoms. Mumps is usually preceded

by a set of prodromal symptoms including low-grade fever, headache,

and malaise. This is followed by progressive swelling of one or both parotid

glands. Parotid gland swelling usually lasts about one week. Other symptoms of

mumps can include dry mouth, sore face and/or ears and some patients find it

difficult to talk. Painful testicular swelling which can cause sterility

and rash may also occur. Symptoms in adults are often more severe than in

children.

Mumps is preventable by vaccination, and since its use cases in the United

States have declined by 96%.

In 2014, six outbreaks had been reported from the Punjab.

Table showing the Mumps outbreaks in Punjab, 2014

Date District No of Blood

Samples

Result

15.2.14 Fatehgarh Sahib 5 4 positive

01.3.14 SAS Nagar 5 3 positive

12.4.14 SBS Nagar 4 3 Positive

17.4.14 SBS Nagar 5 3 positive

14.5.14 Ropar 12 8 positive

22.11.14 Ropar 15 10 Positive

112

Bacteriological Status of Drinking Water

113

Bacteriological Status of Drinking Water

Water is one of the most important and basic natural resources. Water is not

only one of the most essential commodities of our day-to-day life, but the

development of this natural resource also plays a crucial role in economic and

social development processes.

Samples for BOD and bacteriological analyses should be stored at a

temperature below 4°C and in the dark as soon as possible after sampling. In the

field this usually means placing them in an insulated cool box together with ice

or cold packs. Once in the laboratory, samples should be transferred as soon as

possible to a refrigerator. If samples collected for chemical oxygen demand

COD) analysis cannot be analysed on the day of collection they should be

preserved below pH 2 by addition of concentrated sulphuric acid. This

procedure should also be followed for samples for ammoniacal nitrogen, total

oxidised nitrogen and phenol analysis.

Samples which are to be analysed for the presence of metals, should be

acidified to below pH 2 with concentrated nitric acid. Such samples can then be

kept up to six months before they need to be analysed. After labeling and

preservation, the samples should be placed in an insulated ice box for

transportation. Samples should be transported to concerned laboratory as soon

as possible, preferably within 48 hours. Analysis of bacteriological samples

should be started and analysed within 24 hours of collection. If samples are

being brought to the laboratory they should be transported in less than 24 hours.

The sampling frequency is governed by the level of variation in water quality of

a water body. If variations are large in a short duration of time, a larger

frequency is required to cover such variations. On the other hand, if there is no

significant variation in water quality, frequent collection of sample is not

required. The water quality variations could be of two types i.e. random and

cyclic or seasonal.

114

For bacteriological samples, when collected from tube wells /hand pump, the

spout/outlet of the pump should be sterilised under flame by spirit lamp before

collection of sample in container.

In Punjab, water samples are collected routinely from the schools as well as the

different public water sources. In an outbreak of water borne disease, water

samples are also collected for the bacteriological examination.

In 2014, 4780 sample of water were collected by all the districts of Punjab .Out

of these samples, 64% were from the potable sources while rest were from the

non potable sources.

Out of all the districts of Punjab, maximum numbers of samples were collected

by Hoshiarpur and Kapurthala districts while the number of samples collected

by Jalandhar and Faridkot were minimum.

115

Table Showing the Collection of Water Samples from the Various Districts

of Punjab, 2014

DISTT M.C PWS&S School

Pvt..Resi

&Other

GovtOffices Total

GTotal

PotableNotPotable Potable

NotPotable Potable

NotPotable Potable

NotPotable Potable Not Potable Potable

NotPotable

Amritsar 3 0 0 0 31 1 55 0 3 0 92 1 93

Bathinda 17 1 104 30 61 32 86 27 6 4 274 94 368

Barnala 5 2 31 14 8 6 23 14 0 0 67 36 103

Ferozepur 0 0 13 9 91 64 32 17 17 3 153 93 246

Faridkot 0 0 0 0 0 0 0 0 0 0 0 0 0

Fazilka 0 0 13 11 41 31 30 6 13 1 97 49 146

F.G.Sahib 22 1 2 1 45 20 70 39 10 3 149 64 213

Gurdaspur 1 0 8 0 101 33 72 27 6 1 188 61 249

Hoshiarpur 2 1 8 0 255 130 65 32 16 3 346 166 512

Jalandhar 0 0 0 0 0 0 0 0 0 9 0 9 9

Kapurthala 9 1 2 6 145 108 132 80 22 7 310 202 512

Ludhiana 15 1 0 0 31 14 34 18 3 2 83 35 118

Mansa 0 2 5 0 24 15 30 12 4 1 63 30 93

Moga 7 2 31 16 116 60 54 57 15 7 223 142 365

Muktsar 0 0 76 51 72 51 61 46 1 0 210 148 358

Patiala 0 2 50 28 88 37 188 158 11 5 337 230 567

Ropar 0 0 6 0 64 47 17 7 0 1 87 55 142

Sangrur 0 0 11 7 141 70 59 44 22 2 233 123 356SASNagar 13 0 20 5 70 34 91 64 13 7 207 110 317

SBS Nagar 0 0 26 5 71 43 87 57 29 6 213 111 324

Tarntaran 0 0 0 0 10 24 2 3 0 0 12 27 39

Total 94 13 406 183 1465 820 1188 708 191 62 3344 1786 5130

116

050

100150200250300350400

No of WaterSamples

Name of District

Graph showing the Number of water Samples collected by VariousDistricts of Punjab, 2014

Potable

Non Potable

117

Swine Flu (H1N1)

118

H1N1 ( Swine Flu)

Swine Influenza (swine flu) is a respiratory disease of pigs caused by type A

influenza virus that regularly causes outbreaks of influenza in pigs. Swine flu

viruses cause high levels of illness and low death rates in pigs. Swine influenza

viruses usually circulate among swine throughout the year, but most outbreaks

occur during the late fall and winter months similar to outbreaks in humans.

The classical swine flu virus (an influenza type A,H1N1 virus) was first isolated

from a pig in 1930. Recently, human cases of swine influenza A (H1N1) virus

infection have been recently reported in several countries. This is a novel

influenza A virus that has not been identified in people before, and human-to-

human transmission of the virus appears to be ongoing and thus represents a

real pandemic threat.

The current situation regarding the outbreak of swine influenza A(H1N1) is

evolving rapidly. As on 29 April 2009, nine countries have officially reported

148 confirmed cases of swine influenza A/H1N1 infection.

The symptoms of swine flu in people are expected to be similar to the

symptoms of regular human seasonal influenza like fever, lethargy, lack of

appetite and cough. Some people have also reported runny nose, sore throat,

nausea, vomiting and diarrhoea.

For diagnosis of swine influenza A infection, respiratory specimen would

generally need tobe collected within the first 4 to 5 days of illness (when an

infected person is most likely to be shedding virus). However, some persons,

especially children, may shed virus for 10 days or longer.

119

Case Definition of H1N1 in Humans

HUMANS

A suspected case of swine influenza A (H1N1) virus infection is defined as a

person with acute febrile respiratory illness (fever ≥ 380 C) with onset.

• Within 7 days of close contact with a person who is a confirmed case of

swine influenza A (H1N1) virus infection, or

• Within 7 days of travel to areas where there are one or more confirmed swine

influenza A(H1N1) cases, or

• Resides in a community where there are one or more confirmed swine

influenza cases.

A probable case of swine influenza A (H1N1) virus infection is defined as a

person with an acute febrile respiratory illness who:

• Is positive for influenza A, but unsubtypable for H1 and H3 by influenza RT-

PCR or reagents used to detect seasonal influenza virus infection, or

• Is positive for influenza A by an influenza rapid test or an influenza

immunofluorescence assay (IFA) plus meets criteria for a suspected case, or •

Individual with a clinically compatible illness who died of an unexplained acute

respiratory illness who is considered to be epidemiologically linked to a

probable or confirmed case.

A confirmed case of swine influenza A (H1N1) virus infection is defined as a

person with an acute febrile respiratory illness with laboratory confirmed swine

influenza A (H1N1) virus infection at WHO approved laboratories by one or

more of the following tests:

• Real Time PCR

• Viral culture

• Four-fold rise in swine influenza A (H1N1) virus specific neutralizing

antibodies.

OTHER DEFINITIONS

120

Close contact is defined within 6 feet of an ill person who is a confirmed,

probable or suspected case of swine influenza A (H1N1) virus infection during

the infectious period.

High-risk group for complications of influenza is defined as a person such as:

• Resident of institutions for elderly people and the disabled.

• People with certain chronic health conditions (chronic heart or lung disease,

metabolic or renal disease or immunodeficiencies).

• Elderly people and very young children.

Infectious period: The infectious period for a confirmed case of swine

influenza A (H1N1) virus infection is defined as 1 day prior to the onset of

illness to 7 days after onset.

The categorization of the H1N1 patients will be done in three categories as

follows:

Categories of Swine Flu

Category A

Mild fever plus cough / sore throat with or without body ache, headache,

diarrhoea and vomiting will be categorised as Category-A.

They do not require Oseltamivir and should be treated for the symptoms

mentioned above.

The patients should be monitored for their progress and clinically

reassessed at 24 to 48 hours.

No testing of the patient for H1N1 is required.

Patients should confine themselves at home and avoid mixing up with

public and high risk members in the family.

121

Category B

In addition to all the signs and symptoms mentioned under Category-A,

(i) High grade fever and severe sore throat

(ii) Individuals having one or more of the following high risk

conditions:

Children less than 5 years old;

Pregnant women;

Persons aged 65 years or older;

Patients with lung diseases, heart disease, liver disease, kidney disease,

blood disorders, diabetes, neurological disorders, cancer and HIV/AIDS;

Patients on long term cortisone therapy

All patients of Category-B (i) and (ii)

Require No testing for H1N1

Require Oseltamivir administration as per dosage

Require home quarantine and need avoid mixing with public

Category C

In addition to the above signs and symptoms of Category-A and B, if the

patient has one or more of the following:

1. Breathlessness, chest pain,

2. Drowsiness,

3. Fall in blood pressure,

4. Sputum mixed with blood,

5. Cyanosis

6. Irritability among small children, refusal to accept feed;

7. Worsening of underlying chronic conditions

All these patients mentioned above in Category-C require

- testing for H1N1

122

-immediate hospitalization and

-treatment

Laboratory tests:

• Rapid Antigen Tests: not as sensitive as other available tests.

• RT-PCR

• Virus isolation

• Virus Genome Sequencing

• Four-fold rise in swine influenza A (H1N1) virus specific neutralizing

antibodies

The anti-flu drug, Oseltamivir, under the trade name of Tamiflu in India

(manufactured by CIPLA), Ranbaxy, Roche India and Hetro Drugs is a very

effective against H1N1 virus. Antiviral treatment (Oseltamivir) should be

initiated immediately after confirmation of diagnosis as per category. Benefits

are maximum when started within 48 hours of onset of symptoms.

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123

Preparedness of State:- Ever since the pandemic of 2009, the

Department. of Health & Family Welfare took initiatives for the

preparedness of the State for medical examination of suspected cases,

confirmed through lab investigations and to provide complete treatment to

the patients and its contacts to prevent further spread.

The Nodal Officers at State and Districts have been identified

and their contact numbers for the information of community

published in leading news papers.

The Rapid Response Teams (RRTs) including members as

Medical Specialist, Microbiologist, Pediatrician,

Epidemiologist activated in all districts for immediate

management of cases.

Focus on early screening of Influenza Like Illness(ILI)-

Separate areas for initial screening of all ILI patients reporting

in districts/Sub Divisional hospitals.

Identification of Isolation Wards & Ventilators- Identified and

maintained in all districts. However, it is planned that

anesthetists Physicians etc and 2-3 staff nurses from each

district be retrained / resensitized for handling of ventilators.

Sufficient logistics like medicines, Tamiflu, in all strengths of

75mg, 45mg & 30mg, VTM bottles and masks available in

sufficient quantity at State H.Q and in all the districts and being

provided to patients, and its contacts free of cost.

124

In addition to the Virology Lab at PGI Chandigarh, where the

suspected samples are tested free before providing full

treatment to the patients and contacts, an influenza lab has

already been planned and recently discussed for upgradation at

Govt. Medical College, Amritsar under supervision and funding

of ICMR.

Continuous sensitization of Epidemiologists, Distt. Health

Officers, Medical officers, medical and Para Medical Staff in

Medical Colleges being undertaken in all the forums of disease

surveillance for early detection of ILI including H1N1 cases.

Daily reporting: - A daily report of suspected cases in

mandatory from all the districts and other institutions which

will continue as NIL report, even if there is no case reported on

a particular day.

State Advisory Committee Meeting on Swine Flu (24-1-15):

A meeting of the periodic review of the Swine Flu positive cases, its

management and resultant deaths was held on 24th January 2015 under the

chairmanship of Dr D. Behera, Head of the Pulmonary Medicine in PGI,

Chandigarh.

The following members attended the meeting:

1. Dr Behera, Prof & Head of Department of Pulmonary Medicine, PGI,

Chandigarh, Chairman

2. Dr Rajesh kumar, Prof & Head, Deptt. Of Community Medicine, PGI,

Chandigarh

125

3. Dr R K Ratho, Prof.and Head, Deptt. Of Virology, PGI, Chandigarh

4. Dr Ashish Bhagat, Asstt. Prof. Medicine, GMC, Patiala

5. Dr Deepak Bhatia, SSO cum Project Coordinator (IDSP),Member

Secretary

6. Dr.Avtar Singh Dhanju, Associate. Prof., Department of Medicine unit 4,

GMC, Amritsar.

Recommendations of the Committee

1. The state should be on high alert about the occurrence of H1N1 as a

number of cases are being reported from different parts of the country

2. The presentation which was made will be circulated to all the medical

colleges and health facilities of the state to sensitize the doctors and Dr

Bhatia will take necessary steps on this.

3. The government of Punjab should continues IEC and publicizing

activities through various newspapers, Radio, TV and in the form of the

pamphlets etc particularly Do’s and Do not’s.

4. The diagnosis of H1N1 of suspected cases should be done by the

accredited laboratories. For the region, the test of the suspected case of

H1N1, the Virology department of the PGI is done free of charge. It

should be brought to the notice of the public that they need not pay any

money to anybody. The outside laboratories at present are not accredited.

5. The state should gear up handling such cases. It should develop isolation

wards, ICU care facilities including the provision of the working

ventilators. The team is to be identified, sensitized and trained. In case

the isolation facilities and ICU care is not feasible immediately, they

should have tie up with private hospitals. The committee felt that the

medical colleges should be the ideal places and should be upgraded.

126

6. The standard operating procedures (SOPs) should be in place in each of

these centers that includes the care equipment, gowns, masks,

prophylaxis, vaccination procedures etc.

7. The transportation of any suspected patients of H1N1 as per guidelines in

the presentation should be undertaken.

8. The state should have enough stock of drugs and vaccinations for the

vulnerable group. At present PGI is giving these vaccinations to the

persons (Health care workers including doctors) who are vulnerable. The

state may take similar policy decision.

9. All private/corporate hospitals need to notify all such cases they

encounter/admit/treat to the state authorities.

10 The state needs to upgrade the respiratory departments of the Medical

Colleges in term of manpower and equipment as a long term plan.C FLU

The cases had also been reported from Punjab. Maximum suspected cases (582)

of Category C had been reported in 2013 out of which183 were laboratory

confirmed. In 2014, 121 category C suspected cases were reported, out of which

27 were laboratory confirmed.

The following table shows the status of the H1N1 in Punjab from April 2009 to

December 2014.

127

Category-B

Treatment without

testing

Category-C

Suspected cases

Totalnumberof cases

Lab.confirme

d

TotalContact

casesgiven

treatment

TotalNo. ofdeaths

PatientsfromotherStateswho

died inPunjab

Total Cases ofH1N1 in thefirst phase

(April, 09 toApril, 2010)

305 641 252 3843 40 0

Post PandemicPhase (Aug,10 till Dec,

2011)

27 239 46 592 23 4

Post PandemicPhase (Jan 12to Dec, 2012)

2 101 15 93 4 0

From1st Jan 13 to31st Dec,2013

0 582 183 2395 42 5

From 1stJan 14 to 31stDec, 2014

0 121 27 92 3 3

The number of deaths from the swine flu was amlost equal and high in the

first phase (40) and in 2013 (42) outbreak. The mortality was less in 2012

128

and 2014. The deaths had also been reported from the patients of other states

admitted in hospitals of Punjab.

Graph Showing the Number of Deaths From the First Phase of Swine Flu

Till the End of 2014 from Punjab and Other States

During the prepration of annual report, H1N1 cases has been reported from the

state in 2015. The status is as shown in table below :

Table showing Status of H1N1 Cases in Punjab 2015 ,(Up to 28.2.15)

Category-

B

Treatmen

t without

testing

Category-C

Suspectedcases

Totalnumber ofcases Lab.confirmed

TotalContact

casesgiven

treatment

TotalNo. ofdeaths

Patientsfrom otherStates who

died inPunjab

Jan

2015 till

28.2.15

71 420 181 129 40 2

0

5

10

15

20

25

30

35

40

45

No ofCases

128








Category-

B

Treatmen

t without

testing

Category-C

Suspectedcases


TotalContact

casesgiven

treatment

TotalNo. ofdeaths


died inPunjab

Jan

2015 till

28.2.15

71 420 181 129 40 2

Firstphase

Aug, 2010to Dec,2011

Jan 2012to Dec,2012

1st Jan2013 to

31st Dec,2013

1st Jan2014 to

31st Dec,2014

40

23

4

42

30

4

0

53

Year

128








Category-

B

Treatmen

t without

testing

Category-C

Suspectedcases


TotalContact

casesgiven

treatment

TotalNo. ofdeaths


died inPunjab

Jan

2015 till

28.2.15

71 420 181 129 40 2

1st Jan2014 to

31st Dec,2014

Total No. ofdeaths fromPunjab State

Patients fromotherStates who diedin Punjab

131

Ebola

132

Ebola Preparedness

Ebola virus disease (also known as Ebola hemorrhagic fever) is a severe, often-

fatal disease caused by infection with a species of Ebola virus. The first Ebola

virus species was discovered in 1976 in what is now the Democratic Republic

of the Congo near the Ebola River. Since then, outbreaks have appeared

sporadically.

The virus family Filoviridae includes 3 genera: Cuevavirus, Marburgvirus,

and Ebolavirus. There are 5 species that have been identified: Zaire,

Bundibugyo, Sudan, Reston and Taï Forest. The first 3, Bundibugyo

ebolavirus, Zaire ebolavirus, and Sudan ebolavirus have been associated with

large outbreaks

The current outbreak in West Africa, (first cases notified in March 2014), is

the largest and most complex Ebola outbreak since the Ebola virus was first

discovered in 1976. The most severely affected countries, Guinea, Sierra

Leone and Liberia have very weak health systems, lacking human and

infrastructural resources, having only recently emerged from long periods of

conflict and instability.

Globally, as of January 7, 2015, a total of 21121 cases and 8304 deaths were

reported out of which 13408 are laboratory-Confirmed Cases.

The incubation period ranges from 2 to 21 days (most commonly 8-10 days).

Early symptoms include sudden fever, chills, and muscle aches.

Nausea, vomiting, chest pain, sore throat, abdominal pain, and diarrhea may

follow.

The average EVD case fatality rate is around 50%. Case fatality rates have

varied from 25% to 90% in past outbreaks.

On 8th August, 2014 WHO Director-General declared this outbreak a Public

Health Emergency of International Concern.

133

Diagram Showing Life Cycle of the Ebola Virus

Checklist for Managing Ebola Virus Diseases

1. Regarding the Institutional Framework for Managing Ebola virus,

the Chief Secretary convened a meeting of the State Crisis Management

committee to review preparedness and response for the Ebola Virus

Disease ( EVD) in health sector and sectors other than health.

State Coordination Committee already established at State Level under

Chairmanship of worthy Chief Secretary to review the disease situation

and its preparation. A discussion on the issue and preparedness for Ebola

Virus Disease was held with Principal Secretary Health and State Health

officers on 16/10/14, prior to Video Conferencing with Cabinet

Secretary, GOI.

The reviews was done regarding surveillance and response mechanisms,

hospital preparedness setting up and training RRTs and physicians, stock

134

of medicines, PPEs and other critical care equipment public awareness

movement control/ restriction orders, etc.

As discussed in the meeting above, training of Rapid Response Teams,

medical college staff including Physician, Microbiologist, Public Health

Specialist and Nursing Supdtt., will be ensured as per GOI directives.

PPE kits already available under IDSP will be distributed and public

awareness about this disease and preventive steps thereof to be displayed

in every district hospital in local languages.

The State Health Department draw up its Contingency plan for managing

EVD. Disease Protocol is already in place. Monitoring of suspected

passengers arriving in State and deboarding at International airport being

done. Isolation wards and ventilators in districts and State Referral

Hospital, Guru Nanak Dev Hospital, Amritsar identified.

State level officers of Department of Health, Revenue, Police, Home, and

Panchayati Raj issued clear communications to their ground level staff in

all aspects of preparedness, control and containment in accordance with

the action plan and guidelines.

Guidelines regarding EVD (Ebola Virus Disease) and its prevention had

already been forwarded to various related departments.

A technical Advisory Group/ Committee is formed under Director,

Health Services to advice the State Government on technical matters.

There is already a team in place with inclusion of State Nodal Officer,

Epidemiologist and newly trained Medical College staff and earlier

trained field doctors for MERS CoV and related virus diseases. The

technical committee reports to Director Health Services, about the status

& preparedness on daily basis.

A nodal officer identified to deal with all matters related to EVD. Name

and contact number of nodal officer conveyed to MOHFW.

Dr Deepak Bhatia - 9914452403

135

State Surveillance Officer, IDSP Punjab

The State had set up formal advisory committee to engage with

professional bodies in the State such as State unit of Indian Medical

association and Indian Academy of Paediatrics, NGO’s etc.

At District level, coordination is being initiated with Indian Medical

Association and other local bodies to communicate awareness for Ebola

Virus Disease.

Airport in the State which has connecting flights to the affected

countries had been identified and flight details acquired from MOCA.

Raja Sansi Airport identified for screening of passengers. Screening is

done on daily basis. As per information from CMO Airport, Dr

S.P.Singh, there is no direct flight from affected countries but there are

three flights which operate indirectly from these countries and are routed

through Dubai and Sharjah. The passengers from these flights are being

screened regularly and monitoring of such passengers is continued for

the incubation period through State Health department network.

The display informing passengers about Ebola affected countries and

screening requirement was displayed at airports. Immigration has

dedicated desk for passengers from affected countries.

Airport Health organization has also placed a dedicated counter in the

pre-immigration area. Digital gun is already available and in use at

Airport.

The passengers are screened on the basis of low, medium and high risk

passengers. All the airlines landing at International Airport at Amritsar

circulate Health cards during journey to the passengers coming from

affected countries. These cards carry national helpline number with

stamped local helpline nos. (0183-2565337, 9814014417), as

communicated through airport authorities.

136

Isolation facilities are available at the airports and /or identified hospitals

attached to airports for isolation of suspected cases.

There are two doctors i.e. Dr S.P.Singh and Dr Vinay Sukhija for

screening of passengers on the airport. Tracking mechanism had been

established for tracking and monitoring medium risk passengers.

RRTs are already trained and are in operation for communicable

diseases. Specific training for EVD done as well as ToT for Master

Trainers on 21st October. Another batch of RRT, specific for EVD trained

at Delhi from 27th October to 29th October 2014.

Guidelines had been sent to all Civil Surgeons and IEC activities to

follow. The reports being sent on daily basis on formats sent by NCDC,

GOI

Laboratory Diagnosis

Guidelines had been issued to all medical colleges and districts for sample

collection and transportation. The complete details of contact persons of

NCDC, Delhi / NIV, Pune is available with the Nodal Officer. Dedicated

Laboratory in NCDC, New Delhi is being identified (for managing Ebola

Cases) for testing

Hospital Preparedness and Response

Hospitals with isolation facilities had been identified for clinical

management and critical care management in state. Guru Nanak Dev

hospital in Amritsar had been inspected by team from Govt. of India on

17-11-2014.

Clinicians and Nurses and other dedicated staff working in Ebola

isolation ward was trained and provided with treatment protocol and

hospital infection control practices. Training was done from 19-21st

October and 27th - 29th October. Para Medical staff, wards attendants and

mortuary staff being sensitized by ToT team in Medical Colleges for

Infection Control Practices, Nursing.

137

The personal protective equipments had been procured and ready for use

in state. Non- Permeable PPEs had been made available at Guru Nanak

Dev Hospital and Civil Surgeon Office, Amritsar. Blood Banks have

been attached to identified hospital adequately stocked with blood,

plasma, platelets etc. Hospitals had also been intimated prescribed

Guidelines for Ebola Waste Management.

Material Logistics

The Personal Protective Equipments are available for field investigation

and hospital management of Ebola cases. Body bags are also available to

dispose dead body available

Human Resources

Rapid Response Teams at State and district level trained already trained.

Specific training of RRT for EVD had been done from 27th-29th October.

Communication

Print and visual media materials for risk communication had been

prepared and distributed.

Dr Karanjit Singh, DHS and Dr Deepak Bhatia, State Nodal Officer was

the Spokesperson to brief the media.

138

Command and Control- Helpline numbers

The Control Room is ready for operationalization and 104 is the helpline

number under NHM.

It includes the Phone numbers of Officers – 9914452403, (Dr. Deepak

Bhatia), 9501022020 (Dr. Seema Aggarwal)

Summary Sheet For Punjab for Ebola Suspects :

As on 31-01-15

Number of new

passengers entered in the

line list (Format B)

today.

Total number of

passengers under

observation.

Total number of

passengers who have

completed their

observation period

(Monitored).

01 (Liberia)

39

139

Bird Flu

140

Bird Flu in Punjab

Background:

Avian influenza is highly contagious viral disease. It was first identified in

1930’s.It is caused by influenza virus. In 2006, 1000 chickens died of influenza

in Maharashtra. Also, in Nandurbar district of Maharashtra 30,000 chickens

died. After that, every year, during the month of November / December, Eastern

part of India reported the cases. In 2008 - Recent outbreaks of Avian influenza

was reported in Assam and West Bengal. In 2012, Cases reported in Central

Poultry Farm, Hesaraghatta, Bengaluru.

Influenza is an acute Respiratory Tract Infection (RTI), caused by Influenza

virus, characterized by sudden onset of:

Fever/chills

Headache, myalgia

Sore throat

Cough & coryza

Prostration

Range of symptoms differ by age

Vomiting & diarrhea in children/elderly

Fever alone in infants

May be atypical in elderly

Serious complications can occur among high risk groups.

Timeline

On 19.12.14, In view of the Bird flu (H5N1) positive cases declared at Sukhna

Lake Chandigarh, Punjab geared up already planned preparedness to tackle the

situation. Accordingly surveillance was started in 3 Kilometer radius of Sukhna

lake i.e.in village Nayagaon and Kansal to detect any human effects of disease

there or on the cullers or other persons residing in those areas who had come in

contact with infected birds.

141

In some other places of Punjab also like district Taran Taran, Faridkot,

Fatehgarh Sahib and Gurdaspur, the birds were reported dead and caused scare

in the minds of general population on the issue of H5N1 bird flu. Accordingly

the department of Animal husbandry was contacted at state level and at the

concerned district level to conduct survey and collect samples of the dead birds

for the detection of H5N1.

Three places in Punjab reported death of birds as the same type of incidence.

A. The information was received on 20-12-14 regarding the death of four

Murgabian in village Wander jatana, PHC Panjgrain Kalan, Distt Faridkot. All

the samples have been tested negative at RDDL Jalandhar and the same were

forwarded to advanced testing lab at Bhopal for confirmation.

B. Death of about 300 crows was reported on 20-12-2014 from village Baghiari

CHC Kasel Distt Taran Taran In a field growing popular trees. Animal

Husbandry department was immediately informed at district level who

conducted the postmortem on dead crows. The preliminary report suggested

that there were no signs of Bird flu (H5N1) in them and the samples were

further forwarded to advanced testing lab at Bhopal for confirmation.

C. Death of four pigeons was reported from Fatehgarh Churian of Gurdaspur

district on 26.12.14.

Steps for Human Surveillance Undertaken in SAS Nagar :

As per guidelines, 3 km radius around the site of confirmation of disease is to

be surveyed to detect early signs of Bird flu in humans due to contact with

diseased birds. Accordingly, the population in village Kansal, which is forest

area in 3 km radius and village Nayagaon outside 3 km radius of the Sukhna

Lake were surveyed by the teams from district Mohali on daily basis through

house to house visits to detect early signs of the disease in population with

history of contact as well as to educate people regarding bird flu and

prevention.

142

1. Till date, 14257 houses and 85822 populations were surveyed in Kansal

village while 6887 houses and 44503 populations were surveyed in

Nayagaon village of Gharuan block of SAS Nagar.

Table Showing Houses and Population Surveyed in Kansal and Nayagaon

Villages of SAS Nagar, 2014

Dates Kansal village Naya Gaon village

Houses

Surveyed

Population

Surveyed

Houses

Surveyed

Population

Surveyed

20.12.2014 734 3259 2148 12849

21.12.2014 699 3832 0 0

22.12.2014 694 4580 4739 31654

23.12.2014 1013 5571 0 0

24.12.2014 1543 9558 0 0

25.12.2014 1876 11730 0 0

26.12.2014 1946 11704 0 0

27.12.2014 1968 11740 0 0

28.12.2014 1878 11704 0 0

29.12.14 1906 12144 0 0

Total 14257 85822 6887 44503

143

Graph Showing Houses and Population Surveyed in Kansal and Nayagaon


2. One boat man at Kansal village being a contact was suspected in

Nayagaon village and referred to sector 16 General hospital for

confirmation. His samples were tested negative.

3. Seven persons involved in culling process and residing in Nayagaon,

Kansal and Mullanpur villages were put on chemoprophylaxis on

20.12.14 and their treatment completed on 29.12.14.

4. As per telephonic conversation with Dr Sandha, Director Animal

Husbandry Department, it had been confirmed that all birds samples sent

to Bhopal for the confirmation of H5N1 had been tested negative, just

ruling out H5N1 in birds population which had been reported dead in the

Punjab state in last few days.

0

5000

10000

15000

20000

25000

30000

35000

Number

143














Time

Kansal Houses Surveyed

Kansal Population Surveyed

Naya Gaon Houses Surveyed

Naya Gaon Population Surveyed

143














Kansal Houses Surveyed

Kansal Population Surveyed

Naya Gaon Houses Surveyed

Naya Gaon Population Surveyed

144

5. The daily surveillance required for ten days in the vicinity i.e. Nayagaon

and Kansal in this case, has been completed on 29.12.14.

6. The daily report after the survey in area had been communicated

regularly to DHS, UT, CSU, Delhi, DHS Punjab and compiled at IDSP

Punjab.

Prevention and Control Activities Already Undertaken in State:

1 Activation of already trained Rapid Response Teams (RRTs) for survey

and detection of cases.

2 Maintenance of already identified Isolation wards in all the district

hospitals.

3 Maintenance of Personal protective equipments like PPE Kits, gloves,

masks etc for health care workers.

4 Education of community regarding prevention from Bird Flu (H5N1) and

Swine Flu (H1N1).

145

Brucellosis

146

Brucellosis Project in Jalandhar

Background:

Brucellosis is the most common zoonotic disease that leads to considerable

morbidity and loss of man-days across the globe and thus perpetuates poverty.

The disease presents as an acute or persistent febrile illness with a diversity of

clinical manifestations. The disease occurs worldwide, except in those countries

where bovine brucellosis (Brucella abortus) has been eradicated, which means

absence of any reported cases for at least five years. The Mediterranean

countries of Europe, northern and eastern Africa, Near East countries, India,

Central Asia, Mexico and Central and South America are especially affected.

Furthermore, brucellosis is also considered as a re-emerging problem in many

countries such as Israel, Kuwait, Saudi Arabia, Brazil and Colombia, where

there is an increasing incidence of B. melitensis or B. suis biovar 1 infection in

cattle.

In human, consumption of contaminated food and occupational contact are the

major risks of infection. The main routes of infection are consumption of

unpasteurized dairy products, small ruminants, camel milk and milk products

like cheese and sour milk. It has been shown that the organism can survive

pickling and inadequate smoking. Contact with infected materials such as

aborted foetuses, placentas, urine, manure, carcass and salvaged animals has

been reported in some countries to cause human brucellosis in 60–70% of cases.

Infection by contact has been reported to be common among veterinarians,

abattoir workers, farmers, rendering-plant workers, packing-house employees,

animal handlers and others who work with animals and their products.

147

In India the prevalence of animal brucellosis has been well studied. In Punjab

the apparent overall prevalence of brucellosis was reported to be 12.09%.

Hence, close association between human and animals, stray cattle, consumption

of unpasteurised milk and dairy products and inappropriate waste disposal are

some of the principal factors perpetuating infection in humans. So far, some

studies have been done on public health significance of brucellosis using

serology with little or no emphasis to risk factors.

In Haryana, 34% prevalence of human brucellosis was recorded among

veterinarians and para-veterinarians having direct contact with animals. Since

1975, high prevalence of Brucellosis has been recorded in West Bengal

(Chowdhury and Chatterjee, 1975). De et al. (1982) had recorded 15.7%

brucellosis in organized farms in West Bengal. Over the years, prevalence of

brucellosis is on increase and around 25% of animals was found to be sero-

positive, revealing the high endemic nature of brucellosis in cattle.

In humans, both, acute and chronic arthritis of suspected cases of brucellosis

have been reported in rural areas, however, the prevalence is still to be

determined. Also, the animal-related risk factor that causes infection in humans

is not well-established in India.

So in order to know the prevalence of Brucellosis in Punjab, the pilot study will

be done in three blocks of Jalandhar and then will be expanded to the whole

district.

Objectives:

1.This study aimed at determine the epidemiology of Brucellosis among both

human and livestock populations in three blocks of Jalandhar district

2. To determine the Seroprevalence of Brucellosis in these blocks of Jalandhar

148

Methods:

This is a prospective study designed to estimate the proportion of human

patients meeting the case definition for ‘pyrexia of unknown origin (PUO)’ that

are Brucella antigen positive (by PCR) at the time of presentation to a medical

clinic. The study also estimates prevalence of Brucella exposure amongst cattle

and buffalo herds in the same area from where these cases come by doing a

herd survey.

The RDDL, Jalandhar supplies the logistic supports well as the transport of the

samples. The mechanism of the logistic availability as well as transport will be

done by the RDDL. The RDDL will provide the health laboratory with the

required proformas, syringes as well as the tubes for sample collection.

The samples will be taken from the three sites i.e. civil hospital, Nakodar, CHC,

Kala Bakra and CHC, Kartarpur.

As the patient reports to the physician in OPD of the hospital, he is clinically

examined and the history of the patient is taken. The patients having fever who

do not have clear sign and symptoms of a disease, they are labeled as having

fever of unknown origin. So we want to know what proportion of the patients

among PUO are suffering from brucellosis.

The blood sample of the patients labeled as fever of unknown origin will be

tested for Brucellosis. As the facility for this test is not available in these

hospitals, so these samples will be tested at RDDL, Jalandhar. After taking

sample from the patients, it will be stored in laboratory at appropriate

temperature.These samples will be sent to the regional laboratory at Jalandhar

for testing once a week.

The results of these tests will be sent by the in charge of the laboratory to the

IDSP unit on the same day by e mail.

149

Visit of the team (21-23.1.15):

The team comprised of Dr Rattan Lal Ichhpujani, Public health surveillance and

laboratory adviser, GDD India centre, Dr Vinay Mohan, Joint director, RDDL,

Jalandhar and Dr Satish Kumar, from IDSP, Punjab, Chandigarh.

The team was of the view that the places from where the samples were

collected earlier should be activated. So the team visited first the Civil hospital,

Nakodar, Community health centre, Kala Bakra and CHC, kartarpur for the

sensitization of the officials and the laboratory staff.

At the Civil hospital, Nakodar, we had a meeting with senior medical officer,

Dr Varinder Jagat, laboratory staff and Dr Ram Murti, Veterinary officer. All

were sensitized about the collection and transport of the blood samples. The

samples will be collected from the hospital by the veterinary staff once a week

to be sent to RDDL, jalandhar.

At the CHC, Kala Bakra, the team held meeting with senior medical officer, Dr

Surinder Jagat, medical officer, Dr Kamaplal sidhu, laboratory staff and

Veterinary officer, Dr Harjit singh. They were sensitized and apprised about the

activities to be taken.

The team also visited CHC, kartarpur for the sensitization the staff. Senior

medical officer, Dr Jai kishan was in meeting at civil surgeon office, Jalandhar

and he had deputed Dr Sarabjit singh Bhogal, medical specialist. So the team

sensitized the medical specialist, the laboratory staff of the CHC as well as the

local Veterinary officer, Dr Kamaljit singh about the project and the role each

one to play for its implementation.

The team also visited the RDDL, Jalandhar and met the Veterinary officers Dr

Charanjit Sarangal, Dr Vikram singh and Dr gagandeep Banga and the

150

laboratory staff. They appraised in detail the different procedures and functions

done by the institute.

In the last, all the detail of the visits and activities done were briefed to the Civil

surgeon, Jalandhar. He told that as no expenditure is involved, So the project

should be restarted at the three sites. Gradually the project can be started at the

rest of the two blocks i.e. Civil hospital, Phillaur and CHC, Adampur.

The samples of milk for the detection of Brucella in animals in the catchment

areas will also be done by the Veterinary department.

After meeting the Civil Surgeon, Jalandhar, it was decided that for smooth

functioning of the activities, the State Surveillance officer, Punjab should be

requested to depute EISO, Dr Satish Kumar to oversee periodically in close

collaboration and coordination with Dr Vinay Mohan, Joint Director, RDDL,

Jalandhar.

Previous Activities Undertaken: In October 2013, the blood samples

collection was started from the two blocks of Jalandhar district namely CH

Nakodar and CHC Kala Bakra. 52 samples were taken from CH Nakodar and

66 samples from Kala Bakra. The samples were tested at RDDL, Jalandhar. Out

of these samples, 7 samples were tested positive from Nakodar (prevalence-

13.5%) while 1 sample was positive from Kala Bakra (prevalence-1.5%).

151

Silicosis

152

Silicosis

Pneumoconiosis is resulting from exposure to free silica may be the commonest

and most extensively studied occupational disease of the lung. And even today,

it continues to be among the most serious occupational diseases. The problem

of silicosis is confined not only to the developing nations, but is also not

uncommon in industrialized nations.

The term silicosis is reserved for the lung disorder caused by inhalation of free

silica, which is an untreatable progressive disease and is the commonest and

most widespread of all occupational diseases. Exposure to large amount of free

silica can pass unnoticed because, silica is odorless, non-irritant and does not

cause any immediate noticeable effect and hence is confused with ordinary

dust. Chronic exposure to silica predisposes to tuberculosis, which is still a

major health problem in developing countries including India. Recently

crystalline silica has been classified as a human carcinogen (Group I) by

International Agency for Research on Cancer (IARC). Silicosis increases the

risk of contracting Tuberculosis and possibility of developing lung cancer in the

future. Silicosis is strongly associated with scleroderma and rheumatoid

arthritis.

Silica and silicates constitute the bulk of most kind of rocks, clays and sands.

Mining, tunneling, sand stone industry, stone quarrying and dressing, iron and

steel foundries, flint crushing are the occupations most closely related to the

hazard of silica exposure. Some of the occupations such as slate pencil industry

and agate grinding industry which carry high risk of silicosis are peculiar to

India.

There are very few epidemiological studies on silicosis in India where the

prevalence of silicosis varies from 3.5% in ordnance factory to 54.6% in slate

pencil industry.

The success of prevention programme will largely depend upon the active

cooperation of all the stakeholders. Silicosis is an age-old occupational disease

153

and remains a major occupational health problem in India. It is responsible for

high morbidity and mortality in industrial workers. Since there is no specific

therapy for this progressive and irreversible disease, all steps should be taken

for its prevention. The benefits of prevention include the economic benefits

such as increased production by healthy workers, reduction of sickness

absenteeism and less expenditure on health care and above all the alleviation of

human suffering.

In the absence of specific therapy for silicosis, there is a need for planning a

national strategy for the prevention and control of silicosis.The strategy to

prevent and control Silicosis in the Country should focus on the following

components:

Identify the population at risk nationwide in various sectors specially in

the unorganized sector

Define "Diagnostic criteria- What constitutes a case of Silicosis?

Dynamic sample survey in the high-risk sectors.

Central nodal agency that consolidates data on Silicosis from all sectors.

Creating awareness among all stake holders and sensitizing community

consciousness for Silicosis.

Involve Print, TV media and NGO's to build and sustain pressure on

lobbies with vested interest and Regulatory authorities.

Implementation of the actual control measures.

Capacity building, Training family physicians and Primary Health Care

doctors.

Ambulatory and Participatory Occupational Health Service for the

unorganized sector.

Vested environmental activism should be discouraged.

154

Activities Undertaken:

To assess the action taken by the States, the first meeting on the subject

with States was held on 1-3-2011 by National Human rights Commission

(NHRC) at New Delhi. It was decided at State level that a survey would

be conducted through Deptt of Labour and Employment by Asstt.

Director of Factories (Medical) in identified hazardous industries and

medically examine workers exposed to silica dust.

Since then, the Deptt of Labour and Employment has been regularly

sending reports about the individual medical examination to the State

Program Officer (SPO). However no patient was found positive for

silicosis so far as very few industrial units in the State are producing or

using silica dust.

The detail of the factories in 2011 as provided by Er Sodhi Mal, Deptt. of

Labour and employment is as given below.

Table Showing the Total Number of Workers Susceptible to

Airborne Dust

Sr.no Name of thefactories

Number ofregisteredfactories

Number of workersemployed inhazardous industries

Number ofworkerssusceptible toairborne dust

1. Foundries 721 10929 17822. Stone crushing

industries88 895 320

3 Ceramic andglass

9 148 85

4 Cement industries 4 729 154Total 822 12701 2341

155

Table Showing Number of Factories/Workers Examined

Sr.no Type of factory No. of

factories

No. of

workers

examined

No. of workers sent

for Chest X-ray

examination

1. Casting/Foundries 585 4094 16

2. Stone Crushers 114 648 11

3. Cement &

Ceramics6 237 Nil

Total 705 4979 27

A meeting was held on 17.4.14 under the chairmanship of Secretary,

Punjab, Building and Other Construction Workers Welfare Board cum

Labour Commissioner in Chandigarh.

It was suggested that a “Mobile Laboratory Services/Scheme” should be

initiated for preliminary screening and further diagnosis of suspected

patients of silicosis through regular checkups of the workers in industrial

units be carried out.

It was requested to representatives of Health department to make a

proposal with technical details for establishing a mobile unit which

would comprise of all the basics eg; machinery, equipment, staff,

reagents etc required for screening and investigations of the workers

working in industrial units and susceptible to silicosis due to prolonged

exposure to silica dust.

The screening/checkups in the factories will be done by a chest and TB

specialist or Factory Medical Officer /Asstt Director Factories (Medical) .

Presently there is one post of Asstt Director Factories (Medical) in each

Distt Jalandhar, Mohali and Ludhiana who can periodically visit the

factories with mobile medical unit and detect susceptible and exposed

156

workers for further investigations. All the susceptible/ exposed workers

showing initial signs will be examined by the Medical Team, followed up

by on spot diagnosis, investigations like X-rays, sputum etc and on the

spot medical facility if needed, through the medical unit established in

the van with use of spirometer etc for confirmation of diagnosis of

silicosis.

One mobile van will be insufficient as one Asstt Director Medical has to

cover 6-7 distts each, it was proposed that there should be one Mobile

Medical Unit (MMU) in each region to give maximum coverage for

diagnostic purposes for silicosis as well as to other occupational health

problems. The paramedical manpower like X-ray technician, physician,

rehabilitator/counselor may also be required in each of these MMU for on

the spot investigation and rehabilitation.

This proposal was further discussed in a meeting held on 04-06-14 which

was attended by Dr. Deepak Bhatia, PO IDSP and Dr Seema Aggarwal,

State Epidemiologist IDSP. It was suggested by Dr. Deepak Bhatia that the

workers in cement factories, stone crushers and Brick Kilns are more

susceptible to silicosis and related diseases and therefore should be

examined on priority basis by the Medical Officers working with the Dept.

of Labour. All suspected cases should be sent for further investigations in

the nearest government hospitals.

A team of medical experts will carry out the screening of workers working in

dust prone industries on a random basis. A mobile van should have at least

one lab assistant along with a Medical Officer who can do the screening and

collect sputum samples of suspected cases for further investigations.

In case a person is found to be in advanced stage of Silicosis or any related

disease, X-Ray should be taken and sent to radiologist of district hospital for

further analysis of the same.

157

The Medical Board under Employees Compensation Act should have 4

members and an expert doctor from each district may be nominated for

further assistance to be extended to the board. The last meeting held by

commission on 4th May, 2012 was attended by Dr. Deepak Bhatia, PO IDSP.

Recently, survey report regarding the silicosis obtained from the Additional

director of factories (Medical) Jalandhar is as follows:

Table Showing Number of Factories/Workers Examined from

August to December 2014 in Jalandhar

Sr.no No. of

factories

No. of

workers

examined

No. of workers

sent for Chest X-

ray examination

Found Positive

1. 82 925 43 Nil

158

Fluorosis

159

National Programme for Prevention & Control of Fluorosis (NPPCF)

Fluorosis a major public health problem caused by the excess intake of

fluorides through drinking water/ food products/ industrial pollutants, over a

longer period and results in major health disorders like Dental Fluorosis,

Skeletal Fluorosis and non- skeletal Fluorosis. The main sources of fluoride

intake are drinking water, food, drugs & industrial emissions.

Fluoride endemicity has been reported in 196 districts of 19 states and UT’s of

the country. The affected population with Fluorosis is about 66 million in the

country based on baseline survey data. National Programme for Prevention of

Fluorosis was envisaged during the 11th five year plan. The goal of the

programme was to prevent and control Fluorosis in the country by the following

objectives:

1. To collect, assess and use the baseline survey data of Fluorosis of Deptt.

of Drinking Water Supply.

2. Comprehensive management of Fluorosis in the selected areas.

3. Capacity building for prevention, diagnosis and management of Fluorosis

cases.

The project was implemented in 100 out of 196 endemic districts in 19

States/UTs in phase wise manner during the remaining part of 11th Five year

Plan. In the 12th year plan, it has been decided to implement the National

Programme for Prevention and Control of Fluorosis in all the remaining

fluoride endemic new districts in phased manner in addition to the existence

100 districts in which programme has been launched at different times,

during the 11th five year plan.

The expected outcome of the National Programme for Control of

Fluorosis in the districts covered under the programme will be:-

160

1. Number of Fluorosis cases managed and rehabilitated.

2. Capacities of laboratory testing built –up.

3. Trained health sector manpower in Government set up.

4. Improved information base of the community

Following results are proposed to be achieved at the end of the 12th Plan

period i.e. by March 2017.

a) To expand the programme to the remaining Fluoride endemic districts

with the following interventions:

1. Capacity building of different level of health personnel.

2. Health education.

3. Early detection of dental and skeletal Fluorosis cases.

4. Case management through conservative management, surgical

intervention and/or rehabilitation.

5. Coordinating with the PHE department for provision of safe

drinking water.

b) All of above mentioned interventions will also be continued and

strengthened in the 100 districts already covered under the programme

during 11th year plan.

National programme for Prevention & Control of Fluorosis came into

existence in Punjab in year 2009. Two districts which were found endemic

in baseline survey data namely Sangrur and Ferozepur were chosen for this

programme. The NPPCF Programme was started in Sangrur in year 2010

and in District Ferozepur in 2012. The basic data regarding the surveys

conducted and lab investigations carried out in both districts is as follows:-

161

1. Status of Fluorosis in Ferozepur from 2012 - 2014

S.no Compiled report of FluorosisProgramme 2012 2013 2014

1 Number of urine samples taken 7 963 3262 No. of urine samples having high fluoride content

(1.5 mg/l)0

777 1123 Number of water samples taken 230 138 974 No. of samples found unfit for drinking 80 12 285 No of community surveys conducted in villages 50 899 216 No of villages covered for collecting water samples 160 53 217 No of villages covered for collecting urine samples 110 71 218 Number of persons covered 260 3372 7159 Suspected cases of dental & Skeletal fluorosis

dental- 17

dental -963,

skeletal- 6

dental-170,

skeletal-10

10 IEC Activities

S.no Indicators1 No. of new cases of dental Fluorosis from total

surveyed17

963 1702 No. of new cases detected of skeletal and non-

skeletal Fluorosis from the total surveyed0

6 103 No. of persons trained:-

a) orientation training for doctors at PHC and CHCs nil 20 46b) Lab Technicians nil nilc) Para medicals nil 55 63d) Health workers, ASHA Workers and AWWs nil 299 135e) Sensitization for policy makers of health, PHE,Deptt of WCD, School Education and literacy.

nilnil nil

f) Advocacy PRIs, VHSC and Teachers. nil 87 704 Establishment of lab with Equipment yes yes yes5 Number of cases identified for disability correction

by yearnil

nil nil6 No. of surgeries performed/corrective treatment. nil nil nil7 No. of persons provided with rehabilitation aids nil nil nil8 No. of persons covered for Health Education. 260 3372 715

162

Status of Fluorosis in Sangrur from 2012- 2014:

S.no Compiled report of FluorosisProgramme

20122013 2014

1 Number of urine samples taken 391 145 7012 No. of urine samples having high fluoride content (1.5

mg/l)219 119 364

3 Number of water samples taken 678 381 3964 No. of samples found unfit for drinking 96 33 415 No of community surveys conducted in villages 149 4 86 No of villages covered for collecting water samples 149 61 1277 No of villages covered for collecting urine samples 149 61 128 Number of persons covered 18770 9319 8059 Suspected cases of dental & Skeletal fluorosis 310

&12112&12

160&5

10 IEC Activities

S.no Indicators1 No. of new cases detected of dental Fluorosis from

the total surveyed310 112 160

2 No. of new cases detected of skeletal and non-skeletal Fluorosis from the total surveyed

12 12 5

3 No. of persons trained:-a) orientation training for doctors at PHC and CHCs 30 27b) Lab Techniciansc) Para medicals 60d) Health workers, ASHA Workers and AWWs 90 30 72e) Sensitization for policy makers of health, PHE,Deptt of WCD, School Education and literacy.f) Advocacy PRIs, VHSC and Teachers. 144 228 60

4 Establishment of lab with Equipment yes yes yes5 Number of cases identified for disability correction by

year end.nil nil nil

6 No. of surgeries performed/corrective treatment. nil nil nil7 No. of persons provided with rehabilitation aids nil nil nil8 No. of persons covered for Health Education. 18770 9319 7259 No. of households receiving safe drinking water (from

PHE record)407

163

The basic data of fluoride concentration in drinking water, as conducted by

Department of Water Supply & Sanitation Punjab, based on which more

endemic district have to be identified is given as under :

S.

N

o.

Dist

rict

BlockVilla

ge

Habit

ation

Locati

on

Type

Of

Sour

ce

Lab

Name

Testin

g Date

Above

Permiss

ible

Limit

1 Barnala SEHNA JAN

GIA

NA

JANG

IANA

SC139

1683

Deep

Tube

well

WATE

R

TESTI

NG

LAB

BARN

ALA

8/29/2

012

Fluoride

[1.60

Mg/L]

2 Bathind

a

BATHI

NDA

JASS

I

PAU

WAL

I

JASSI

PAU

WALI

Near

Sec.

Schoo

l /

SC232

9205

Canal Water

Quality

Testing

Lab

Bathind

a

1/3/20

13

Fluoride

[78.00

Mg/L]

3 Bathind

a

BHAG

TA

BHAI

KA

GAU

NSP

URA

GAU

NSPU

RA

NEar

Schoo

l /

SC233

1183

Canal Water

Quality

Testing

Lab

Bathind

a

1/7/20

13

Fluoride

[1.75

Mg/L]

4 Bathind PHUL SAIL SAIL Near Deep State 1/2/20 Fluoride

164

a BRA

H

BRA

H

Bus

Stand

/

SC234

1417

Tube

well

Water

Testing

Lab

13 [4.25

Mg/L]

5 Bathind

a

RAMP

URA

DAU

LAT

PUR

A

DAU

LATP

URA

Near

Schoo

l /

SC233

0990

Canal Water

Quality

Testing

Lab

Bathind

a

1/16/2

013

Fluoride

[35.00

Mg/L]

6 Bathind

a

SANG

AT

GUR

THA

RI

GURT

HARI

Sukh

winde

r

Singh

/

P0001

13849

9

Shall

ow

Tube

well

Water

Quality

Testing

Lab

Bathind

a

4/10/2

012

Fluoride

[2.65

Mg/L]

7 Bathind

a

SANG

AT

PAC

CA

KAL

AN

PACC

A

KAL

AN

SC598

494

Deep

Tube

well

Water

Quality

Testing

Lab

Bathind

a

9/12/2

012

Fluoride

[40.00

Mg/L]

8 Faridkot FARID

KOT

FARI

DKO

T

FARI

DKO

T

SC600

040

Shall

ow

Tube

WATE

R

TESTI

5/19/2

012

Fluoride

[2.00

Mg/L]

165

(RUR

AL)

RUR

AL

well NG

LAB

FARID

KOT

9 Faridkot FARID

KOT

GHU

MIA

RA

GHU

MIAR

A

SC589

489

Canal WATE

R

TESTI

NG

LAB

FARID

KOT

4/7/20

12

Fluoride

[2.00

Mg/L]

1

0

Faridkot KOTK

APURA

BEH

BAL

KAL

AN

BEHB

AL

KAL

AN

SC597

930

Canal WATE

R

TESTI

NG

LAB

FARID

KOT

4/7/20

12

Fluoride

[2.00

Mg/L]

1

1

Faridkot KOTK

APURA

BHA

IRO

N-

KI-

BHA

TTI

BHA

RON

KI

BHAT

TI

Indivi

sual

House

Hold

Conne

ction /

H1590

152

Deliv

ery

Point

WATE

R

TESTI

NG

LAB

FARID

KOT

4/7/20

12

Fluoride

[3.00

Mg/L]

1

2

Faridkot KOTK

APURA

CHA

K

CHA

K

H9779

96

Deliv

ery

WATE

R

5/26/2

012

Fluoride

[2.00

166

KAL

YAN

KAL

YAN

Point TESTI

NG

LAB

FARID

KOT

Mg/L]

1

3

Faridkot KOTK

APURA

DHIL

WAN

KAL

AN

DHIL

WAN

KAL

AN

SC588

906

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FARID

KOT

5/26/2

012

Fluoride

[2.00

Mg/L]

1

4

Faridkot KOTK

APURA

HAR

I

NAU

HARI

NAU

Near

Govt.

Sec.

Schoo

l /

H1620

512

Deliv

ery

Point

WATE

R

TESTI

NG

LAB

FARID

KOT

5/26/2

012

Fluoride

[2.00

Mg/L]

1

5

Faridkot KOTK

APURA

THA

RA

THAR

A

On

Link

Road

11 Km

From

Kotka

pura /

SC611

656

Canal State

Water

Testing

Lab

5/16/2

012

Fluoride

[1.89

Mg/L]

167

1

6

Fatehga

rh Sahib

KHER

A

BAD

ALI

ALA

SING

H

BAD

ALI

ALA

SING

H

Near

Dhara

mshal

a /

SC142

7484

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.80

Mg/L]

1

7

Fatehga

rh Sahib

KHER

A

BAD

ALI

MAI

KI

BAD

ALI

MAI

KI

Badali

Mai

Ki /

SC453

7501

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.83

Mg/L]

1

8

Fatehga

rh Sahib

KHER

A

BAS

SIAN

BASS

IAN

SC632

774

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.65

Mg/L]

1

9

Fatehga

rh Sahib

KHER

A

BHA

GRA

NA

BHA

GRA

NA

SC635

973

Deep

Tube

well

WATE

R

TESTI

NG

6/20/2

012

Fluoride

[1.93

Mg/L]

168

LAB

FATEH

GARH

SAHIB

2

0

Fatehga

rh Sahib

KHER

A

BHA

INI

KAL

AN

BHAI

NI

KAL

AN

H1021

532

Deliv

ery

Point

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

2/15/2

013

Fluoride

[1.52

Mg/L]

2

1

Fatehga

rh Sahib

KHER

A

BHU

A

KHE

RI

BHU

A

KHER

I

Near

Gurud

uara

Sahib

/

SC142

7492

Deep

Tube

well

Punjab

Biotech

Incubat

or

5/1/20

12

Fluoride

[1.53

Mg/L]

2

2

Fatehga

rh Sahib

KHER

A

BHU

A

KHE

RI

BHU

A

KHER

I

Near

Gurud

uara

Sahib

/

SC142

7492

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.73

Mg/L]

169

2

3

Fatehga

rh Sahib

KHER

A

BOR

AN

BOR

AN

SC622

398

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.64

Mg/L]

2

4

Fatehga

rh Sahib

KHER

A

BRA

SS

BRAS

S

SC634

445

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.86

Mg/L]

2

5

Fatehga

rh Sahib

KHER

A

CHU

NNI

KAL

AN

CHU

NNI

KAL

AN

SC233

8821

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.81

Mg/L]

2

6

Fatehga

rh Sahib

KHER

A

CHU

NNI

KHU

RD

CHU

NNI

KHU

RD

SC233

8654

Deep

Tube

well

WATE

R

TESTI

NG

6/20/2

012

Fluoride

[2.04

Mg/L]

170

LAB

FATEH

GARH

SAHIB

2

7

Fatehga

rh Sahib

KHER

A

CHU

NNI

KHU

RD

CHU

NNI

KHU

RD

SC233

8654

Deep

Tube

well

State

Water

Testing

Lab

11/23/

2012

Fluoride

[2.60

Mg/L]

2

8

Fatehga

rh Sahib

KHER

A

DUB

HALI

DUB

HALI

SC633

869

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.64

Mg/L]

2

9

Fatehga

rh Sahib

KHER

A

HAR

IPUR

HARI

PUR

SC631

958

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/19/2

012

Fluoride

[1.94

Mg/L]

3

0

Fatehga

rh Sahib

KHER

A

HAR

NA

HAR

NA

SC611

187

Deep

Tube

well

WATE

R

TESTI

NG

6/19/2

012

Fluoride

[1.96

Mg/L]

171

LAB

FATEH

GARH

SAHIB

3

1

Fatehga

rh Sahib

KHER

A

HIN

DUP

UR

HIND

UPUR

SC639

830

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/19/2

012

Fluoride

[1.78

Mg/L]

3

2

Fatehga

rh Sahib

KHER

A

JAMI

TGA

RH

JAMI

TGAR

H

SC638

774

Deep

Tube

well

Punjab

Biotech

Incubat

or

5/1/20

12

Fluoride

[1.51

Mg/L]

3

3

Fatehga

rh Sahib

KHER

A

JAMI

TGA

RH

JAMI

TGAR

H

SC638

774

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/19/2

012

Fluoride

[1.61

Mg/L]

3

4

Fatehga

rh Sahib

KHER

A

JHA

MPU

R

JHAM

PUR

SC644

643

Deep

Tube

well

Punjab

Biotech

Incubat

or

5/1/20

12

Fluoride

[1.69

Mg/L]

172

3

5

Fatehga

rh Sahib

KHER

A

JHA

MPU

R

JHAM

PUR

SC644

643

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/19/2

012

Fluoride

[1.91

Mg/L]

3

6

Fatehga

rh Sahib

KHER

A

JHA

MPU

R

JHAM

PUR

SC644

643

Deep

Tube

well

State

Water

Testing

Lab

11/23/

2012

Fluoride

[2.30

Mg/L]

3

7

Fatehga

rh Sahib

KHER

A

KHA

NPU

R

BEH

LAN

KHA

NPUR

BEHL

AN

SC636

320

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.79

Mg/L]

3

8

Fatehga

rh Sahib

KHER

A

KHE

RA

KHER

A

SC637

159

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.64

Mg/L]

173

3

9

Fatehga

rh Sahib

KHER

A

KHE

RI

BHA

I KI

KHER

I

BHAI

KI

NEAR

SHA

MSH

ANG

HAT /

SC233

6034

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.70

Mg/L]

4

0

Fatehga

rh Sahib

KHER

A

LOH

A

KHE

RI

LOH

A

KHER

I

SC613

741

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.94

Mg/L]

4

1

Fatehga

rh Sahib

KHER

A

MAN

HER

A

JATT

AN

MAN

HERA

JATT

AN

SC634

705

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/19/2

012

Fluoride

[1.67

Mg/L]

4

2

Fatehga

rh Sahib

KHER

A

MUK

ARO

NPU

R

MUK

ARO

NPUR

SC635

357

Deep

Tube

well

WATE

R

TESTI

NG

6/20/2

012

Fluoride

[1.65

Mg/L]

174

LAB

FATEH

GARH

SAHIB

4

3

Fatehga

rh Sahib

KHER

A

NAN

DIAL

I

NAN

DIALI

Near

Schoo

l /

SC142

6861

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.64

Mg/L]

4

4

Fatehga

rh Sahib

KHER

A

PAM

OUR

PAM

OUR

SC234

0549

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.81

Mg/L]

4

5

Fatehga

rh Sahib

KHER

A

PAT

ARSI

KHU

RD

PATA

RSI

KHU

RD

NEAR

GUR

UDU

ARA

SAHI

B /

SC233

6418

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/26/2

012

Fluoride

[1.74

Mg/L]

175

4

6

Fatehga

rh Sahib

KHER

A

PAT

TON

PATT

ON

PATT

ON /

SC430

1611

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.93

Mg/L]

4

7

Fatehga

rh Sahib

KHER

A

PAW

ALA

PAW

ALA

PAW

ALA /

SC436

3862

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.81

Mg/L]

4

8

Fatehga

rh Sahib

KHER

A

PIR

JAIN

PIRJA

IN

SC671

456

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/20/2

012

Fluoride

[1.65

Mg/L]

4

9

Fatehga

rh Sahib

KHER

A

RAJI

NDE

RGA

RH

RAJI

NDER

GAR

H

SC673

208

Deep

Tube

well

WATE

R

TESTI

NG

6/20/2

012

Fluoride

[1.81

Mg/L]

176

LAB

FATEH

GARH

SAHIB

5

0

Fatehga

rh Sahib

KHER

A

SIND

HRA

N

SIND

HRA

N

SC650

983

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

7/20/2

012

Fluoride

[1.60

Mg/L]

5

1

Fatehga

rh Sahib

KHER

A

TIM

BER

PUR

TIMB

ERPU

R

NEAS

SCHO

OL /

SC222

8349

Deep

Tube

well

Punjab

Biotech

Incubat

or

5/1/20

12

Fluoride

[1.58

Mg/L]

5

2

Fatehga

rh Sahib

KHER

A

TIM

BER

PUR

TIMB

ERPU

R

NEAS

SCHO

OL /

SC222

8349

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

7/20/2

012

Fluoride

[1.63

Mg/L]

5

3

Fatehga

rh Sahib

SIRHIN

D

MANDI

BEH

LOL

PUR

BEHL

OLPU

R

SC634

574

Deep

Tube

well

State

Water

Testing

11/23/

2012

Fluoride

[1.60

Mg/L]

177

Lab

5

4

Fatehga

rh Sahib

SIRHIN

D

MANDI

CHH

ALE

RI

KAL

AN

CHH

ALER

I

KAL

AN

Near

Primar

y

Schoo

l /

SC142

6287

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/12/2

012

Fluoride

[1.56

Mg/L]

5

5

Fatehga

rh Sahib

SIRHIN

D

MANDI

CHH

ALE

RI

KHU

RD

CHH

ALER

I

KHU

RD

Near

Sub

S.H.C

/

SC142

6282

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/12/2

012

Fluoride

[1.61

Mg/L]

5

6

Fatehga

rh Sahib

SIRHIN

D

MANDI

HAL

LOT

ALI

HALL

OTAL

I

Near

Shams

hangh

at /

SC142

6228

Deep

Tube

well

WATE

R

TESTI

NG

LAB

FATEH

GARH

SAHIB

6/12/2

012

Fluoride

[1.60

Mg/L]

5

7

Fatehga

rh Sahib

SIRHIN

D

MANDI

JAG

O

CHA

JAGO

CHA

NART

NEAR

SCHO

OL /

Deep

Tube

well

WATE

R

TESTI

6/12/2

012

Fluoride

[1.66

Mg/L]

178

NAR

THA

L

HAL SC233

5992

NG

LAB

FATEH

GARH

SAHIB

5

8

Firozep

ur

ABOH

AR

KHA

IRPU

RA

KHAI

R

PURA

Near

Schoo

l /

SC145

1363

Canal Water

Testing

Lab

Abohar

6/18/2

012

Fluoride

[180.00

Mg/L]

5

9

Firozep

ur

FAZIL

KA

GHA

RUM

I

GHA

RUMI

Near

Schoo

l /

H1619

622

Deliv

ery

Point

Water

Testing

Lab

Fazilka

3/6/20

13

Fluoride

[2.00

Mg/L]

6

0

Firozep

ur

FAZIL

KA

GHA

RUM

I

GHA

RUMI

Near

Schoo

l /

H2590

295

Deliv

ery

Point

Water

Testing

Lab

Fazilka

3/9/20

13

Fluoride

[2.00

Mg/L]

6

1

Firozep

ur

FAZIL

KA

JAN

DWA

LA

BHI

ME

SHA

H

JAND

WAL

A

BHIM

E

SHAH

H8738

83

Deliv

ery

Point

Water

Testing

Lab

Fazilka

7/11/2

012

Fluoride

[7.31

Mg/L]

6 Firozep FAZIL JOR JORK Near Deliv Water 3/9/20 Fluoride

179

2 ur KA KI

KAN

KAR

WAL

I

IKAN

KAR

WALI

Schoo

l /

H2590

434

ery

Point

Testing

Lab

Fazilka

13 [2.00

Mg/L]

6

3

Firozep

ur

FAZIL

KA

JOR

KI

KAN

KAR

WAL

I

JORK

IKAN

KAR

WALI

Near

Schoo

l /

SC233

2291

Deep

Tube

well

Water

Testing

Lab

Fazilka

3/6/20

13

Fluoride

[2.00

Mg/L]

6

4

Firozep

ur

FAZIL

KA

JOR

KI

KAN

KAR

WAL

I

JORK

IKAN

KAR

WALI

SC507

493

Deep

Tube

well

Water

Testing

Lab

Fazilka

2/16/2

013

Fluoride

[2.00

Mg/L]

6

5

Firozep

ur

FAZIL

KA

JOR

KI

KAN

KAR

WAL

I

JORK

IKAN

KAR

WALI

SC507

493

Deep

Tube

well

Water

Testing

Lab

Fazilka

2/18/2

013

Fluoride

[2.00

Mg/L]

6

6

Firozep

ur

FAZIL

KA

RAN

A

RAN

A

Indivi

dual

House

hold

Conne

Deliv

ery

Point

Water

Testing

Lab

Fazilka

2/1/20

13

Fluoride

[2.50

Mg/L]

180

ctions

/

H1633

819

6

7

Firozep

ur

FAZIL

KA

RAN

A

RAN

A

Indivi

dual

House

hold

Conne

ctions

/

H1633

819

Deliv

ery

Point

Water

Testing

Lab

Fazilka

3/11/2

013

Fluoride

[2.00

Mg/L]

6

8

Firozep

ur

FAZIL

KA

RAN

A

RAN

A

Indivi

dual

House

hold

Conne

ctions

/

SC148

7317

Deep

Tube

well

Water

Testing

Lab

Fazilka

2/20/2

013

Fluoride

[2.50

Mg/L]

6

9

Firozep

ur

JALAL

ABAD

CHA

K

CHH

APRI

WAL

A

CHA

K

CHAP

PRI

WAL

A

Near

Schoo

l /

H2590

775

Deliv

ery

Point

Water

Testing

Lab

Fazilka

1/17/2

013

Fluoride

[2.50

Mg/L]

181

7

0

Firozep

ur

JALAL

ABAD

CHA

K

CHH

APRI

WAL

A

CHA

K

CHAP

PRI

WAL

A

Near

Schoo

l /

SC233

2616

Deep

Tube

well

Water

Testing

Lab

Fazilka

2/6/20

13

Fluoride

[2.00

Mg/L]

7

1

Firozep

ur

JALAL

ABAD

CHA

K

CHH

APRI

WAL

A

CHA

K

CHAP

PRI

WAL

A

Near

Schoo

l /

SC233

2616

Deep

Tube

well

Water

Testing

Lab

Fazilka

3/14/2

013

Fluoride

[2.00

Mg/L]

7

2

Firozep

ur

JALAL

ABAD

CHA

K

CHH

APRI

WAL

A

CHA

K

CHAP

PRI

WAL

A

Near

Schoo

l /

SC233

2616

Deep

Tube

well

Water

Testing

Lab

Fazilka

3/16/2

013

Fluoride

[2.00

Mg/L]

7

3

Firozep

ur

JALAL

ABAD

CHA

K

CHH

APRI

WAL

A

CHA

K

CHAP

PRI

WAL

A

Near

Schoo

l /

SC233

2616

Deep

Tube

well

Water

Testing

Lab

Fazilka

2/23/2

013

Fluoride

[2.00

Mg/L]

7

4

Firozep

ur

JALAL

ABAD

CHA

K

DHU

MAL

CHA

K

DHU

MAL

H8690

83

Deliv

ery

Point

Water

Testing

Lab

Fazilka

1/17/2

013

Fluoride

[2.40

Mg/L]

182

7

5

Firozep

ur

JALAL

ABAD

CHA

K

DHU

MAL

CHA

K

DHU

MAL

SC496

386

Deep

Tube

well

Water

Testing

Lab

Fazilka

3/14/2

013

Fluoride

[2.00

Mg/L]

7

6

Firozep

ur

JALAL

ABAD

CHA

K

DHU

MAL

CHA

K

DHU

MAL

SC496

386

Deep

Tube

well

Water

Testing

Lab

Fazilka

3/16/2

013

Fluoride

[2.00

Mg/L]

7

7

Firozep

ur

JALAL

ABAD

CHA

K

DHU

MAL

CHA

K

DHU

MAL

NERA

SCHO

OL /

SC515

4335

Deep

Tube

well

Water

Testing

Lab

Fazilka

2/6/20

13

Fluoride

[2.00

Mg/L]

7

8

Firozep

ur

JALAL

ABAD

CHA

K

DHU

MAL

CHA

K

DHU

MAL

NERA

SCHO

OL /

SC515

4335

Deep

Tube

well

Water

Testing

Fazilka

2/23/2

013

Fluoride

[2.00

Mg/L]

7

9

Firozep

ur

JALAL

ABAD

DHA

B

KHU

SHA

L

JOYI

A

DHA

B

KHUS

HAL

JOYI

A

Indivi

dual

House

hold

Conne

ctions

/

H1283

97

Deliv

ery

Point

Water

Testing

Lab

Fazilka

7/26/2

012

Fluoride

[1.60

Mg/L]

8 Firozep JALAL DHA DHA Near Deep Water 7/7/20 Fluoride

183

0 ur ABAD B

KHU

SHA

L

JOYI

A

B

KHUS

HAL

JOYI

A

Schoo

l /

SC233

2389

Tube

well

Testing

Lab

Fazilka

12 [1.60

Mg/L]

8

1

Firozep

ur

JALAL

ABAD

DHA

B

KHU

SHA

L

JOYI

A

DHA

B

KHUS

HAL

JOYI

A

Near

Schoo

l /

SC233

2389

Deep

Tube

well

Water

Testing

Lab

Fazilka

6/14/2

012

Fluoride

[1.60

Mg/L]

8

2

Firozep

ur

JALAL

ABAD

HAZ

ARA

RAM

SING

H

WAL

A

HAZ

ARA

RAM

SING

H

WAL

A

H8744

27

Deliv

ery

Point

Water

Testing

Lab

Fazilka

9/10/2

012

Fluoride

[8.10

Mg/L]

8

3

Firozep

ur

JALAL

ABAD

JAM

AL

KE

JAMA

L KE

H8763

96

Deliv

ery

Point

Water

Testing

Lab

Fazilka

1/1/20

13

Fluoride

[2.00

Mg/L]

8

4

Firozep

ur

JALAL

ABAD

JAM

AL

KE

JAMA

L KE

H8763

96

Deliv

ery

Point

Water

Testing

Lab

Fazilka

1/19/2

013

Fluoride

[2.40

Mg/L]

184

8

5

Firozep

ur

GURU

HAR

SAHAI

GUR

UHA

R

SAH

AI(R

URA

L)

GUR

U

HAR

SAHA

I

SC496

425

Deep

Tube

well

Water

Testing

Lab

Fazilka

3/2/20

13

Fluoride

[120.00

Mg/L]

8

6

Firozep

ur

GURU

HAR

SAHAI

PIR

BAK

HAS

H

CHO

HAN

PIR

BAX

CHO

UHA

N

Near

Schoo

l /

SC400

2844

Deep

Tube

well

Water

Quality

Testing

Lab

Ferozep

ur

5/2/20

12

Fluoride

[40.00

Mg/L]

8

7

Firozep

ur

MAMD

OT

JAM

A

RAK

HIA

HITH

AR

JAMA

RAK

HIA

HITT

AR

H8658

19

Deliv

ery

Point

Water

Quality

Testing

Ferozep

ur

8/24/2

012

Fluoride

[7.30

Mg/L]

8

8

Firozep

ur

ZIRA KAS

OAN

A

KASS

OAN

A

Near

Road /

SC400

9597

Deep

Tube

well

Water

Quality

Testing

Lab

Ferozep

ur

9/18/2

012

Fluoride

[30.00

Mg/L]

8

9

Mansa BUDH

LADA

BAH

ADA

RPU

BAH

ADU

RPUR

Megh

Singh

/

Deep

Tube

well

WATE

R

TESTI

12/12/

2012

Fluoride

[1.80

Mg/L]

185

R P0001

38945

7

NG

LAB

MANS

A

9

0

Mansa BUDH

LADA

MAG

HAN

IAN

MAG

HANI

AN

Teja

Singh

/

P0001

18122

7

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

6/9/20

12

Fluoride

[2.20

Mg/L]

9

1

Mansa BUDH

LADA

MAG

HAN

IAN

MAG

HANI

AN

Darba

ra

Singh

/

P0001

18122

8

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

6/9/20

12

Fluoride

[2.40

Mg/L]

9

2

Mansa BUDH

LADA

PHU

LUW

ALA

DOD

PHUL

UWA

LA

DOD

Bhola

Singh

/

PU00

01181

232

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

6/9/20

12

Fluoride

[2.50

Mg/L]

9

3

Mansa BUDH

LADA

PHU

LUW

ALA

PHUL

UWA

LA

Gurja

nt

Singh

Deep

Tube

well

WATE

R

TESTI

6/9/20

12

Fluoride

[2.30

Mg/L]

186

DOD DOD /

PU00

01181

233

NG

LAB

MANS

A

9

4

Mansa BUDH

LADA

REO

ND

KHU

RD

REON

D

KHU

RD

Narin

der

Singh

/

P0001

18122

2

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

6/9/20

12

Fluoride

[2.50

Mg/L]

9

5

Mansa BUDH

LADA

REO

ND

KHU

RD

REON

D

KHU

RD

Major

Singh

/

P0001

18122

5

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

6/9/20

12

Fluoride

[2.40

Mg/L]

9

6

Mansa JHUNI

R

RAIP

UR

RAIP

UR

Resha

m

Singh

/

PU00

01223

981

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

8/11/2

012

Fluoride

[1.80

Mg/L]

9

7

Mansa SARDU

LGAR

H

BHA

GWA

NPU

BHA

GWA

NPUR

Near

Schoo

l /

Canal WATE

R

TESTI

1/15/2

013

Fluoride

[4.00

Mg/L]

187

R

HIG

NA

HING

NA

SC144

0998

NG

LAB

MANS

A

9

8

Mansa SARDU

LGAR

H

PHU

S

MAN

DI

PHUS

MAN

DI

SC664

175

Deep

Tube

well

WATE

R

TESTI

NG

LAB

MANS

A

12/12/

2012

Fluoride

[2.90

Mg/L]

S.

N

o.

District Block Villa

ge

Habit

ation

Locati

on

Type

Of

Sour

ce

Lab

Name

Testin

g Date

Above

Permiss

ible

Limit

1 Moga MOGA-

I

MAN

DIR

ANW

ALA

Mandi

ran

Wala

Nawa

n

New

Water

Works

/

SC440

1657

Deep

Tube

well

State

Water

Testing

Lab

4/9/20

12

Fluoride

[2.18

Mg/L]

2 Moga MOGA-

II

SING

HAN

WAL

A

SC

Basti

Hand

Pump

/

SC477

1228

Shall

ow

Tube

well

Water

Testing

Lab

Moga

11/12/

2012

Fluoride

[5.90

Mg/L]

3 Moga NIHAL

SINGH

RAN

SIH

RANS

IH

SC639

368

Deep

Tube

Water

Testing

11/15/

2012

Fluoride

[35.00

188

WALA KAL

AN

KAL

AN

well Lab

Moga

Mg/L]

1 Muktsar KOT

BHAI

AT

GIDDE

RBAH

A

BHA

LAIA

NA

BHAL

LIAN

A

Handp

ump

Near

Petrol

Pump

/

PU00

01158

930

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[2.45

Mg/L]

2 Muktsar KOT

BHAI

AT

GIDDE

RBAH

A

BUT

TAR

BAK

HUA

BUTT

ER

BAK

HUH

A

Near

Bus

Stand

/

H4474

689

Deliv

ery

Point

State

Water

Testing

Lab

5/8/20

12

Fluoride

[2.38

Mg/L]

3 Muktsar KOT

BHAI

AT

GIDDE

RBAH

A

DOD

A

DOD

A

Handp

ump

Near

Gurud

wara /

PU00

01158

954

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[6.38

Mg/L]

4 Muktsar KOT

BHAI

AT

SUK

HA

ABL

SUKH

NA

ABLU

Handp

ump

Near

Shall

ow

Tube

State

Water

Testing

5/8/20

12

Fluoride

[11.05

Mg/L]

189

GIDDE

RBAH

A

U Harija

n

Basti /

PU00

01158

944

well Lab

5 Muktsar LAMBI ABU

L

KHU

RAN

A

ABUL

KHU

RAN

A

Handp

ump

New

Abadi

/

PU00

01159

410

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[3.33

Mg/L]

6 Muktsar LAMBI KILL

IAN

WAL

I

KILLI

AN

WALI

Handp

ump

Near

Gurud

wara /

PU00

01159

411

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[2.33

Mg/L]

7 Muktsar MALO

UT

DAN

E

WAL

A

DAN

EWA

LA

Handp

ump

Near

Schoo

l /

PU00

Khad

ins/N

adis/

Tank

as/Po

nds/

State

Water

Testing

Lab

5/8/20

12

Fluoride

[2.12

Mg/L]

190

01158

012

Wells

/Oora

nis

8 Muktsar MALO

UT

MAL

OUT

PIND

MAL

OUT

VILL

AGE

Handp

ump

Near

Dispe

nsary /

PU00

01157

910

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[1.54

Mg/L]

9 Muktsar MALO

UT

PAT

TI

KAR

AM

PATT

I

KAR

AM

H1036

582

Deliv

ery

Point

Water

Testing

Lab

Malout

5/17/2

012

Fluoride

[2.25

Mg/L]

1

0

Muktsar MUKT

SAR

BAR

KAN

DI

BAR

KAN

DI

Handp

ump

Near

Schoo

l /

PU00

01158

918

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[21.85

Mg/L]

1

1

Muktsar MUKT

SAR

CHA

K

DUH

E

WAL

CHA

K

DUH

E

WAL

Handp

ump

Near

Bus

Stop /

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[1.99

Mg/L]

191

A A PU00

01158

010

1

2

Muktsar MUKT

SAR

GON

IAN

A

GONI

ANA

SC660

070

Deep

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[2.45

Mg/L]

1

3

Muktsar MUKT

SAR

RUP

ANA

RUPA

NA

Handp

ump

Near

Pond /

PU00

01158

916

Shall

ow

Tube

well

State

Water

Testing

Lab

5/8/20

12

Fluoride

[2.74

Mg/L]

1 Patiala BHUN

NERHE

RI

ALIP

UR

WAZ

IR

SAHI

B

ALIP

UR

WAZI

R

SAHI

B

Dera

Ajit

Singh

/

SC258

0726

Shall

ow

Tube

well

State

Water

Testing

Lab

11/2/2

012

Fluoride

[1.60

Mg/L]

2 Patiala BHUN

NERHE

RI

BUD

HMO

RE

BUD

HMO

RE

Near

Govt.

Eleme

ntary

Schoo

l /

SC142

1412

Deep

Tube

well

State

Water

Testing

Lab

7/4/20

12

Fluoride

[1.87

Mg/L]

192

3 Patiala BHUN

NERHE

RI

HAD

IAN

A

HADI

ANA

Dera

Hadia

na /

SC258

0736

Shall

ow

Tube

well

State

Water

Testing

Lab

11/2/2

012

Fluoride

[1.90

Mg/L]

4 Patiala BHUN

NERHE

RI

PANJ

ETA

PANJ

ETA

SC589

081

Deep

Tube

well

State

Water

Testing

Lab

3/6/20

13

Fluoride

[1.60

Mg/L]

5 Patiala BHUN

NERHE

RI

PAR

OR

PARO

R

SC594

015

Deep

Tube

well

State

Water

Testing

Lab

3/6/20

13

Fluoride

[2.10

Mg/L]

6 Patiala BHUN

NERHE

RI

PUR PUR SC594

004

Deep

Tube

well

State

Water

Testing

Lab

3/6/20

13

Fluoride

[1.60

Mg/L]

7 Patiala GHAN

OUR

ALI

MAJ

RA

ALI

MAJR

A

SC578

602

Deep

Tube

well

State

Water

Testing

Lab

10/12/

2012

Fluoride

[1.70

Mg/L]

8 Patiala GHAN

OUR

BHA

T

MAJ

RA

BHAT

MAJR

A.

SC586

767

Deep

Tube

well

State

Water

Testing

Lab

10/30/

2012

Fluoride

[1.70

Mg/L]

9 Patiala GHAN

OUR

BHU

RI

MAJ

BHU

RI

MAJR

Near

Shams

han

Deep

Tube

well

State

Water

Testing

10/12/

2012

Fluoride

[2.10

Mg/L]

193

RA A Ghat /

SC232

8648

Lab

1

0

Patiala GHAN

OUR

GAD

APU

R

GAD

APUR

Near

Mandi

r /

SC142

4765

Deep

Tube

well

State

Water

Testing

Lab

8/22/2

012

Fluoride

[2.05

Mg/L]

1

1

Patiala GHAN

OUR

GHU

NGR

AN

GHU

NGR

AN

H9620

01

Deliv

ery

Point

WATE

R

TESTI

NG

LAB

RAJPU

RA

5/5/20

12

Fluoride

[5.00

Mg/L]

1

2

Patiala GHAN

OUR

GHU

NGR

AN

GHU

NGR

AN

SC590

109

Deep

Tube

well

State

Water

Testing

Lab

3/12/2

013

Fluoride

[5.75

Mg/L]

1

3

Patiala GHAN

OUR

HAR

PAL

PUR

HARP

ALPU

R

Near

Schoo

l /

SC378

7543

Deep

Tube

well

State

Water

Testing

Lab

8/22/2

012

Fluoride

[2.19

Mg/L]

1

4

Patiala GHAN

OUR

JAK

HEP

AL

JAKH

EPAL

Near

Villag

e

Road /

Deep

Tube

well

State

Water

Testing

Lab

8/22/2

012

Fluoride

[2.25

Mg/L]

194

SC142

4761

1

5

Patiala GHAN

OUR

KHA

NPU

R

GAN

DIA

N

KHA

NPUR

GAN

DIAN

H9488

46

Deliv

ery

Point

WATE

R

TESTI

NG

LAB

RAJPU

RA

5/5/20

12

Fluoride

[5.00

Mg/L]

1

6

Patiala GHAN

OUR

KUT

HA

KHE

RI

KUT

HA

KHER

I

SC595

485

Deep

Tube

well

State

Water

Testing

Lab

8/22/2

012

Fluoride

[3.57

Mg/L]

1

7

Patiala GHAN

OUR

MAD

ANP

UR

MAD

ANPU

R

SC589

479

Deep

Tube

well

State

Water

Testing

Lab

8/21/2

012

Fluoride

[4.41

Mg/L]

1

8

Patiala GHAN

OUR

MAN

DOU

LI

MAN

DOU

LI

SC579

820

Deep

Tube

well

State

Water

Testing

Lab

8/23/2

012

Fluoride

[1.69

Mg/L]

1

9

Patiala GHAN

OUR

RAJ

GAR

H

RAJG

ARH

SC585

792

Deep

Tube

well

State

Water

Testing

Lab

8/21/2

012

Fluoride

[1.89

Mg/L]

2

0

Patiala GHAN

OUR

SAH

AL

SAHA

L

SC589

066

Deep

Tube

well

State

Water

Testing

3/14/2

013

Fluoride

[5.75

Mg/L]

195

Lab

2

1

Patiala GHAN

OUR

SHEI

KHU

PUR

SHEI

KHUP

UR

SC572

084

Deep

Tube

well

State

Water

Testing

Lab

10/30/

2012

Fluoride

[5.25

Mg/L]

2

2

Patiala GHAN

OUR

SON

E

MAJ

RA

SONE

MAJR

A

SC579

166

Deep

Tube

well

State

Water

Testing

Lab

8/27/2

012

Fluoride

[1.76

Mg/L]

2

3

Patiala GHAN

OUR

TEPL

A

TEPL

A

On

The

Villag

e

Road /

SC145

5420

Deep

Tube

well

State

Water

Testing

Lab

8/22/2

012

Fluoride

[2.26

Mg/L]

2

4

Patiala PATIA

LA

CHA

MAR

HERI

CHA

MAR

HERI

Cham

arheri

/

SC474

0589

Deep

Tube

well

State

Water

Testing

Lab

12/28/

2012

Fluoride

[1.70

Mg/L]

2

5

Patiala PATIA

LA

CHA

MAR

HERI

CHA

MAR

HERI

SC589

794

Deep

Tube

well

State

Water

Testing

Lab

7/24/2

012

Fluoride

[1.87

Mg/L]

2

6

Patiala PATIA

LA

MEH

MOO

DPU

MEH

MOO

DPUR

On

Villag

e

Deep

Tube

well

State

Water

Testing

12/28/

2012

Fluoride

[1.70

Mg/L]

196

R

JATT

AN

JATT

AN

Road /

SC472

7296

Lab

2

7

Patiala PATIA

LA

MIT

HU

MAJ

RA

MITH

U

MAJR

A

SC380

0124

Deep

Tube

well

State

Water

Testing

Lab

12/28/

2012

Fluoride

[1.70

Mg/L]

2

8

Patiala PATIA

LA

PUNI

A

JATT

AN

PUNI

A

JATT

AN

Near

Link

Road /

SC232

9084

Deep

Tube

well

State

Water

Testing

Lab

8/16/2

012

Fluoride

[1.74

Mg/L]

2

9

Patiala PATIA

LA

PUNI

A

JATT

AN

PUNI

A

JATT

AN

Near

Schoo

l /

SC378

7966

Deep

Tube

well

State

Water

Testing

Lab

12/28/

2012

Fluoride

[1.90

Mg/L]

3

0

Patiala PATIA

LA

RAIP

UR

RAIP

UR

Raipur

/

SC472

9792

Deep

Tube

well

State

Water

Testing

Lab

12/28/

2012

Fluoride

[1.70

Mg/L]

3

1

Patiala RAJPU

RA

AKA

R

AKA

R

SC592

302

Deep

Tube

well

State

Water

Testing

Lab

8/28/2

012

Fluoride

[1.77

Mg/L]

3

2

Patiala RAJPU

RA

ALA

MPU

R

ALA

MPU

R

Near

High

Schoo

Deep

Tube

well

State

Water

Testing

8/23/2

012

Fluoride

[1.73

Mg/L]

197

l /

SC182

7816

Lab

3

3

Patiala RAJPU

RA

BHA

TERI

BHAT

ERI

SC606

891

Deep

Tube

well

State

Water

Testing

Lab

8/24/2

012

Fluoride

[1.60

Mg/L]

3

4

Patiala RAJPU

RA

BHO

GLA

N

BHO

GLA

N

SC587

201

Deep

Tube

well

State

Water

Testing

Lab

10/15/

2012

Fluoride

[4.25

Mg/L]

3

5

Patiala RAJPU

RA

CHA

MAR

U

CHA

MAR

U

Near

Schoo

l /

SC378

7765

Deep

Tube

well

State

Water

Testing

Lab

8/27/2

012

Fluoride

[3.02

Mg/L]

3

6

Patiala RAJPU

RA

DHA

BALI

DHA

BALI

SC602

888

Deep

Tube

well

State

Water

Testing

Lab

8/24/2

012

Fluoride

[2.22

Mg/L]

3

7

Patiala RAJPU

RA

DHA

KAN

SU

KAL

AN

DHA

KANS

U

KAL

AN

H9465

83

Deliv

ery

Point

WATE

R

TESTI

NG

LAB

RAJPU

RA

5/5/20

12

Fluoride

[1.80

Mg/L]

3 Patiala RAJPU DHA DHA SC574 Deep State 3/14/2 Fluoride

198

8 RA KAN

SU

KAL

AN

KANS

U

KAL

AN

597 Tube

well

Water

Testing

Lab

013 [3.75

Mg/L]

3

9

Patiala RAJPU

RA

DHA

KAN

SU

KAL

AN

DHA

KANS

U

KAL

AN

SC574

597

Deep

Tube

well

State

Water

Testing

Lab

8/24/2

012

Fluoride

[2.50

Mg/L]

4

0

Patiala RAJPU

RA

DHI

NDS

A

DHIN

DSA

H9487

10

Deliv

ery

Point

State

Water

Testing

Lab

10/17/

2012

Fluoride

[1.90

Mg/L]

4

1

Patiala RAJPU

RA

DHI

NDS

A

DHIN

DSA

SC576

730

Deep

Tube

well

State

Water

Testing

Lab

8/23/2

012

Fluoride

[1.89

Mg/L]

4

2

Patiala RAJPU

RA

FARI

DPU

R

FARI

DPUR

SC579

557

Deep

Tube

well

State

Water

Testing

Lab

11/6/2

012

Fluoride

[2.10

Mg/L]

4

3

Patiala RAJPU

RA

FARI

DPU

R

FARI

DPUR

SC579

557

Deep

Tube

well

State

Water

Testing

Lab

8/23/2

012

Fluoride

[2.24

Mg/L]

4

4

Patiala RAJPU

RA

GHA

RAM

A

GHA

RAM

A

Near

Primar

Schoo

Deep

Tube

well

State

Water

Testing

10/17/

2012

Fluoride

[1.70

Mg/L]

199

KAL

AN

KAL

AN

l /

SC232

8947

Lab

4

5

Patiala RAJPU

RA

GOP

ALP

UR

GOPA

LPUR

Near

Shams

han

Ghat /

SC232

8971

Deep

Tube

well

State

Water

Testing

Lab

8/24/2

012

Fluoride

[1.58

Mg/L]

4

6

Patiala RAJPU

RA

JAN

DOU

LI

JAND

OULI

Near

Jaggi

Colon

y /

SC472

6900

Deep

Tube

well

State

Water

Testing

Lab

10/17/

2012

Fluoride

[3.75

Mg/L]

4

7

Patiala RAJPU

RA

KHA

IRPU

R

JATT

AN

KHAI

RPUR

JATT

AN

SC576

817

Deep

Tube

well

State

Water

Testing

Lab

8/28/2

012

Fluoride

[4.73

Mg/L]

4

8

Patiala RAJPU

RA

KHA

NDO

ULI

KHA

NDO

ULI

Near

Primar

y

Schoo

l /

SC142

4752

Deep

Tube

well

State

Water

Testing

Lab

8/28/2

012

Fluoride

[1.92

Mg/L]

200

4

9

Patiala RAJPU

RA

KHA

NPU

R

BAR

RIN

G

KHA

NPUR

BARR

ING

Near

Shams

han

Ghat /

SC232

8135

Deep

Tube

well

State

Water

Testing

Lab

10/17/

2012

Fluoride

[2.60

Mg/L]

5

0

Patiala RAJPU

RA

KHE

RI

GUR

NA

KHER

I

GUR

NA

On

Villag

e

Road /

SC232

8409

Deep

Tube

well

State

Water

Testing

Lab

8/27/2

012

Fluoride

[1.58

Mg/L]

5

1

Patiala RAJPU

RA

KOT

LA

KOTL

A

SC585

451

Deep

Tube

well

State

Water

Testing

Lab

8/24/2

012

Fluoride

[2.02

Mg/L]

5

2

Patiala RAJPU

RA

MAN

DWA

L

MAN

DWA

L

SC593

570

Deep

Tube

well

State

Water

Testing

Lab

8/27/2

012

Fluoride

[2.63

Mg/L]

5

3

Patiala RAJPU

RA

MOH

I

KAL

AN

MOHI

KAL

AN

SC590

253

Deep

Tube

well

State

Water

Testing

Lab

10/17/

2012

Fluoride

[1.70

Mg/L]

5

4

Patiala RAJPU

RA

MOH

I

KAL

AN

MOHI

KAL

AN

SC590

253

Deep

Tube

well

State

Water

Testing

Lab

8/27/2

012

Fluoride

[1.86

Mg/L]

201

5

5

Patiala RAJPU

RA

NAL

AS

KAL

AN

NAL

AS

KAL

AN

SC586

014

Deep

Tube

well

State

Water

Testing

Lab

8/28/2

012

Fluoride

[2.19

Mg/L]

5

6

Patiala RAJPU

RA

SEH

RA

SEHR

A

Near

Govt.

Schoo

l /

SC142

4890

Deep

Tube

well

State

Water

Testing

Lab

8/24/2

012

Fluoride

[1.73

Mg/L]

5

7

Patiala RAJPU

RA

SUR

AJG

ARH

SURA

JGAR

H

SC580

503

Deep

Tube

well

State

Water

Testing

Lab

8/27/2

012

Fluoride

[1.83

Mg/L]

5

8

Patiala RAJPU

RA

UPP

ALH

ERI

UPPA

LHER

I

Near

Schoo

l /

SC232

7496

Deep

Tube

well

State

Water

Testing

Lab

8/23/2

012

Fluoride

[1.88

Mg/L]

5

9

Patiala SANO

UR

BUD

ANP

UR

BUD

ANPU

R

SC590

834

Deep

Tube

well

State

Water

Testing

Lab

8/16/2

012

Fluoride

[1.70

Mg/L]

6

0

Patiala SANO

UR

JAL

ALP

UR

JALA

LPUR

SC603

326

Deep

Tube

well

State

Water

Testing

Lab

8/16/2

012

Fluoride

[1.57

Mg/L]

6 Patiala SANO MEH MEH SC589 Deep State 3/12/2 Fluoride

202

1 UR ARG

ARH

BAT

TA

ARG

ARH

BATT

A

117 Tube

well

Water

Testing

Lab

013 [2.10

Mg/L]

6

2

Patiala SANO

UR

MEH

ARG

ARH

BAT

TA

MEH

ARG

ARH

BATT

A

SC589

117

Deep

Tube

well

State

Water

Testing

Lab

8/16/2

012

Fluoride

[1.78

Mg/L]

6

3

Patiala SANO

UR

NOO

R

KHE

RIA

N

NOO

R

KHER

IAN

SC593

272

Deep

Tube

well

State

Water

Testing

Lab

8/16/2

012

Fluoride

[1.76

Mg/L]

6

4

Sangrur DHURI RAJ

O

MAJ

RA

RAJO

MAJR

A

SC603

510

Deep

Tube

well

Water

Quality

Testing

Lab

6/28/2

012

Fluoride

[2.10

Mg/L]

203

Correlation Between Fluorosis and Anaemia

As anemia is a big problem in our country, it would be useful to explore new

options for mitigating the problem. It is proposed that a study be taken up to

look for any linkages between fluoride ingestion and presence of anemia

amongst pregnant women attending antenatal clinics and children under School

health Programme.

Mata Kaushalaya hospital in district Patiala was selected for this study purpose.

Consultant under NPPCF from District Sangrur along with Lab Technician

visiting the hospital once in a week on an anti natal day and collect urine

samples from the patients to investigate fluoride contents in urine for which Lab

at NPPCF Sangrur is being utilized. The data regarding anemia collected from

the hospital general lab, which is collaborated with the results of urine samples

collected to assess fluoride level.

The data as received from District Sangrur is detailed below:

Report of Month April 2014 of Anaemic Pregnant Women

S.No Name of patient Haemoglobin level

Fluoride

Level

1 Suman 8.7 2.3

2 Sukhwinder 8.7 1.7

3 Poonam 8.7 1.2

4 Kaushalaya 8.6 0.5

5 Kulwinder Kaur 8.7 2.2

6 Gurwinder Kaur 8.5 1.9

7 Harwinder Kaur 8.5 2

8 Amritpal Kaur 8.5 0.7

9 Sushil Rani 8.5 1.4

10 Kamaljit Kaur 8.5 2

11 Kulwinder Kaur 8.5 1.9

204

12 Dilpreet Kaur 8.5 0.7

13 Reena 7 1.2

14 Simran 8.5 2.1

15 Sohanpreet 8.5 1.4

16 Kuldeep Kaur 8 1.9

17 Ravinder Kaur 8.5 2.3

18 Sandeep Kaur 8.2 0.8

19 Gagandeep Kaur 9 0.9

20 Jaspal Kaur 8 1.3

21 Harjeet Kaur 8 2

22 Karmjit Kaur 8.2 2.2

23 Chahat 8.5 0.5

24 Bhalljit Kaur 8.5 2

25 Raj Kaur 7 1.6

26 Neena 8.5 1.8

27 Jagtar Kaur 8.5 0.9

28 Harjeet pal 8.5 1.1

29 Jyoti 8 0.6

30 Ravreet Kaur 8.5 1.3

31 Amandeep Kaur 8.5 1.3

32 Jaswinder Kaur 8 1.6

33 Pooja Rani 8.6 2

34 Pooja 8.5 1.8

35 Vaina Devi 8 1.1

36 Manpreet Kaur 8 0.6

37 Suman 8 1.5

38 Gurdeep Kaur 8 2.1

39 Angrej 7 1.6

205

40 Karampal Kaur 8.5 0.8

41 sunita 6 1.2

42 Neelam 8 1.5

43 Veerpal Kaur 8 2.1

44 Sujal 8.5 1.4

45 Gurmeet Kaur 8.5 2.3

46 Harjeet Kaur 7 2.5

47 Kiranpal Kaur 8 1.2

48 Harpreet Kaur 8.5 0.9

49 Amita 8.5 1.4

50 Jaspreet Kaur 6.2 1.1

51 Sarbjeet Kaur 7.5 0.8

52 Jaspal Kaur 8 1.8

53 Diksha 8 1.9

54 Jaspreet Kaur 7 0.6

55 Rajneet Kaur 8 2.1

56 Mandeep Kaur 7 0.6

57 Dimple 8 2.3

58 Vibha Devi 9 0.9

59 Mandeep Kaur 8 2.1

60 Kamaldeep Kaur 8 1.5

61 Sarbjit Kaur 8 1.3

62 Amandeep Kaur 8.5 1.2

63 Charanjit Kaur 8 2

64 Parmjit Kaur 8.2 1.8

206

Report of Month May 2014 of Anaemic Pregnant Women

S.No Name of Patient

Haemoglobin

Level

Fluoride

Level Pregnancy

1

Balwinder K W/O

Manpreet 10.4 1.5 2

2

Ranjit Kaur W/O Bhusan

Singh 8.5 0.9 4

3

Karmjeet Kaur W/O

Karmjeet Singh 9.3 1 1

4 Rimpy W/O Jagtar Singh 8 2.6 1

5 Gagandeep W/O Ramtaj 10 1.9 2

6

Baljit Kaur W/O Sukhdev

Singh 8.3 1.7 1

7 Neetu W/O Ragveer 7.5 2.1 1

8 Parmjit K W/O Karmjit 9.8 1.6 3

9 Kiran W/O Amit Kumar 8.5 0.8 2

10

Soni Singla w/o Sunil

Singla 9.3 1.8 1

11

Jasbir W/O Harbhajan

singh 9.5 2.5 3

12

Baldeep W/O Hardeep

singh 7.8 1.4 1

13 Rimpi W/O Raju 8.8 1 2

14

Rajwinder W/O Mandeep

Singh 9.4 3.8 3

15 Renu W/O Gaurav 8.6 2.6 1

16 Gagandeep W/O Rajpal 8.5 1.4 2

17 Sandeep Kaur W/O 9.2 1 2

207

Tejinder Singh

18 Anita Rani W/O Rampal 8.3 2.1 2

19 Reena W/O Tarsem Singh 9 0.8 4

20

Karmjeet W/O Varinder

Khan 8.4 1.5 1

21

Hardeep Kaur W/O

Angrej Singh 9.1 2.2 3

22

Pinky Rani W/O Sohna

Singh 8 1.3 2

23

Rupinder Kaur W/O Deep

Kumar 9.8 1.9 3

24

Mini Kaur W/O Babli

Singh 7.8 1.6 4

25

Amandeep Kaur W/O

Pritpal Singh 10 1 1

26 Arsh Rani W/O Vivesh 9 0.9 2

27

Hardeep Kaur W/O Teerth

Singh 8.5 2.3 1

28

Kuldeep Kaur W/O

Nirbhai Singh 8 1.1 2

29

Sukhwant Kaur W/O

Dilbara Singh 8.8 1.4 1

30

Manpreet Kaur W/O

Happy Singh 10 0.9 1

31

Sandeep Kaur W/O

Amritpal Singh 7.8 1.3 2

32

Gurmeet Kaur W/O

Ajitpal Singh 8.8 1.6 1

208

33

Sarbjeet Kaur W/O Amrit

Singh 9.2 2.1 3

34

Manjeet Kaur W/O Tegpal

Singh 8.5 1.9 3

35

Sunita W/O Jaspreet

Singh 7.3 1.8 2

36

Manjeet Kaur W/O

Gurpreet Singh 10 0.9 1

37

Kulwinder Kaur W/O

Jagatpal Singh 9 2.2 2

38

Darshan Kaur W/O

Gurcharan Singh 9.3 0.8 2

39

Jaspreet Kaur W/O Harpal

Singh 10.2 1.4 2

40

Harpreet Kaur W/O

Hardeep Singh 7.8 1.9 1

41

Jaspal Kaur W/O

Bhupinder Singh 9.6 0.6 2

42

Sunita Rani W/O Jagjeet

Singh 8.5 1.5 2

43

Sukhwinder Kaur W/O

Jagtar Singh 9 2.3 2

44

Randeep Sharma W/O

Gurmeet Singh 8.5 1.9 1

45

Mandeep Kaur W/O

Jatinder Kumar 9 0.8 2

46

Sukhwinder Kaur W/O

Sarbjeet 9.3 1.4 2

209

47

Shalini Verma W/O Mono

Verma 8.5 1.8 1

48

Asha Rani W/O

Balwinder Singh 8.4 1.2 2

49 Shanta W/O Rajesh Singh 7.8 0.9 2

50

Lakhwinder Kaur W/O

Lakhveer Singh 8 1.4 1

51

Parmjeet Kaur W/O

Rajinder Singh 9.7 1.6 1

52

Balbir Kaur W/O Jagtar

Singh 9 3.1 1

53

Veerpal Kaur W/O Yodha

Singh 9.2 1.6 3

54

Soni Kaur W/O Satnam

Singh 8.1 2.5 1

55

Hardeep Kaur W/O

Harpreet Singh 10 1 2

56

Charanjeet Kaur W/O

Gurjeet Singh 7.9 1.9 2

Report of Month June 2014 of Anaemic Pregnant Women


Haemoglobin

Level

Fluoride

Level Pregnancy

1 Rani W/O Joginder Singh 8.5 1 2

2

Amninder Kaur W/O

Harpreet Singh 10.6 2 2

3

Amandeep Kaur W/O

Narinder Singh 9 1 3

210

4

Jaspreet Kaur W/O Nirpal

Singh 8.8 2.1 2

5

Veerpal Kaur W/O

Dharampal Singh 9 0.9 1

6

Veerpal Kaur W/O Harpal

Singh 9.1 1.1 3

7

Satveer Kaur W/O Nirmal

Singh 8.5 1.6 2

8 Renu W/O Rakesh 6.5 2.5 1

9 Savitri W/O Jogesh 7.1 0.9 2

10

Jaswinder Kaur W/O

Ajminder Singh 8.5 1 1

11 Manjinder Kaur W/O Sanju 9 1.7 1

12

Harmeet Kaur W/O

Darshan Singh 7.8 0.7 3

13

Charanjit Kaur W/O Ranjit

Singh 8.3 1.6 1

14

Amarjot Kaur W/O Labh

Singh 9 3.5 2

15

Karmjeet Kaur W/O

Gobind Singh 10.2 2.1 2

16

Jagtar Kaur W/O

Dharampal Singh 8.5 1.3 3

17

Ranbir Kaur W/O

Parminder Singh 9.3 2.5 1

18

Parmjeet Kaur W/O Jogesh

Singh 9.6 1.4 1

19 Golo Kaur W/O Ruldu 6.8 1.3 1

211

Singh

20 Manpreet Kaur W/O Goldy 7.5 1.9 1

21

Jashan Kaur W/O Gurtaj

Singh 9 2 3

22

Parmjeet Kaur W/O

Dalbara Singh 8.4 1.8 1

23

Jasmeet Kaur W/O

Rajinder Singh 8.5 1.2 2

24

Jasveer KaurW/O Harmel

Singh 9 2.6 3

25 Neerja W/O Harmesh 7.8 3.1 2

26

Harmeet KaurW/O

Joginder 8.3 1.7 1

27

Arshpreet Kaur W/O

Gurdeep Singh 9.8 2.1 2

28

Ramanpreet Kaur W/O

Karmjeet Singh 10 0.9 1

29 Preeti W/O Deep Singh 8.5 2.1 2

30

Gurmeet Kaur W/O Ruldu

Singh 8 1.7 1

31

Nirmal Verma W/O Malkit

Verma 8.4 1.2 2

32

Gagandeep Kaur W/O

Balwinder Singh 10 0.9 3

33

Kiranjeet Kaur W/O

Rajwinder Singh 10 1.3 1

34

Sandeep Kaur W/O

Harpreet Singh 8.5 1 2

212

35

Sukhwinder Kaur W/O

Charanjeet Singh 8.1 1.5 2

36

Inderjeet Kaur W/O

Harvinder Singh 9.8 1 1

37

Neelam W/O Baljinder

Singh 8 2 2

38

Sandeep Kaur W/O Manak

Singh 9 0.8 2

39

Dharamjeet Kaur W/O

Harjeet Singh 9.5 0.8 1

40

Richa Sharma W/O Munish

Sharma 8.4 0.9 1

Report of Month Aug 2014 of Anaemic Pregnant Women


Haemoglobin

Level

Fluoride

Level Pregnancy

1

Gurmeet Kaur W/O

Dharampal Singh9.8 1.7 3

2

Charnjeet Kaur W/O Rubal

Singh7.5 1.2 2

3

Pushpinder Kaur W/O

Nirmal Singh8.9 0.9 3

4 Semla W/O Ajay 7.5 2 3

5

Harmeet Kaur W/O Gopal

Singh9.3 0.9 2

6 Sarbjeet Kaur W/O Amrik 9.8 1.4 1

213

Singh

7 Priyanka W/O Rajesh 9 2.6 2

8

Harmeet Kaur W/O Gopal

Singh8 1.5 1

9

Gurmeet Kaur W/O Karnail

Singh7.3 1.8 3

10

Sonia Rani W/O Pritpal

Sharma7.8 0.9 1

11

Rajni Bala W/O Naresh

Kumar8.5 2.9 2

12

Jasmeet Kaur W/O Narinder

Singh8 1.2 1

13 Kiran W/O Mithoo Singh 10 1.5 2

14

Harsharan Kaur W/O

Karmjeet Singh8.5 0.9 1

15

Karmjeet Kaur W/O

Harpreet Singh10 1.9 1

16

Amandeep Kaur W/O

Shamsher Singh9.8 2 2

17

Gurpreet Kaur W/O

Amarjeet Singh8.8 1.6 2

18

Simran W/O Tarlochan

Singh9.5 1.9 1

19

Harbans Kaur W/O Rajveer

Singh6.8 2 2

20 Meenakshi W/O Bittu 9.6 1.4 1

21

Gagandeep W/O Bikram

Singh8.9 1.6 3

214

22

Rupinder Kaur W/O Avtaar

Singh8.5 2 2

23

Nirmala Kaur W/O

Ashwinder Singh9 0.8 3

24

Amandeep Kaur W/O

Harmel Singh10 1.3 1

25 Neelam W/O Mohesh 8.8 1.9 2

26 Jaswinder W/O Lakhwinder 9 3.1 3

27 Sunena W/O Jaskaran 8.1 1.6 2

28

Pardeep Kaur W/O Nirmal

Singh9.5 2 2

29 Rohini W/O Nobel 8.5 1.5 3

30

Jasveer Kaur W/O Gurdeep

Singh9 1.8 1

31 Charanjit W/O Kindi 7.5 1.9 2

32

Hardeep Kaur W/O

Kulwinder Singh9.6 1.5 2

33 Harsimran W/O Jasbir 10 1 2

34

Taranjeet Kaur W/O

Gurwinder Singh8.9 0.9 3

35 Pooja W/O Jony 7.8 1.1 3

36

Manjeet Kaur W/O Amritpal

Singh9.8 1 1

37

Sarbjeet Kaur W/O

Chamkaur Singh8.9 2.3 2

38 Preet Kaur W/O Jasbir Singh 8.5 1 3

39 Ramwati W/O Akhilesh 9 1.6 3

40 Amandeep Kaur W/O Jaspal 10 0.9 2

215

Singh

41

Manjeet Kaur W/O Satnam

Singh9.5 0.8 1

42 Archana W/O Pritam 6.5 1.6 1

43 Mamta W/O Rajesh 8.6 1.4 3

44 Harmeet W/O Narinder 9 2.1 2

45 Baljeet W/O Narinder 7.9 1.3 1

46 Charanjit W/O Kulveer 8.4 1.2 3

47 Archana W/O Gurpreet 6.3 2.2 2

48 Kiranpal W/O Parem 10 1.6 3

49 Mamta W/O Rahul 8.1 0.9 2

50 Shakeeta W/O Dilbar 8.5 1.3 3

51

Pardeep Kaur W/O Kuldeep

Singh9.8 1.6 2

52

Bimla Devi W/O Mangal

Das8.5 3.3 1

53

Jasvir Kaur W/O Lakhwinder

Singh8.8 1.4 2

54

Balwinder Kaur W/O

Manpreet Singh10.4 1.5 2

55

Ranjit Kaur W/O Bhushan

Singh8.5 0.9 4

216

Arsenicosis

217

Surveillance on Arsenicosis

Arsenic poisoning or Arsenicosis is a condition caused by the ingestion,

absorption or inhalation of dangerous levels of arsenic. Arsenic is a natural

semi-metallic chemical that is found all over the world in groundwater. Arsenic

contamination of groundwater is often due to naturally occurring high

concentrations of arsenic in deeper levels of groundwater. It is a high-profile

problem due to the use of deep tubewells for water supply in the Ganges Delta,

causing serious arsenic poisoning to large numbers of people. A 2007 study

found that over 137 million people in more than 70 countries are probably

affected by arsenic poisoning of drinking water. Arsenic contamination of

ground water is found in many countries throughout the world, including USA.

The acceptable level as defined by WHO for maximum concentrations of

arsenic in safe drinking water is 0.01 mg/L.

Some of systemic symptoms due to short term exposure include-

1 Abdominal pain, vomiting and diarrhea.

2 Drowsiness, headaches and confusion

3 Metallic taste in the mouth with excess saliva and problem in swallowing

and garlic like smell.

4 Blood in the urine

5 Loss of hair, skin rashes and flushing

6 Stomach, muscle cramps and convulsions with excessive sweating etc.

Long-term exposure (over many years or decades) to high levels of arsenic

in drinking water may also lead to Cancer, Liver diseases, Diabetes,

Nervous loss, Hearing problems and digestive difficulties as well

thickening skin of palms and soles and discolouration of skin with

numbness/ tingling sensation.

218

Action Taken by the State

The inter-sectoral co-ordination was maintained with Deptt of Water

Supply and Sanitation, to make available results of all water testing reports

for Heavy metals including Arsenic, under taken time to time to enable

Health deptt to conduct surveys where ever required and to maintain

constant surveillance.

A total of 7176 no. of drinking water tests conducted so far in state

between 2009-13, with special focus on Malwa region where cancer cases

were reported in high number, were shared as village wise data of

investigations with this deptt for surveillance.

The levels of Arsenic in Punjab drinking water are generally less than

0.005 mg/L (0.005 parts per million – ppm) which is generally much

below permissible limit of 0.05mg/L, although concentrations may be

higher in some areas. Department of Water Supply and Sanitation have

also installed nearly 1900 R.O systems from year 2008 – 2014 as a

preventive measure, mainly in Malwa region, where Arsenic levels were

suspected to be high.These R.Os are periodically tested for water quality

and other parameters and if any problem is found, it is rectified by

Department of Water Supply and Sanitation.

The facility of heavy metal testing is also available at State Public Health

Lab, Sec 11 Chandigarh under Deptt of Health and Family Welfare, done if

the water samples are sent by districts specifically for heavy metals testing

along with bacteriological testing.

Surveillance based on any susceptible area, if evident from reports of

drinking water for any water based disease is immediately carried out in

219

concerned distt with focus on educative component of prevention,

detection and immediate management.

Accordingly, though till date, no patient has been specifically detected

reported suffering from Arsenicosis in the State. Civil Surgeons were

directed to instruct the Medical Officers of their respective districts to keep

special vigil on the patients, if any reporting with similar symptoms as of

long and short term exposure to Arsenic and report to this office.

220

lndia Epidemic Intelligence Service (EIS) Programme

221

lndia Epidemic Intelligence Service (EIS) Programme

In India, there is a dedicated cadre of Public Health professionals in some

states, but the majority of states lack applied epidemiological capacity pointing

to the need for an Epidemic Intelligence Service (EIS) Programme.

To address this need, the National Centre for Disease Control launched the

lndia EIS Programme on October 4, 2O12. In the first batch in year 2012, one

EIS officer had been placed at the IDSP, Punjab from the New Delhi. One EIS

officer from the state health services Punjab had been placed at National

Institute of TB and Respiratory diseases, New Delhi.

The India EIS is a 2 year programme in applied epidemiology, in which the

trainee officers develop skills working within Indian public health agencies /

programmes. It is imperative the India EIS Programme be of the highest

quality, producing epidemiology who can address the pressing public health

needs of the nation. Therefore, the programme trains only extremely keen,

enthusiastic medical doctors with an aptitude for public health and with at least

two years of public health experience. Selection is through a highly competitive

process by a committee of experts, The selected EIS officers are assigned to a

single placement for the two years under the technical supervision of an

experienced mentor.

The officers who complete the programme benefit in terms of career

opportunities and playing a leadership role in public health operations in the

country. Global Disease Detection India Centre is committed to facilitating

epidemiologic capacity development in India and strengthening practical

&applied epidemiology training. A key component of this is creation of the

India ElS Programme which is modeled on the EIS Programme in the United

States

The Epidemic Intelligence Service (EIS), based at the U.S. centers for Disease

control and Prevention (CDC), is a 2-year programme. This programme focuses

222

on hands-on training in epidemiologic service for public health professionals.

Trainees, called EIS Officers, engage in outbreak investigation, designing and

analyzing epidemiological studies, analysis and evaluation of surveillance data,

scientific communication, and other activities in preparation for careers as field

epidemiologists.

Although there is a dedicated cadre of public health professionals in the Central

Health Service (CHs) and in some states, most of the states lack applied

epidemiological capacity and hence the need for such training Programme.

The India EIS Programme through field experience includes;

1. Field assignment epidemiologic services provided under supervision.

2. Classroom instruction through periodic short didactic sessions is included to

prepare the officers for their field duties. The sessions included exercises and

case studies.

3. Tuesday seminars for presentations by the officers themselves or invited

lectures on epidemiologic or other public health topics, and/or a Journal club

and to provide a forum for additional instructions, practice presentations, and

team building.

During the 2-year training, officers will be placed in field assignments suitable

to fulfill prescribed core activities of learning (CALsJ. This will be under the

supervision of the officer's identified mentor and periodic contact courses in

NCDC:

Each 2nd-year officer will be encouraged to submit an abstract to an

international conference such as the U,S. EIS Conference, TEPHINET

Conference, or other appropriate conferences. Officers whose abstracts are

accepted for presentation will be supported to attend that conference. In

addition, the lndia EIS Programme will support all znd year EIS officers to

attend the U.S. Centers for Disease Control and Frevention EIS Conference in

Atlanta, GA" USA" and possibly work with a specific CDC programme related

directly to their ongoing assigament.

223

Poster Presentation & Studies

224

Study 1

International Poster Presentation

EIS officer Dr Tripurari Kumar placed at the IDSP, Punjab had presented two

poster presentation. Out of this, one was the “Vibrio cholera outbreak in Batala,

Punjab, India 2013”.The second outbreak was the “Risk Factors for Death

among Hospitalized Influenza A (H1N1) Patients, Punjab, India -2013”.

The outbreaks were investigated under the guidance of Dr Deepak Bhatia,

Project Coordinator, IDSP and Dr Rajesh Kumar, Post Graduate Institute of

Medical Education & Research, Schools of Public Health, Chandigarh.

226

Study 2

Title: Study on Risk factors for Deaths Due to Influenza-A (H1N1) in

Punjab State-2013

T. Kumar1, D. Bhatia2, R. Kumar3, P. Lakshmi3, T. Dikid4, J. P. Narain5;

1National Center for Disease Control, Integrated Disease Surveillance Program,

State Surveillance Unit, Punjab, Chandigarh/IN, 2Director Health Services,

State Surveillance Unit, Integrated Disease Surveillance Program,

Chandigarh/IN, 3Post Graduate Institute of Medical Education & Research,

Schools of Public Health,, Chandigarh/IN, 4National Center for Disease

Control, Epidemiology Division, Delhi/IN,5National Center for Disease

Control, EIS Division, Delhi/IN

Abstract:

Since 2009, influenza A (H1N1) has caused significant morbidity and mortality

in Punjab state, India. We described hospitalized cases & conducted a case

control study. Socio-demographic and clinical data were collected using an

existing WHO questionnaire through hospital record reviews and via telephonic

interviews with controls and next-of-kin of cases. Logistic regression analysis

was performed to identify independent risk factors. From January-April 2013, a

total of 183 lab-confirmed H1N1 cases (99 males, 84 females) were

hospitalized from 21 hospitals in Punjab; 42 (23%) patients died. We compared

42 cases with 80 controls. Those who died were significantly more likely to be

younger than 50 years (AOR=10.6, 95%CI=1.8-21.1), be obese (AOR=16.7,

95%CI=1.6-170.7) and visit more than two healthcare facilities before

laboratory confirmation (AOR=25.8, 95%CI=5.4-121.6). Mortality among

hospitalized influenza A (H1N1) patients was high in Punjab. The community

should be sensitized about influenza symptoms, risk factors and to seek medical

advice early in the course of illness in order to reduce the risk of death due to

H1N1 in the State.

227

Background:

The influenza virus has been circulating as a pathogen since the 16th century.

The virus is notable for its unique ability to cause fast and unpredictable

antigenic changes leading to epidemics and pandemics. Each century has seen

some pandemics rapidly progressing to all parts of the world due to emergence

of a novel virus to which the overall population holds no immunity. Influenza

pandemics are caused by new influenza viruses that have recently adapted to

humans through genetic re-assortments.

Influenza like Illness caused by Influenza A (H1N1), a novel re-assorted

influenza virus, was reported from Mexico on 18th March, 2009 and rapidly

spread to neighboring United States and Canada. Subsequently the disease

spread to all the continents. World Health Organization [WHO] has raised the

level of Influenza pandemic alert from phase 5 to 6 on 11th June 2009

indicating the emergence of the new influenza pandemic. India reported its first

case on 13th May, 2009 in Hyderabad. Most of the reported cases were travel-

related. Pune reported the 1st death attributed to H1N1 on 4th August, 2009.

The pandemic outbreak of 2009 occurred late in the season, and appeared to

affect young people disproportionately. Most cases of severe and fatal infection

occurred in adults between the ages of 30 and 50 years. The pandemic caused

widespread social disruptions around the world.

Influenza viruses are transmitted from person to person primarily through

contact with infected respiratory secretions, especially airborne droplets

generated by coughing and sneezing. In general, the incubation period for

influenza is estimated to range from 1 to 4 days with an average of 2 days. The

amount of virus shed is greatest in the first 2-3 days of illness and appears to

correlate with fever, with higher amounts of virus shed when temperatures are

highest. For these recommendations, however, the infectious period for

influenza is defined as one day before fever begins until 24 hours after fever

228

ends. Viral replication and shedding are key considerations in the timing of

treatment, infection control and chemoprophylaxis.

Worldwide estimates 250-500,000 deaths per year with an estimated 3-5 million

severe cases per year (WHO). There is limited data available for Tropical

settings like India. Influenza also causes substantial economic impact (Direct

health care cost, societal cost and other trade related losses). Data available for

USA suggests influenza costs approx. 37.5 billion dollars every year.

Punjab is a small state situated in the Northwest part of India. Punjab only

occupies 1.6 percent of the total area of India and 2.3% of the Indian

population. The population size is 27.7 million. Sikhism is the dominant

religion in the state. In Punjab positive cases have been reported from June

2009 onwards. On 14th June, 2009, the first cluster of 7 positive cases was

reported in Jalandhar, Punjab, from a team of students returned after visiting the

United States. Initially cases were reported among those who returned from

foreign countries but now the disease occurs within the community. In 2013

since 1st January there were 183 positive cases & 42 deaths reported in Punjab

(CFR= 21.8%) till 30th April 2013. Since every year Influenza pandemic

(HINI) cases are being reported in Punjab in addition to the peak in H1N1

hospitalized cases in 2013, high mortality among these cases were observed, so

this study was thus sought to evaluate the high Case Fatality Ratio among the

hospitalized cases and evaluate risk factors for H1N1 associated death in Punjab

for 2013. We had two specific study objectives: first, to describe the

229

hospitalized cases and deaths associated with influenza A H1N1 in Punjab by

time, place and person in 2013; and second, to analyze the risk factors and co-

morbidities associated with mortality among the hospitalized H1N1 cases.

Methodology:

Cases were identified throughout India using SARI surveillance-and specimens

were only tested for H1N1. Cases were defined using SARI- defined as a

hospitalized patient with severe high grade fever plus cough/sever sore throat,

worsening chronic conditions or in a high risk group with laboratory-confirmed

H1N1 influenza A virus detected by (RT)-PCR. Surveillance of influenza A

(H1N1) in Punjab is conducted by the integrated disease surveillance program

or IDSP. Both public and private hospitals send nasal/throat swabs from SARI

cases to one designated lab for laboratory confirmation, using real time RT

PCR, through the district surveillance units. Lab confirmed patients are notified

to the district and state IDSP. The districts provide complete treatment to

positive cases and close contacts with approved drugs and collect data on any

deaths.

We conducted a descriptive study for our first objective and an unmatched case

control study for the second objective. For the descriptive study, we evaluated

all confirmed cases and deaths between 1 January and 15th April 2013. For the

case control study, we selected all deaths, and then selected controls (surviving

cases) from those hospitals (21 hospitals) where deaths due to H1N1 had

occurred between 1st January to 15th April 2013. For the case control study, we

defined a case as a death among hospitalized patients of confirmed influenza A

(H1N1) infection, in Punjab, reported from Jan 1 through April 15 2013. A

control was defined as a surviving case from one of the same hospitals where

deaths were reported in the same time period. We calculated that a sample size

of 41 cases and 82 controls was required to estimate an odds ratio of 3 with

95% confidence and 80% power assuming 30% of the controls had exposures

230

such as obesity, pregnancy, and co-morbid illnesses. There were 182 total

H1N1 cases, but only 163 H1N1 cases came from the 21 hospitals where a

death occurred. Of these 163, 42 were deaths and are the cases for the case

control study. Out of the remaining 121 H1N1 cases, 14 left against medical

advice without a known outcome and were thus excluded, leaving 107 HIN1

surviving cases. We could enroll 80 of these as controls, as medical records

were only available for these 80 patients (Fig-2 flow diagram of case and

control selection). Patients for whom records were not available were

significantly younger than those whose records were available but there was no

difference by sex.

Socio-demographic and clinical and co morbid data were collected from

hospital records using an existing WHO questionnaire and, if missing, via

telephonic interviews with controls and next-of-kin of cases. Data were entered

in Epi info-7 software and exported to SPSS-version -16 for analysis. We

performed bivariate and multivariate analysis and calculated odd ratios (OR),

adjusted OR, and 95% CI for risk factors associated with H1N1 mortality.

Results:

From 1st January to 15th April 2013, there were 559 SARI cases tested for

H1N1; 182 (33%) were found positive. The median age of the cases was 46

years. Males were 54%.There was no history of travel found among cases and

also no one was found to have a history of prior vaccination against H1N1. 42

deaths were reported, with a case fatality ratio of 23%.

231

Week wise H1N1 cases in Punjab, 2103

All 22 districts reported H1N1 cases, and cases were reported from urban as

well as rural areas. There were no clusters of cases observed in villages. The

south-eastern part of Punjab reported a higher prevalence, in particular in

Mohali, Fatehgarh sahib and Bathinda districts. The first case was reported on

1st January and cases started increasing from the first week of January, peaked

in mid -February and then declined by the end of March in epidemic curve. The

last case was reported on 3rd April 2013.

0

5

10

15

20

25

30

35

401-

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7-13

th Ja

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14-2

0th…

21-2

7th…

28-3

rd…

4-10

th…

11-1

7th…

18-2

4th…

25-3

rd…

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7th…

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4th…

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No.

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ases

Week of Reporting

Positive CaseDeath Case

232

Distribution of H1N1 Cases, 2013

The greater no of cases were among patients between 15-49 yrs. in the age and

sex distribution of H1N1 cases and deaths. The CFR was highest among those

15-49 yrs. old and those >65 yrs. There were no significant differences by sex.

Table showing the age and sex distribution of positive cases and deaths from

H1N1 in 2013

Age group/

Gender

No. of +ve

cases

(n=183)

( %) No. of

Deaths

(n=42)

( %) Case

Fatality

Ratio

(CFR)

<5 12 6.6 1 2.4 8.3

5-14 4 2.2 0 0 0

15-29 22 12.0 4 9.5 18.2

30-59 121 66.1 30 71.4 24.8

60+ 24 13.1 7 16.7 29.2

Male 99 54.1 21 50 21

Female 84 45.9 21 50 25

Total 183 100.0 42 100.0 23

232






H1N1 in 2013

Age group/

Gender

No. of +ve

cases

(n=183)

( %) No. of

Deaths

(n=42)

( %) Case

Fatality

Ratio

(CFR)

<5 12 6.6 1 2.4 8.3

5-14 4 2.2 0 0 0

15-29 22 12.0 4 9.5 18.2

30-59 121 66.1 30 71.4 24.8

60+ 24 13.1 7 16.7 29.2

Male 99 54.1 21 50 21

Female 84 45.9 21 50 25

Total 183 100.0 42 100.0 23

232






H1N1 in 2013

Age group/

Gender

No. of +ve

cases

(n=183)

( %) No. of

Deaths

(n=42)

( %) Case

Fatality

Ratio

(CFR)

<5 12 6.6 1 2.4 8.3

5-14 4 2.2 0 0 0

15-29 22 12.0 4 9.5 18.2

30-59 121 66.1 30 71.4 24.8

60+ 24 13.1 7 16.7 29.2

Male 99 54.1 21 50 21

Female 84 45.9 21 50 25

Total 183 100.0 42 100.0 23

233

On uni-variate analysis, comparison of socio-demographic characteristics of

cases versus controls revealed that cases were almost 3 times more likely to be

less than 50 years old than controls (OR=2.8, 95% CI= 1.2–6.4), and twice as

likely to be of a religion other than Sikh (OR=2.2, 95%CI= 1.0–4.8). Cases

were 10 times more likely to be obese than controls (OR=10.2, 95% CI= 2.7–

39). Other co morbid conditions like diabetes, cardio vascular, liver disorder,

blood disorder and kidney disorders, pregnancy and post-partum period were

not significantly associated with being a case.

Clinical Risk Factors in Cases and Controls

CharacteristicsCase

n=42 (%)

Control

n=80 (%)

Odds

ratio95%CI

Respiratory disease 1 2 7 9 0.2 0.0-2.1

Diabetes 13 31 20 25 1.3 0.5-3.0

Hypertension 16 38 37 46 0.7 0.3-1.5

Obesity (BMI>30) 8 19 3 4 6.0 1.5-24.1

HIV/AIDS 2 5 1 1 3.9 0.3-44.8

Oseltamivir is most effective when started in the first 48 hours after illness start.

We compared the delays in the initiation of treatment between cases and

controls. No cases and only 1 control started treatment within 48 hours and less

than a 3rd of both cases and controls started treatment within 1 week. Cases

were over 30 times more likely than controls to visit more than two places

234

before receiving the appropriate H1N1 diagnosis (OR=31.7, 95%CI=9.5-105.4).

Such patients were also more likely to consult more than two health care

facilities before laboratory confirmation and received antiviral treatment after

48 hours of onset of symptoms.

On multivariate logistic regression model, we used a backward elimination

modeling strategy and evaluated all variables which were statistically

significant in bi-variate analysis.

Risk Factors Associated with Mortality

Adjusted Odds Ratio

Characteristics Crude Oddsratio Estimate 95% CI p

Age <50 yrs. 2.82 10.1 1.8-55.5 0.00Non-Sikh 2.22 5.5 0.8-37.1 0.07Obesity 6.04 105.6 4.6-2413.8 0.00

Ventilator support 27.42 19.1 1.5-239.1 0.02

Age less than 50 years (AOR=10.1, 95%CI=1.1-21.1), obesity (AOR=16.7,

95%CI=1.6-170.7), and referral to more than two centers before diagnosis

confirmation remained independently associated with mortality (AOR=25.8,

95%CI=5.4-121.6), even after controlling for disease severity, that is, ventilator

support (AOR=19.1, 95%CI=1.5-139.1). Gender, residence, educational level,

religion and HIV infection were not significantly associated with deaths among

these patients.

Discussion:

History of Obesity, age less than 50 years and delay in starting of antiviral

drugs were the independent predictors of mortality. The findings of our study

would be useful in reducing the mortality due to influenza during subsequent

transmission.

235

Most of the affected individuals were aged between 15-49 years and about 23%

of the laboratory confirmed patients died. The age distribution of influenza

cases as well as the case fatality ratio observed in our study was similar to other

studies describing the epidemiology of the disease in India as well as other

countries12. About half of the laboratory confirmed cases and 55% of deaths

occurred in four cities of Punjab. Awareness about the disease as well as

location of the laboratory facilities might have led to testing more number of

symptomatic as well as detection of positive cases from the four cities.

Most of the cases caused by the influenza A (H1N1) virus have been mild and

self-limiting in nature with higher risk of adverse outcome among certain risk

groups7. In Punjab, 46% of the lab-confirmed patients and 61% of the fatal

cases had at least one of these known risk factors. However, presence of

Obesity was the only known risk factor that was found to be associated with

increased risk of death. In a study of 272 patients infected with H1N1,

hospitalized in USA, Jain et al found that 73% of these had a single co

morbidity on admission. In our study, 63% of patients had one or more risk

factors. Presence of risk factors increases the severity of disease and alters the

prognosis in ventilator patients.

Treatment with a neuraminidase inhibitor is especially important for influenza

patients with underlying risk factors, including pregnancy, and those with

severe or progressive clinical illness. Early therapy within 48 hours of onset

with Oseltamivir was also found to reduce the duration of hospitalization and

the risk of progression to severe disease requiring ICU admission or resulting in

death. In another study in USA, patients who received the antivirals early had a

positive outcome. According to the Government of India’s guidelines for

categorization of influenza A H1N1 cases for home isolation, testing, treatment,

and hospitalization, patients with milder symptoms should be isolated at home

(category A); patients with influenza like illness with known risk factors or high

grade fever are treated with Oseltamivir with home isolation (category B),

236

while patients with severe symptoms such as breathlessness, chest pain,

drowsiness, fall in blood pressure, sputum mixed with blood, bluish

discoloration of nails etc. should be hospitalized and treated with Oseltamivir

(Category C).

In Punjab, all the laboratory confirmed patients were given anti-viral drugs

irrespective of the severity of illness, but such therapy was started after 48

hours in majority of cases. The association between visit to more than two

health facility before laboratory confirmation and death also indicates the delay

in the starting the antiviral treatment.

Corticosteroids are occasionally used as an adjunctive therapy for the treatment

of acute respiratory distress syndrome (ARDS) in severe influenza due to their

immune modulatory properties. In a recent meta-analysis, the use of low-dose

corticosteroids was also found to improve the mortality and morbidity outcomes

among the patients with acute lung injury and ARDS. Recently published

retrospective observational studies among the patients of influenza H1N1

showed that the corticosteroid treatment was associated with a higher likelihood

of ICU admission, mortality as clinical outcome, slower viral clearance as well

as longer duration of viral shedding. The WHO guidelines for pharmacological

management of pandemic influenza strongly recommend that patients having

severe illness including viral pneumonitis, respiratory failure and acute

respiratory distress syndrome due to influenza virus infection should not be

given systemic corticosteroids unless indicated for other reasons. In our study,

the use of corticosteroid was more among patients who died and such treatment

was associated with increased risk of death. First, 64% of the influenza cases in

the state received treatment from private hospitals, Second, about two third of

the patients receiving treatment from private hospitals received antivirals after

48 hours of onset of symptoms and the delay in treatment onset was an

independent risk factor for death. Educating the health providers in private

237

hospitals could substantially reduce the number of deaths due to influenza in the

subsequent seasons of transmission.

Our study has few limitations. First, our study was conducted among

hospitalized laboratory-confirmed cases only; not all suspects may have

accessed the hospital, and not all suspects were tested in the laboratory due to

logistic or transport issues getting the specimen to the laboratory. Furthermore,

medical records were missing on 27 surviving cases. Second, we may also have

had recall bias from controls and next of kin for cases, which may have over or

under estimated the presence of potential risk factors. Third, the information

about certain variables such as height and weight data was not available for

every case record of cases as well as controls. In absence of this information,

we considered built of the individual as a proxy for their BMI and collected

these details from the respondents. This however is likely to introduce a

misclassification error.

In conclusion; In Punjab, in 2013, there was an increased number of

hospitalized cases of H1N1 with high case fatality. All districts were affected

with no clusters seen. The most affected ages were those 15-49 years. Delays in

accessing an appropriate diagnosis were significantly associated with an

adverse outcome. Obesity was an additional risk factor for death.

Based on our findings, we made the following recommendations: The

community should be sensitized about influenza symptoms, co morbid

conditions (middle age groups & obesity) and to seek medical advice early in

the course of illness. Healthcare providers should be prepared before the

influenza season for early identification of signs and symptoms and early

referral for laboratory confirmation & treatment. Surveillance activities

should be strengthened by increasing laboratory testing facilities in the state

and collecting additional information like disease severity and co-morbidity,

for all cases.

238

Study 3

Mumps Outbreak in Dental Care Providers in a North Indian Dental College

Mumps is an acute viral infection affecting primarily the parotid gland but can

also involve other major salivary glands. It is caused by a Paramyxovirus and is

spread via droplets or by direct contact with salivary and respiratory secretions

of infectious persons. Transmission of the virus is very common in high density

close contact environments such as schools, hostels, etc. Patients often mistake

parotid swellings for tooth related problems. Resulting transmission can cause

an outbreak in the dental care setting including dental care personnel. In

February 2012, we received the information that two dentistry students had

developed bilateral swelling of the parotid glands; the possible source was an

infectious patient. An epidemiological investigation was required in this

situation to determine the existence of epidemic of mumps, if any, to identify

the source, and to recommend and adopt control measures. A line‑list was

prepared, active case search was made and the active cases were then admitted

in the isolation ward.

For all cases, information on personal details, time of onset, and immunisation

history was obtained. Sera from five cases were collected for immunoglobulin

M (IgM) antibodies for Mumps virus by enzyme‑linked immunosorbent assay

(ELISA), buccal swabs in Viral Transport Medium (VTM) were sent to the

State Reference Laboratory (SRL) for virus isolation by the District

Surveillance unit (DSU) of the Integrated Disease Surveillance Programme

(IDSP) Punjab with the SRL confirming a Mumps outbreak. There are 200

dental students in the college among which were found seven cases of mumps-

three females and four males, the average age was 22.57 years (22-24 years).

All seven cases had bilateral parotiditis, while two of them presented with the

additional involvement of the submandibular glands. All cases received

239

measles, mumps, and rubella (MMR) vaccination in childhood. All the cases

were treated symptomatically with paracetamol for pain relief, warm saline

gargles, soft diet, and rest. Convalescence was uneventful and no serious

complications were reported in this outbreak. To prevent the transmission of

infectious agents in healthcare settings the Center for Disease Control (CDC)

Atlanta, formulated the Universal Precautions in 1987-88. This further

developed into two tiers of precautions namely, Standard Precautions (e.g.

Respiratory Hygiene/Cough Etiquette, Safe Injection Practices etc) and

Transmission ‑ Based Precautions (e.g. Contact Precautions, Droplet

Precautions, Airborne Precautions).

Standard Precautions is the primary strategy for the prevention of health care

associated transmission of infectious agents, applicable to the care of all

patients in all health care settings, regardless of the suspected or confirmed

presence of an infectious agent.

Transmission ‑ Based Precautions are for patients who are known or are

suspected to be infected with certain pathogens, which require additional

control measures to effectively prevent transmission. When Contact, Droplet, or

Airborne Precautions are specified, Standard Precautions also apply.

Hands are the most common mode of transmission of nosocomial pathogens

among health care workers.

To prevent or reduce the risk of exposure to the virus, the standard precautions

mandates that all dental care practitioners (DCPs) use Personal Protective

Equipment (PPE) like gloves, mask, and head cap during dental procedures.

However, gloves do not provide complete protection against infection, studies

have shown that nearly one third of health care workers (HCW) who wore

gloves during patient contact were positive for patients bacterial flora. The

pathogens presumably contaminated the hands during glove removal.

240

Therefore wearing gloves does not eliminate the need for appropriate hand

hygiene practices. Mumps outbreaks among vaccinated populations are reported

world‑wide and are not rare. There are lower clinical attack rates among

vaccinated populations, but epidemics occur much later in the second and third

decade often with severe complications. There is a growing body of evidence

demonstrating waning immunity overtime (greater than 15 years) leading to

secondary vaccine failure.

Current mumps outbreak measures generally concentrate on gathering good

surveillance data and advising individuals in the affected area who are not fully

vaccinated to complete their MMR vaccination. The potential for more

extensive disease transmission behoves that efforts be made to improve the

surveillance for mumps by timely reporting to the DSU/IDSP by medical and

dental practitioners and clinics. Awareness programs regarding vaccination with

MMR for children and adults cannot be understated.

There are very few contraindications to mumps vaccination except for those

with immune deficiency or immunosuppression. All persons who work in

dental‑care facilities should have presumptive evidence of immunity to mumps

and those who require a second dose of MMR should be advised one.

To prevent transmission among susceptible persons, a check-list or a visual

gallery can be used to identify mumps cases and other infectious conditions.

When a person suspected of having mumps visits a dental‑care facility, only

personnel with adequate presumptive evidence of immunity should be exposed

to the person, and in addition to standard precautions, droplet precautions

should be followed. The DCP should coordinate with the infectious disease unit

or internal medicine department promptly regarding care, isolation and

notification of the patient. MMR prophylaxis after exposure to suspected

mumps does not provide an adequate antibody response soon enough, hence the

best method of protection is adequate immunization prior to exposure.

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Dentists and dental care providers are 18% more at risk of acquiring mumps

from patients as compared to paediatricians 37%, physicians 15% which are

higher compared to non HCW like school teachers 9%. Therefore DCPs should

have adequate knowledge regarding identification of mumps infections,

preventive and protective measures, apart from the timely notification to the

IDSP, thereby helping to contain the spread of mumps and reduce the impact of

mumps outbreaks.

Clarence J Samuel, Abi M Thomas1, Deepak Bhatia2

Departments of Community Medicine, Christian Medical

College, 1Pedodontics and Preventive Dentistry,

Christian Dental College and Hospital,

CMC Ludhiana, 2Health and Family Welfare, Integrated

Disease Surveillance Programme (Punjab), Chandigarh, India.

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Study 4

Hepatitis E Virus Antigen Detection as an Early Diagnostic Marker:

Report From India

Manasi Majumdar,1 Mini P. Singh,1 Sujit Kumar Pujhari,1 Deepak Bhatia,2

Y. Chawla,3 and R.K. Ratho1*

1Department of Virology, Postgraduate Institute of Medical Education and

Research, Chandigarh, India

2Integrated Disease Surveillance Project, Directorate of Health and Family

Welfare, Punjab, Chandigarh, India

3Department of Hepatology, Postgraduate Institute of Medical Education and

Research, Chandigarh, India

Hepatitis E virus (HEV) is implicated in many outbreaks of viral hepatitis in the

Indian subcontinent. The conventional diagnosis of such outbreaks rests on the

detection of anti-HEV IgM antibodies. However, IgM antibodies develop after

4–5 days of infection. An early-diagnostic marker is imperative for timely

diagnosis of the outbreak and also initiation of control measures.

This study aimed to determine the use of hepatitis E virus antigen detection as

an early diagnostic marker in an outbreak in comparison to anti-HEV IgM and

RT-PCR analyses.

Forty samples were collected during a suspected outbreak of viral hepatitis due

to HEV. A total of 36 samples were positive for one or more HEV markers. The

positivity for anti-HEV IgM, HEV antigen, and RT-PCR was 91.6%, 69.4%,

and 47.2% respectively. RT-PCR and HEV antigen detection gave the highest

positive results (100%) in the first 3 days of illness. Positive HEV PCR

declined to 54% by Days 4–7, whereas HEV antigen and IgM detection were

88% and 100%, respectively. Sequencing of representative HEV samples

indicated that the strains responsible for this outbreak belonged to genotype I,

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subtype 1a. HEV antigen was found to be an early diagnostic marker of acute

infection.

HEV antigen was detected in three additional cases in the early phase (1–3

days), and they had no detectable anti-HEV IgM antibodies.

These three samples were also positive for HEV RNA. After Day 7, anti-HEV

IgM was the main diagnostic indicator of infection.

KEY WORDS: hepatitis E virus; HEV antigen; outbreak, ELISA; sequencing

INTRODUCTION

Hepatitis E virus (HEV) is an important cause of epidemic and sporadic

hepatitis in Asia, Africa, the Middle East, and Central America [Labrique et al.,

1999; Worm et al., 2002]. Once known as a disease of the developing world,

recently viral hepatitis E has been encountered increasingly in developed

countries including Australia, Spain, the UK, and the USA [Pina et al., 1998;

Huang et al., 2002; Meng et al., 2002]. Epidemics and large outbreaks of HEV

have been due to genotypes 1 and 2. Genotypes 3 and 4 cause mainly sporadic

cases and they have been isolated from animals [Meng, 2010]. Nearly 30–70%

of the sporadic outbreaks of hepatitis in India are attributed to hepatitis E

[Aggarwal and Jameel, 2011]. Sewage contamination of drinking water is the

commonest mode of virus transmission. The disease presents with a subclinical

infection, acute selflimited viral hepatitis, or life-threatening acute liver failure.

Chronic sequelae have also been documented in immunocompromised patients

[Kamar et al., 2008]. The disease has a low mortality of 0.2–1% in the general

population.

The clinical presentation during pregnancy varies in different geographical

regions. Studies from North India documents up to 20% mortality in pregnant

women [Khuroo et al., 1981; Jilani et al., 2007], whereas studies from Egypt

suggest a benign course in pregnant women with no significant rise in mortality

[Navaneethan et al., 2008].

244

The present study describes an outbreak of HEV in a group of factory workers

in Punjab, North India.

Ethical approval: Due to an outbreak situation, the samples were received for

clinical diagnosis, and prior ethical clearance for this study was not sought.

However, written informed consent was obtained from each patient.

Materials & Methods

Specimens

The Department of Virology was informed of an outbreak of fever and jaundice

in a factory in Lalru, Punjab, North India. Surveillance of the affected unit was

carried out and 40 samples were collected from patients with suspected acute

viral hepatitis. Approximately 3 ml of venous blood was collected from each

patient and samples were transported on ice to the virology laboratory. Since

the samples were received for clinical diagnosis due to an outbreak, prior

ethical clearance was not obtained. However, all patients provided informed

consent.

Serology Serum samples were tested for markers of acute viral hepatitis: anti-

HAV IgM (Orgenics, Yavne, Israel), hepatitis B virus surface antigen (HBsAg;

J Mitra, New Delhi, India), anti-HCV (J Mitra), and anti-HEV IgM

(ImmunoVision, Springdale, WA) using commercial ELISA kits according to

the manufacturer’s instructions. A cocktail of recombinant HEV ORF-2 and

ORF-3 peptide was used for detection of anti- HEV IgM. The manufacturer of

this kit has reported a sensitivity and specificity of >99%. HEV Antigen

Detection HEV antigen was detected using a commercial ELISA kit (Wantai,

Beijing, China) according to manufacturer’s instructions. Briefly, the microwell

strips of this solid phase sandwich ELISA were pre-coated with rabbit anti-

HEV antibodies directed against the structural ORF-2 protein. Patient’s serum

(100 ml) was added to the microwells. HEV antigen in the samples bound to the

anti-HEV antibody and captured by the solid phase. Following a washing step,

monoclonal anti-HEV antibody conjugated with horseradish peroxidase (HRP)

245

was added. After washing, a chromogenic substrate (tetramethylbenzidine) and

urea-peroxide were added, color was produced, and reactions were stopped. The

absorbance was measured at 450 nm.

According to the manufacturer’s information, the mean absorbance value for

three negative controls (NC) was calculated and HEV antigen cut off ¼ 0.12 þ

mean of NC was determined. Samples with absorbance values higher than cut

off were considered positive. RNA Extraction and Reverse Transcription-

Polymerase Chain Reaction (RT-PCR) for Detection of HEV Genome RNA

was extracted from 40 serum samples using Trizol LS reagent (Invitrogen,

Grand Island, NY). Briefly, 250 ml of serum was added to 750 ml of Trizol LS

(1:3 ratio), and RNA was extracted following manufacturer’s protocol. After

washing the RNA pellet three times with 75% ethanol at 12,000 rpm for 10 min

at 48C, pellet was air dried for 5–10 min and dissolved in 20 ml of Tris–EDTA

buffer (pH 8). RNA (10 ml) was reverse transcribed to cDNA using MMuLV

RT and random hexameric primers (Fermentas, Glen Burnie, MD, USA). PCR

amplification was carried out using specific primers against the ORF 1 gene by

a nested PCR protocol [Kumar et al., 2007]. The amplicons of 343 bp were

visualized by 2% agarose gel electrophoresis following ethidium bromide

staining. With each PCR run, both positive and negative controls were included.

Positive control was a recombinant plasmid (pIRES-neo-ORF1), a kind gift

from Dr. Shahid Jameel, ICGEB, New Delhi.

Sequence Analysis

Representative four strains from this outbreak were sequenced for confirmation

of the etiological agent. ABI chromatogram files were viewed using Finch TV

1.4.0, following sequence drafting with bioedit 7.0.9 software. For the

confirmation of these sequences, database search was implemented using

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BLAST program available at NCBI website. Generated sequences were

submitted to genbank.

Drinking Water Source and Water Analysis

Water was collected from the affected unit’s tube well, overhead reservoir, and

the final distribution tap. Samples were sent to the State public health laboratory

for quality assessment.

Results

Epidemiology

The outbreak occurred in the Lalru district of Punjab, North India from June to

July 2010. This region experienced moderate rainfall; and the highest and

lowest recorded temperatures were 45 and 258C, respectively. For the survey of

jaundice cases, teams of multipurpose health workers visited blocks adjacent to

the affected areas and conducted reviews of medical records at local hospitals.

Out of 2,500 population, 102 suffered from acute hepatitis. The symptomatic

attack rate was 4.1% (102/2,500). Patients ranged between 22 and 55 years of

age with a mean age of 30.4 years. Patients presented with fatigue (95.6%),

anorexia (91.3%), dark urine (86.9%), abdominal pain (60.8%), arthralgia

(56.5%), scleral icterus (47.8%), nausea (47.8%), fever (47.8%), loose stools

(43.4%), pruritis (43.4%), and vomiting (34.7%).

Determination of Serological Markers

Four of 40 samples (10%) were negative for all hepatitis markers. Hence, they

were not included for further analysis of the results. Of the 36 positive samples,

25 patients (69.4%) were positive for HEV antigen and 33 (91.6%) patients for

anti-HEV IgM. None of the patients were positive for anti-HAV IgM.

In addition, one patient each was found to be positive for HBsAg (2.6%) and

anti-HCV (2.6%). Thus, the serological data implicated hepatitis E virus as the

main etiological agent of this outbreak.

Detection of Viral Genome

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HEV RNA was detected in 17 of 36 samples (47.2%). Antigen detection and

RT-PCR were able to detect three extra cases which did not show significant

anti- HEV IgM titers. These three samples were collected during the initial part

of the illness (1–3 days).

Sequencing Results

Sequencing of the representative strains from this outbreak (Accession number:

JF414937, JF414938, JF414939, JF414940) revealed that the strain responsible

for this outbreak belong to HEV genotype I, subtype 1a. The outbreak strains

showed 95–100% sequence similarity with one another.

Comparison between Molecular and Serological Methods With Respect to

Sample Age

Sample age was defined as the day of sample collection after the onset of

symptoms. HEV RNA and HEV antigen were detected in 100% of patient

samples collected by Days 1–3 of illness, and the positivity rate of older

samples declined gradually. In contrast, 100% anti-HEV IgM detection was

observed in samples collected 4th day onwards (Fig. 1). Most samples obtained

from patients within 4–7 days of symptoms onset were positive for both HEV

antigen and anti- HEV IgM (87.5%). Detection of HEV antigen in samples

collected after Day 7 declined whereas anti-HEV IgM remained an indicator of

acute infection.

Relationship Between HEV RNA and Antigen

The majority of HEV antigen-positive samples (60% (15/25)) were positive for

HEV RNA and 18.1% (2/11) of HEV antigen-negative samples were positive

for HEV RNA. The total concordance of HEV RNA and HEV antigen was

approximately 66.6% (x2 ¼ 5.360, P ¼ 0.0206).

Intrafamilial Spread

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The patients were contacted by telephone: none of their family members

reported the development of jaundice simultaneously or within 6 weeks. Thus,

no overt intrafamilial spread was seen in the present outbreak.

Environmental Sampling for Assessment of Water Quality

Water analysis data from the tube well, overhead tank, and final distribution tap

water revealed no residual free chlorine, and the microbiological investigations

revealed coliform counts of 15, 20, and 15 coliforms/ 100 ml, respectively.

Because these counts were greater than the desirable limits [BIS. Indian

standard drinking water specification. 2004], hyperchlorination was undertaken

as a corrective measure.

DISCUSSION

This study documents a focal, single peak outbreak of hepatitis E in a set of

factory workers in North India during June–July, 2010. The outbreak possibly

occurred due to sewage contamination of drinking water. Previous outbreaks

from adjacent areas have been reported in Kurali-Mansa in 2003 and Mandi-

Gobindgarh in 2005 [Kumar et al., 2006; Bali et al., 2008].

The conventional diagnosis of acute viral hepatitis from suspected HEV

infection rests on the detection of anti-HEV IgM antibodies. However,

significant variability in the sensitivity and specificity of the markers arises

from (i) complex antigenic character of the virus, (ii) heterogeneity of the viral

strains, (iii) differences in geographic distribution, (iv) competition with other

classes of specific antibodies for the virus, and (v) nature of the capturing

antigens

Table Showing Relationship between HEV Antigen Detection and HEV RNA

Positivity in the Serum Samples

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HEV nRT PCR

HEV antigen Positive Negative Total

25

11

36

Positive 15 10

Negative 2 9

Total 17 19

To improve sensitivity, Yu et al. [2003] developed a class capture ELISA by

immobilizing the mu-chain of anti-HEV IgM onto the solid phase. This assay

was more sensitive than an indirect ELISA, but the specificity was diminished

by IgM rheumatoid factor. Here, we utilized an ELISA kit based on a cocktail

of HEV ORF-2 and -3 recombinant proteins. Overall, the HEV IgM positivity

in the present study was 91.6%, in agreement with Favorov et al. [1992]

showing IgM positivity in 40–100% of epidemic samples. HEV RNA is an

important marker of acute infection, especially during early stages of an

outbreak— before the antibody response becomes evident. RTPCR followed by

sequencing of viral RNA can also identify the nucleotide sequence, the

genotype, and the subtype responsible for the outbreak. Strain identification

helps in tracing and localizing the source of contamination, and expediting

control measures. Another advantage of RT-PCR is its ability to diagnose cases

of HEV infection in immunosuppressed patients who do not mount an adequate

antibody response [Kamar et al., 2008; Singh et al., 2012]. In the era of

molecular techniques, detection of HEV RNA by RTPCR is considered to be

the gold standard [Lin et al., 2000; Takahashi et al., 2005; Myint et al., 2006;

Zhang et al., 2009]. However, these three technical challenges, requirement for

cold transport of samples, specialized laboratory equipped with sophisticated

instruments, and experienced personnel, restrict its wide applicability and limit

its use to reference laboratories.

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In the present outbreak, 17(47.2%) of 36 samples tested were positive for HEV

RNA. RT-PCR detected an additional three cases than the conventional anti-

HEV IgM ELISA. These latter three patients had the illness for 1–3 days, which

explains the absence of an antibody response. Interestingly, these patients were

also positive for HEV antigen. Sequence analysis showed the etiological agent

to be HEV genotype I, subtype 1a. Comparison of the sample age with the HEV

results of the 36 serum samples indicated that HEV- RNA and HEV antigen

were detected in 100% of samples collected during the first 3 days of illness. By

Days 4–7, the positivity of PCR declined to 54.2%, whereas antigen and IgM

detection were 88% and 100%, respectively. After Day 7, anti-HEV IgM was

the main indicator of infection (Fig. 1). Ten samples collected between 4 to 7

days of illness were positive for HEV antigen and anti-HEV IgM but were

negative for HEV-RNA, indicating gradual loss of HEV RNA.

A few studies have suggested HEV antigen as a newer diagnostic marker. Zhao

et al.[2009] reported that the detection of HEV antigen in combination with

anti-HEV IgM compensates for the delay in detection of anti-HEV IgM and can

be useful for diagnosis of HEV infection. In the same study, they observed that

positive HEV antigen values highly correlated with increased levels of liver

enzymes and bilirubin, indicating acute damage to liver, and were transient;

whereas the anti-HEV IgM antibodies persisted for more than 1 month. Thus,

patients diagnosed with acute hepatitis based on anti-HEV IgM alone may

actually be in the convalescent or recovering phase as indicated by gradual

normalization of liver enzymes and bilirubin level. Zhang et al. [2006]

evaluated an in-house ELISA for HEV antigen detection by using serum

samples of experimentally HEV-infected monkeys; detection of both HEV

antigen and anti-HEV IgM overlapped for 2–3 weeks. The authors found that

the HEV antigen appeared earlier than anti- HEV IgM where as anti-HEV IgM

lasted longer. Furthermore, 70.6% of HEV antigen positive sera were also

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positive for HEV RNA [Zhang et al., 2006], which is in concordance with our

finding.

Detection of HEV antigen in an ELISA format may experience wider usage in

endemic and resource-poor countries. An HEV antigen-specific ELISA requires

the same instruments as required for detection of anti-HEV IgM antibodies,

which are available even in the peripheral clinics. Most HEV related outbreaks

occur in rural and peri-urban areas. In such peripheral health care clinics,

molecular detection is not a possibility and transporting samples to reference

laboratories delays sample processing. In such settings, detection of HEV

antigen by ELISA will be highly beneficial as it can allow early diagnosis on

site.

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Way Forward for Surveillance Activities

1 Strengthening of the surveillance activities

2 Strengthening of the all district public health laboratories to detect

epidemic prone diseases

3 Efforts will be made to establish more district public health labs inremaining districts.

4 To maintain target of immediate investigation of the outbreak at 100%

5 To strengthen the communication facilities for quick response and

reporting of incidences

6 To utilize the statistics to improve the disease status

7 Continuous training of the field staff engaged in the surveillance

activities

8 Expanding the IT network for the information, education and awareness

of the general public

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