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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 5  |  Page : 34-40  

Acute diarrheal disease outbreak in Muzaffarpur Village, Chandauli District, Uttar Pradesh, India


1 India EIS Officer, Division of Epidemiology, National Centre for Disease Control, New Delhi, India
2 Joint Director, Division of Epidemiology, National Centre for Disease Control, New Delhi, India
3 Public Health Specialist, US Centers for Disease Control and Prevention, New Delhi, India
4 EIS Resident Advisor, US Centers for Disease Control and Prevention, New Delhi, India

Date of Submission30-Aug-2020
Date of Decision15-Oct-2020
Date of Acceptance08-Dec-2020
Date of Web Publication29-Jan-2021

Correspondence Address:
Ginisha Gupta
B-6 Joshi Colony, Mandawali, Fazalpur, I. P. Extension, New Delhi - 110 092
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_1111_20

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   Abstract 


Background: Acute diarrheal disease (ADD) outbreaks frequently occur in the Gangetic plains of Uttar Pradesh, India. In August 2017, Muzaffarpur village, Uttar Pradesh, reported an ADD outbreak. Objectives: Outbreak investigation was conducted to find out the epidemiology and to identify the risk factors. Methods: A 1:1 area-matched case–control study was conducted. Suspected ADD case was defined as ≥3 loose stools or vomiting within 24 h in a Muzaffarpur resident between August 7 and September 9, 2017. A control was defined as an absence of loose stools and vomiting in a resident between August 7 and September 9, 2017. A matched odds ratio (mOR) with 95% confidence intervals (CIs) was calculated. Drinking water was assessed to test for the presence of any contamination. Stool specimens were tested for Vibrio cholerae, and water samples were also tested for any fecal contamination and residual chlorine. Results: Among 70 cases (female = 60%; median age = 12 years, range = 3 months–70 years), two cases died and 35 cases were hospitalized. Area–A in Muzaffarpur had the highest attack rate (8%). The index case washed soiled clothes at well – A1 1 week before other cases occurred. Among 67 case–control pairs, water consumption from well–A1 (mOR: 43.00; 95% CI: 2.60–709.88) and not washing hands with soap (mOR: 2.87; 95% CI: 1.28–6.42) were associated with illness. All seven stool specimens tested negative for V. cholerae. All six water samples, including one from well–A1, tested positive for fecal contamination with <0.2 ppm of residual chlorine. Conclusion: This outbreak was associated with consumption of contaminated well water and hand hygiene. We recommended safe water provision, covering wells, handwashing with soap, access to toilets, and improved laboratory capacity for testing diarrheal pathogens.

Keywords: Diarrhea, drinking water, matched case-control study, outbreak investigation, waterborne diseases


How to cite this article:
Gupta G, Singh A, Dikid T, Saroha E, Sodha SV. Acute diarrheal disease outbreak in Muzaffarpur Village, Chandauli District, Uttar Pradesh, India. Indian J Public Health 2021;65, Suppl S1:34-40

How to cite this URL:
Gupta G, Singh A, Dikid T, Saroha E, Sodha SV. Acute diarrheal disease outbreak in Muzaffarpur Village, Chandauli District, Uttar Pradesh, India. Indian J Public Health [serial online] 2021 [cited 2021 Feb 28];65, Suppl S1:34-40. Available from: https://www.ijph.in/text.asp?2021/65/5/34/308320




   Introduction Top


Approximately 2 billion cases of acute diarrheal diseases (ADD) occur every year globally.[1] ADD is the second leading cause of mortality among under-five children across the world.[2] Contaminated food or water, person-to-person transmission, and lapses in sanitation and hygiene are known risk factors of ADD.[2] Worldwide, an estimated 780 million people lack access to improved drinking water and 2.5 billion lack improved sanitation.[2]

Since 2001, India has made steady progress in reducing diarrheal illnesses. Yet in 2015, 21% of global under-five diarrheal deaths were reported from India.[3] In 2016, there were estimated 13.9 million cases of waterborne ADD in India.[4] Of all outbreaks reported in 2016, diarrheal diseases and food poisoning constituted 48%.[5] The Integrated Disease Surveillance Programme (IDSP) in India leads the surveillance of diarrheal and other epidemic-prone diseases and investigates outbreaks for effective prevention and control.[5] Investments from the Global Health Security Agenda have renewed India's commitment towards systematic and streamlined outbreak detection, investigation, and response.[6] In 2014, the Government of India launched the Swacch Bharat Abhiyaan (Clean India Mission) to achieve universal sanitation coverage; by2016, 45% rural households had access to sanitary toilets.[7],[8]

The delta of the Ganga Riveris endemic for cholera and other acute diarrheal pathogens; parts of northern India are endemic for Vibrio cholerae.[9],[10] Uttar Pradesh, a populous state in the Gangetic plains of north India, has high burden of communicable diseases with 16% prevalence of diarrhea.[11] In 2016, UP reported 180,000 cases of ADD.[5] The implementation of sanitation programs and policies in the state resulted in access to improved safe drinking water to 95% households and toilets to 25% households in 2016.[7] Yet in rural UP, access to sanitation remains poor; only 22% households had access to improved sanitation and only 2% villages had community toilets in 2016.[7] In Chandauli District, UP, 28% households had improved sanitation facilities, and 89% households had access to an improved source of drinking water.[11]

On August 17, 2017, the IDSP District Surveillance Unitin Chandauli District, UP, reported clustering of diarrheal cases in Muzaffarpur Village. Muzaffarpur is a small village in the cholera-endemic basin of the Ganga River with a population of 3684. It is divided into three areas – Harijan Basti and Usrapur; Dibri and Godam; Muzaffarpur Proper and Lathepur – along caste lines and access to drinking water sources. We investigated this suspected ADD outbreak in Muzaffarpur Village to confirm the outbreak, describe the epidemiology, identify the etiology and risk factors, and to give evidence-based recommendations for prevention and control.


   Materials and Methods Top


Confirmation of outbreak

Data were accessed from weekly ADD surveillance data for Muzaffarpur Village from the health IDSP subcenter. IDSP defines suspected cases of ADD as loose watery stools of <2 weeks' duration and records them in the suspect/syndromic (S) surveillance data form.[12] ADD surveillance data were analyzed for the 4th week of June to the 3rd week of August (week 26–33) for 2014, 2015, and 2016 and compared that data with cases reported in the same time frame of 2017. An outbreak was defined as reported cases in 2017 that exceeded the mean number of cases over the prior 3 years by at least 2 standard deviations in any week.

Case search

Suspected case was defined as three or more loose stools or vomiting within 24 h in a Muzaffarpur Village resident between August 7 and September 9, 2017. Health facility records were reviewed from all sub-centers, primary health centers, and district hospitals that cater to the entire village. Individual case was searched during house-to-house survey where an in-depth interview was carried out with the suspected index case and verbal autopsies (using postneonatal death review forms) with the parents of deceased was completed.[13] Through in-depth interviews, data were collected related to symptoms, illness onset, time to death, treatment, socio-demographics, and risk factors such as drinking water source, sanitation, hygiene, and travel history.

Case–control study

A 1:1 village area-matched case–control study was conducted. Three areas of village were classified as Muzaffarpur as Area–A (Harijan Basti and Usrapur), Area–B (Dibri and Godam), and Area–C (Muzaffarpur Proper and Lathepur). Area–A is inhabited by people from an extremely marginalized caste, Area–B by a marginalized caste, and Area–C a nonmarginalized caste. Each area has exclusive drinking water sources.

All cases that were identified during the case search were enrolled in the study. Control was defined as absence of loose stools and vomiting in a resident of Muzaffarpur Village between August 7 and September 9, 2017. Control was also selected from the same area so as to ensure matching by area. First, a control was searched in the house immediately next-door on the right. If that household had more than one eligible control, then the person whose birthdate was closest to September 2017 was taken as control. If that household did not have an eligible control, then searching was continued to the next house on the right side, and so on. Control exclusion criteria were: same household as the case, suffering from chronic illness for >3 months, and taking any medication for >1 week. If a control could not be selected from that area, then that particular case was excluded from the study.

Semi-structured questionnaire and observation checklist was used to collect data for socio-demographics, drinking water sources (well, hand pump, overhead tank, and others), drinking water storage containers (covered or uncovered; <4 cm or ≥4 cm radius opening), hand contact during retrieval of drinking water (yes/no), drinking water purification at home (boiling, chlorinating, candle filtration, reverse osmosis, filtration, and others), presence of toilet at home (yes/no), handwashing with soap before eating and after defecation (yes/no), and soap availability in toilet and kitchen (yes/no). Cases and controls were also interviewed about anthropogenic practices such as bathing, laundry, washing utensils, and defecation around wells.

Data analysis

From the house-to-house survey, proportions, attack rates, and the case fatality rate was calculated. Matched odds ratio (mOR) with 95% confidence intervals (CIs) was also calculated. Two-tailed McNemar test was performed when there were 20 or more discordant pairs and two-tailed Fisher's exact test was employed when there were fewer than 20 discordant pairs. The analysis was done in Epi Info software, version 7.2. Drinking water sources were stratified by area, and mOR with 95% CI was calculated to determine the risk of illness associated with specific drinking water source.

Laboratory testing

Seven stool specimens were collected and tested from cases for V. cholerae by culture at the regional IDSP laboratory, Lucknow, UP.

Environmental assessment

All drinking water sources (covered, uncovered, public, and private) and toilets (public and private) were enumerated in all three areas (A, B, and C) of Muzaffarpur Village. Water samples from all water sources (well, hand pump, overhead tanks) of Area–A was tested for fecal contamination using hydrogen sulfide (H2S) strip tests and free residual chlorine using ortho-toluidine field test kits was estimated. This same procedure was repeated only on the overhead tanks in Area–B and Area–C. Bacteriological analysis of water samples from wells A1 and A3, where cases clustered, was carried out for indicator organisms, i.e., total and fecal coliform (Escherichia coli) by most probable number (MPN) method. Water samples were collected in sterile containers for testing at the regional IDSP laboratory in Lucknow, UP.

Ethical considerations

The investigation was a public health response to an outbreak as part of the India Epidemic Intelligence Service Program, undertaken with the purpose to identify the source of spread for immediate control of outbreak and intended for benefit of the community at large. Ethical approval is not applicable as part of public health response. The investigation did not involve any human laboratory sample collection for research purpose and there were no invasive investigations or medical interventions/experiments. All the ethical principles and guidelines were adopted and maintained during the outbreak response: the investigation was aimed at achieving public good (beneficence) and collective welfare (solidarity); no harm was done to any individual (non-maleficence); fair, honest and transparent (accountability and transparency); and participants' data were de-identified prior to analysis (confidentiality).


   Results Top


Mean number of ADD cases in Muzaffarpur Village ranged from 2 to 7 per week during the 4th week of June to 3rd week of August (weeks 26–33) during 3 years' period from 2014 to 2016. In 2017, there were 15 ADD cases in Muzaffarpur village during week 28, which exceeded the >2 standard-deviation threshold. Thus, we confirmed the ADD outbreak.

About 70 cases were identified with a median age of 12 years (range: 3 months–70 years). Out of them, 60% were female. Symptoms included three or more loose stools within 24 h (99%), vomiting (63%), and self-reported fever (21%). Out of 70 cases, 43 (61%) had loose stools with vomiting, and none reported blood in stools. Of 70 cases, 35 (50%) were hospitalized and two died for a case fatality rate of 3%. All seven stool specimens collected from cases tested negative for V. cholerae by culture. The overall village attack rate was 2%; it was highest in Area–A (8%), followed by Area–B (2%), and Area–C (1%) [Figure 1].Out of 46 households in Muzaffarpur village, 13 (28%) households (Area–A, 8/27 (30%); Area–B, 1/8 (13%); and Area–C, 4/11 (36%)) had more than one case.
Figure 1: Acute diarrheal diseases cases, deaths and water sources in Area A, B and C of Muzaffarpur Village, Chandauli, Uttar Pradesh, India, August 7, 2017 to September 9, 2017 (n = 70).

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The outbreak started in Area–A on August 7, 2017 and reached its peak on August 17. It first affected Area–A and Area–C, and then spread to Area–B. A few dispersed cases in all areas were reported after the first peak [Figure 2].
Figure 2: Acute diarrheal diseases cases and deaths by date of illness onset in Areas A, B and C of Muzaffarpur Village, Chandauli, Uttar Pradesh, India, August 7, 2017 to September 9, 2017 (n = 70).

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The apparent index case was an adult female resident of Area–A. She reported 1 day of illness characterized by five to six episodes of loose stools and vomiting within 24 h after which she was hospitalized for 6 days. Since her household did not have a toilet and washing area, her family used community wells A1 and A2 for drinking, bathing, laundry, and washing utensils. She reported that her caregiver washed her soiled clothes adjacent to well A1and her stool and vomitus were disposed in nearby fields. The index case did not report hand washing with soap before eating or after defecation. She reported using mud or ash to wash her hands after defecation. We did not observe soap around the household washing area. Her household members did not report use of any water purification method. In her family, she was the only one who suffered from ADD during August 7 to September 9, 2017. Family members caring for her did not become ill. She did not travel outside her village 7 days prior to illness and did not report eating at any community gathering.

There were two infant deaths (infant X and Y) in Muzaffarpur Village. Infant X was an 8-month-old male from Area–A and infant Y was a 9-month-old female from Area–B. In the household of infant X, there were five more ADD cases. In the household of infant Y, there were no more cases. Dates of illness onset were August 17 for infant X and August 19 for infant Y. Both infants had more than three loose stools within 24 h with a median frequency of 8 stools (range: 5–10) as well as vomiting. Infant X died within 2 days of illness onset and infant Y died after 12 days of illness onset. Both infants were malnourished with severe dehydration. They were both hospitalized and treated with intravenous rehydration therapy. Neither infant had a significant medical history prior to becoming ill. Both infants were breastfed, supplemented by home-cooked soft food. The drinking water source for infant X was well A1 and for infant Y was hand pump B1. The households of both infants did not report use of any water purification method. Houses of both infants did not have toilets. Their mothers did not report washing hands after defecation or prior to feeding the child. Both infants did not travel outside their village 7 days prior to illness and did not eat at any community gathering.

For this case control study, 67 of 70 eligible cases were enrolled; the three noneligible cases were from Area–A. An equal number of controls were also enrolled. Consuming well water (mOR: 4.25; 95% CI: 1.43–12.63) and not washing hands with soap (mOR: 2.87; 95% CI: 1.28–6.42) were associated with illness. Consuming hand pump water (mOR: 0.04; 95% CI: 0.006–0.33) and age ≥20 years (mOR = 0.13; 95% CI: 0.04–0.45) were protective [Table 1].
Table 1: Risk factors for acute diarrheal diseases outbreak in Muzaffarpur Village, Chandauli District, Uttar Pradesh, India, August 7–September 9, 2017 (n=134)

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Analysis by specific drinking water sources showed that water of well A1 (mOR: 43.00; 95% CI: 2.60–709.88) was associated with illness and water of hand pump A2 (mOR: 0.12; 95% CI: 0.01–0.53) was protective [Table 2].
Table 2: Analysis of wells and hand pumps of areas A, B and C, Muzaffarpur Village, Chandauli District, Uttar Pradesh, India, August 7–September 9, 2017 (n=134)

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Muzaffarpur Village had 10 wells (covered = 1 and uncovered = 9), 47 hand pumps, and two overhead tanks that catered for 3,684 people in 529 households. The overhead tanks supplied water through pipes to households of Area–B and Area–C. The village did not have a public toilet, and only 27 (5%) households had toilets.

Area–A (population 584 in 129 households) had three uncovered wells (1, 2, and 3), two hand pumps (1 and 2), of which one was public and other is private, and no overhead tank. All uncovered wells were brick-lined dug wells with no seals and head walls around openings with no drainage mechanism to prevent backflow of water into the wells. There was no public toilet in Area–A, and only 3% of households had a toilet. This area had the highest attack rate at 8%. Area–B (population 500 in 135 households) had one uncovered well, two hand pumps, and one overhead tank. There was no public toilet and only 2/135 (1%) households had a toilet. The area had 2% (9/500) attack rate. Area–C (population 2,600 in 265 households) had one uncovered well, two hand pumps, and one overhead tank. There was no public toilet and 21 (8%) households had a toilet. This area had lowest attack rate (1%; 15/2600).

During the house-to-house survey, we observed anthropogenic activities around wells in the village. Of 134 cases and controls, 42% reported doing laundry, 40% bathing, 28% washing utensils, and 6% defecation around wells. A higher proportion in Area–A reported doing laundry (60%), bathing (57%), and washing utensils (41%) around wells than those in Area–B and Area–C, P < 0.05 [Table 3].
Table 3: Anthropogenic activities around area A, B and C wells, Muzaffarpur Village, Chandauli District, Uttar Pradesh, India, August 7–September 9, 2017 (n=134)

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Field tests showed that all six water samples tested from all areas had fecal contamination and free residual chlorine levels of <0.2 ppm. Cases were clustered around well A1 and A2. Two water samples from wells A1 and A3 had MPN counts more than the permissible level of 10 MPN/100 ml.


   Discussion Top


Epidemiological data indicate that the ADD outbreak in Muzaffarpur Village was associated with drinking contaminated well water and poor hand hygiene. The apparent index case was likely contaminated from the water of the unprotected well in Area–A by washing soiled clothes adjacent to it, which probably triggered the outbreak. Due to the sensitive case definition, the interspersed diarrhea cases in Area–B and Area–C appear to be baseline diarrheal cases in the village.

Diarrhea associated with drinking unsafe water constitutes 8% of all deaths in Southeast Asia.[14] In India, diarrhea outbreaks associated with consumption of contaminated drinking water have been reported repeatedly.[13],[14],[15],[16],[17],[18] Therefore, access to safe drinking water during the investigation was prioritized. Alternative drinking water sources and chlorinated all wells of Area–A were also arranged. Health workers were trained for periodic chlorination of wells and fortnightly surveillance of water quality. Covering of all the wells with cement slabs was recommended to prevent contamination. For longer-term prevention, recommendation was given on piped water to all households through two overhead tanks.

Other than safe drinking water, household-based sanitation, and hygiene are also known to prevent diarrhea.[19],[20] In the present manuscript, investigation, illness was associated with not washing hands with soap. Because we did not use standardized water and sanitation survey questions, these results should be interpreted with caution. However, hand washing with soap after defecation and before eating is a simple and cost-effective strategy for the prevention of ADD.[21] Hand hygiene was demonstrated to village residents and provided education about fecal-oral transmission of diarrhea. The construction of toilets was also recommended to the district authorities for all households through the resources available from the Swacch Bharat Abhiyaan (Clean India Mission).[8]

During the investigation, we could not confirm the etiology of the outbreak. However, explosive diarrhea with 50% hospitalization in a cholera-endemic area suggested V. cholerae as a likely etiology.[22] Although all seven stool culture specimens were negative for V. cholerae, stool culture yield is determined by several factors including collection of appropriate specimens, intake of antibiotics prior to specimen collection, specimen storage, transport, and time lag for testing of specimens.[23],[24],[25],[26] During the outbreak investigation, we trained district laboratory staff in stool specimen collection, transportation, and hanging drop slide preparation for testing of V. cholerae. We emphasized the testing of stool specimens for common diarrheal pathogens in the event of future outbreaks.

In this ADD outbreak, Area–A residents, who were from an extremely marginalized caste, were disproportionately affected. They also had minimal access to safe drinking water and sanitation. In India and neighboring countries, caste is an important social determinant that restricts access to resources such as safe drinking water and sanitation to marginalized caste groups.[27],[28],[29] Culturally, different caste groups do not share drinking water and other resources to avoid direct and indirect physical contact. Inequitable distribution of resources results in health gaps between caste groups in rural communities. The focus on controlling the spread of the outbreak prevented an in-depth analysis of caste dynamics during the investigation.

We recommend that in the event of future outbreaks, multi-disciplinary investigation teams examine and address structural barriers to facilitate universal access to safe water, sanitation, and health care. With the Government of India's renewed commitment to mitigate diarrhea-associated preventable morbidity and mortality, communities and public health authorities should maximize the use of available resources to promote health and prevent outbreaks.

Acknowledgements

We thank Dr. Neelam Ojha, Office of Chief Medical Officer, Chandauli District, Uttar Pradesh, India; Dr. Pradeep Khasnobis and Dr. Saurabh Goel, Integrated Disease Surveillance Programme, National Centre for Disease Control (NCDC), New Delhi; and Dr. Sujeet Singh (Director), Dr. C. S. Aggarwal (Additional Director) and Dr. S. K. Jain (Additional Director), NCDC, New Delhi, India for their technical assistance and review.

Financial support and sponsorship

This public health activity was conducted by India Epidemic Intelligence Service (EIS) program of National Centre for Disease Control at the request of the Government of Uttar Pradesh. The National Centre for Disease Control receives funding support for the India EIS Program through cooperative agreement No. NU2GGH001904GH10-1001 from the U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global Health Protection. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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