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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 5  |  Page : 41-45  

Foodborne illness outbreak linked to a rural community kitchen in a rural area of Patiala District, Punjab, India, 2018


1 India Epidemic Intelligence Services Officer, Division of Epidemiology, National Centre for Disease Control, Delhi, India
2 State Surveillance Officer, Integrated Disease Surveillance Programme, Punjab, India
3 Joint Director, Division of Epidemiology, National Centre for Disease Control, Delhi, India
4 Assistant Director, Division of Epidemiology, National Centre for Disease Control, Delhi, India
5 Public Health Specialist, South Asia Field Epidemiology and Technology Network, Delhi, India

Date of Submission30-Aug-2020
Date of Decision28-Nov-2020
Date of Acceptance17-Dec-2020
Date of Web Publication29-Jan-2021

Correspondence Address:
Akshay Kumar
213, Kadambari Apartment, Rohini Sector 09, Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_1112_20

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   Abstract 


Background: In December 2018, an acute gastroenteritis outbreak was reported from Faridpur-Gujjran village, Patiala district, Punjab, India. Objective: The objective of this study was to describe the epidemiology and risk factors of the outbreak and recommend prevention measures. Methods: We conducted a descriptive study and a retrospective cohort study in the village. We defined a case as vomiting or ≥3 loose feces in 24 h plus abdominal pain and/or fever in a resident of the village during December 23–28, 2018. To find cases, we conducted a house-to-house survey; to identify risk factors, we conducted a retrospective cohort study. Fecal specimens were tested for enteric pathogens; water samples were tested for fecal contamination. We also interviewed food handlers. We compared attack rates by level of exposure. From the cohort study, we calculated risk ratios with 95% confidence intervals. Results: From the 261 residents of the village, we identified 116 cases (attack rate 44%) and no deaths. The median age of affected persons was 27.5 years (range 0.5–80 years). The illness was associated with eating in a community kitchen of a temple during December 23–24, 2018. Eating mixed vegetables was associated with illness. We found no pathogens in fecal specimens. All three water samples showed coliform contamination. Cooked food had been left at room temperature before serving. Conclusion: Improper storage practices might have led to microbial proliferation of the food served. Our findings will help guide the enforcement of food safety policies for community kitchens.

Keywords: Cohort study, food safety, foodborne illness, outbreak


How to cite this article:
Kumar A, Grover GS, Dikid T, Kaur S, Patil A, Working Group*. Foodborne illness outbreak linked to a rural community kitchen in a rural area of Patiala District, Punjab, India, 2018. Indian J Public Health 2021;65, Suppl S1:41-5

How to cite this URL:
Kumar A, Grover GS, Dikid T, Kaur S, Patil A, Working Group*. Foodborne illness outbreak linked to a rural community kitchen in a rural area of Patiala District, Punjab, India, 2018. Indian J Public Health [serial online] 2021 [cited 2021 Mar 5];65, Suppl S1:41-5. Available from: https://www.ijph.in/text.asp?2021/65/5/41/308321

Working Group: Rajesh Kumar, Professor and Head, Department of Community Medicine and School of Public Health, Post Graduate Institute for Medical Education and Research, Chandigarh; S.K. Jain, Additional Director and Head, Division of Epidemiology, National Centre for Disease Control; S.K. Singh, Director, National Centre for Disease Control, Delhi, India





   Introduction Top


Foodborne diseases are a major cause of illness and death. Globally, an estimated 600 million persons become ill after eating contaminated food, and 420,000 die annually, resulting in 33 million disability-adjusted life years lost.[1] Each year in India, an estimated 100 million foodborne illnesses and 120,000 foodborne illness-related deaths occur, and 8 million disability-adjusted life years are lost.[1],[2] Foodborne illness outbreaks and acute diarrheal diseases accounted for nearly 40% of all reported outbreaks under India's Integrated Disease Surveillance Project (IDSP) during 2011–2017.[3] For most foodborne illness outbreaks in India, the etiology is infrequently identified because of the lack of laboratory diagnosis.[3]

Punjab, a northern state with a population of 28 million,[4] reported 78 outbreaks of acute diarrheal disease, including 10 outbreaks of foodborne illness, to IDSP during 2015–2018.[3]

On December 25, 2018, the subdistrict hospital of Patiala reported clustering of acute gastroenteritis cases to the district surveillance unit of IDSP. The district surveillance unit initiated an outbreak investigation on the same day. The investigation started on December 26 with the objective to describe the outbreak's epidemiology and determine associated risk factors.


   Materials and Methods Top


Case finding

Records of the government tertiary hospital and two private practitioners in the area were reviewed as a step for confirming the outbreak.

We defined a suspected case of acute gastroenteritis with vomiting or diarrhea (≥3 loose stools in 24 h) plus abdominal pain and/or fever during December 23–28, 2018, in a resident of Faridpur-Gujjran village (population 261), Patiala district. Cases were identified by a house-to-house survey using a structured data-capture tool and information was collected about demographic characteristics, date of illness onset, symptoms, and treatment history.

Subsequently, a retrospective cohort study design was adopted to identify risk factors for illness. We defined our cohort as residents of Faridpur-Gujjran village during December 23, 2018–January 1, 2019 and based on their exposure characteristics.

We collected information in a semi-structured questionnaire for demographic details, clinical history, and food exposure history for 3 days before the acute gastroenteritis outbreak was identified by the house-to-house survey.

Laboratory testing

Fecal specimens were collected and sent to the IDSP-designated Patiala district laboratory for microbiological culture. The laboratory was able to conduct culture and isolation for three enteric pathogens: Shigella, Salmonella, and Vibrio cholerae. Toxin-based testing was not available.

Environment investigation

We interviewed the food handlers about the recent illness. We also evaluated raw material procurement; processing, preparation, and storage of cooked langar food (free community meal); and its distribution to people. We collected water samples and sent them to the state public health laboratory for coliform count and residual chlorine level testing.

Data analysis

We used Epi info 7.3 software developed by Centers for Disease Control and Prevention, Atlanta, Georgia (United States) for data entry and analysis. Data were cleaned before analysis. From the household survey, we summarized the data using means and proportions. We calculated risk using attack rates. We compared attack rates by level of exposure. From the cohort study, we calculated risk ratios (RRs) with 95% confidence intervals (CIs). If cell count was 0, then we added 0.5 to all cells. We used a logistic regression multivariate technique to control for likely confounding effect of two or more food items on the outcome. Food items independently associated with the occurrence of acute gastroenteritis at a cutoff of P < 0.05 were introduced into the model.

Ethical considerations

We conducted the investigation after obtaining written informed consent from respondents ≥18 years of age. For adolescents and children <18 years of age, we obtained consent from parents or legal guardians. We conducted the investigation in accordance with ethical guidelines for biomedical research on human subjects as given in the Declaration of Helsinki (modified 2000) and by the Central Ethics Committee on Human Research of the Indian Council on Medical Research (2017), New Delhi.

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 the outbreak and intended for benefit of the community at large. Ethical approval was not applicable as part of public health response. The investigation did not involve any human laboratory sample collection for research purposes and there were no invasive investigations or medical interventions/experiments. All Government of India ethical principles and guidelines were adopted during the outbreak response: the investigation was aimed at achieving public good (beneficence) and collective welfare (solidarity); no harm was done to any individual (nonmaleficence); fair, honest, and transparent (accountability and transparency); and participants' data were de-identified before analysis (confidentiality).


   Results Top


A review of hospital records from a district hospital and two private practitioners showed an increase in registration of cases of acute diarrheal disease or acute gastroenteritis or vomiting on December 24 and 25. A total of 56 cases were reported from Faridpur-Gujjran village during December 24–27, 2018.

From the house-to-house search, we identified 116 suspected cases of acute gastroenteritis in Faridpur-Gujjran village and no reported deaths; 35 (30%) of all persons were hospitalized. The overall attack rate was 44% (116/261); 63 (54%) ill persons were female. The median age of all ill persons was 27.5 years (range 0.5–80 years). Persons most affected were 21–30 years (21.6%, 25/116). The most common symptoms were fever (107 [92%]), abdominal pain (106 [91%]), and diarrhea (104 [90%]) [Table 1].
Table 1: Characteristics of persons with acute gastroenteritis, Faridpur-Gujjran Village, Patiala District, Punjab, India December 2018

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The first case-patient had onset of symptoms at 09 pm on December 23. There were two peaks observed, one at 09–10 am on December 24 and at 04 pm on December 24, followed by a gradual decline in cases. The last case-patient had onset of symptom at 11 am on December 25. Ninety-two (35%) cases were reported on December 24. The median incubation period was 21.5 h (range: 4–54.5 h) [Figure 1].
Figure 1: Distribution of acute gastroenteritis cases by time and date of symptom onset, Faridpur.Gujjran village, Patiala district, Punjab, India, December 2018 (n = 116).

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We identified 261 residents (54% males) from Faridpur-Gujjran. The illness was associated with eating langar food (free community meal) on December 23 or 24. The attack rate for exposed persons was 64% (113/177) and for unexposed persons, 4% (3/84) with a RR = 18, 95% CI 5.8–54.6. The attack rate was higher for persons who reported eating langar food more than once than for persons who reported eating it once (86% vs. 48%) [Table 2]. We also calculated attack rates on the basis of the time the langar meal was eaten. The attack rate was higher for persons who ate the leftover meal at home in the evening (81%, 17/21) and the next day (100%, 1/1) [Table 2].
Table 2: Acute gastroenteritis attack rate by frequency of meals consumed and time of meal, Faridpur-Gujjran Village, Patiala District, Punjab, India, December 2018 (n=261)

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Univariate analysis showed a statistically significant association with all food items served at the langar meal: mixed vegetables, chapati (flat dough bread), halwa (semolina pudding), and tea. In the multivariate model, only consumption of mixed vegetables was significant for illness (OR = 29, 95% CI 4–203) [Table 3].
Table 3: Risk factors associated with acute gastroenteritis after eating at a langar, Faridpur.Gujjran Village, Patiala District, Punjab, India, 2018 (n=261)*

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Twelve fecal specimens were examined by culture. No pathogens were identified after 24 h of incubation. The laboratory discarded fecal specimens 1 day before samples could be shifted to another laboratory for further testing. In all three water samples collected, the coliform count was 12/100 mL. We found no residual chlorine in the water samples.

On December 23, langar, a free community meal in Punjab, was organized at a local temple in Faridpur-Gujjran village. The langar was prepared for approximately 1000 people expected to visit the temple and travelers on the nearby highway. Volunteers from the village helped prepare the langar. Raw food materials such as vegetables, oil, flour, sugar, and milk were procured on the morning of December 22 from the local market and prepared later that afternoon. All ingredients, including cut raw vegetables, were left at room temperature overnight.

The food was cooked in an open area at the temple. The mixed vegetables were prepared in two batches, one each at 6 am and 8 am. The suji halwa was prepared simultaneously. The mixed vegetables and suji halwa were prepared by five persons from the village. The chapatis were prepared 4–5 times as needed. Dough for the chapatis was rolled freshly by four women from the adjacent village. None of the food handlers were ill. All the prepared food was stocked in large steel containers and left at room temperature for approximately 6 h before serving. The source of water for cooking and drinking was a submersible pump at the temple and a water tanker at the roadside where food was served.

The langar was served at the temple beginning at 12 noon. Food was also carried to the nearby highway for travelers. Food was served until 3 pm. Leftover langar food was distributed among the villagers at approximately 3:30 pm. On December 23, the temperatures of Faridpur-Gujjran Village ranged from 7°C to 20°C. Our interview with the village head revealed that the temple is not registered as a “petty food manufacturer” by the local food safety officer.


   Discussion Top


This point-source foodborne illness outbreak, identified through IDSP, was caused by the ingestion of contaminated mixed vegetables served in a community kitchen organized by a temple. Attack rates were disproportionately high in persons who ate leftover food. Organisms might have proliferated because of prolonged storage of food.

In India, the IDSP usually detects cluster of cases associated with foodborne illness outbreaks;[5] sporadic cases of foodborne illnesses are not detected due to nonavailability of a strong laboratory surveillance. Passive surveillance systems, such as IDSP, underreport foodborne diseases because most persons have mild symptoms of short duration and do not seek medical care; for many persons who do seek care, laboratory tests to determine a specific etiology are not conducted, and of those who seek medical care and have an etiologic diagnosis confirmed, not all are reported to the surveillance system.[6]

In this outbreak, food was served to the people at a langar, which is a community kitchen at a temple that was not registered with the food safety department. Similar outbreaks of foodborne illness from ingestion of food offered as part of rituals in mass gatherings at religious places have been described in India.[7],[8] Offering food in a temple is a cultural practice, and large number of people eat food offered as prasad, bhog, and langar. Preparing large quantities of food during a short time span may at times overwhelm the capacity of food handlers in these places, if they are not run professionally and thus compromise required standards of safety and hygiene. This fact, coupled with lack of awareness about safe food, can result in foodborne illness outbreaks in such settings.

In this outbreak, a large number of persons took leftover langar food to eat later at home. The risk for illness increased with delay in eating leftover food, which suggests increase in pathogen load with time. Bacterial load increases with favorable temperature because of improper storage practices.[9],[10] Food kept at room temperature should be eaten within 4 h. The Food Safety and Standards Authority of India recommends that cooked food meant to be served hot must be held at >60°C and cold food must be held at <5°C.[10]

A rapid and systematic epidemiologic investigation helped identify the food vehicle. Hazard analysis from the environmental investigation identified lapses in food safety critical control points during the preparation of the langar food. We shared the evidence from this investigation with the food safety department of Punjab. Findings will help direct future policies related to maintaining food safety and hygiene in temples. Common high-risk practices during the preparation of foods that are susceptible to contamination in temples can be addressed during training for food handlers, and registering or licensing and regulatory compliance can be ensured through periodic checks. These temples also should ensure regular disinfection and testing of drinking water.

Our investigation had some limitations. The investigation fell short of laboratory confirmation. However, the yield for fecal culture is determined by several factors, including collection of appropriate specimen; intake of antibiotics before specimen collection; and specimen storage, transport, and time lag before testing.[11],[12],[13] We emphasize the need for laboratory training for fecal culture examination and ensuring the availability of supplies in district IDSP laboratories to initiate testing of fecal specimens for common diarrheal pathogens. We could not contact travelers who ate food at the highway because of logistics. We restricted our investigation to the affected village; therefore, we might have underestimated the extent of the outbreak.

This investigation highlights the importance of IDSP surveillance and systematic epidemiologic investigation in identifying and responding to foodborne illnesses at the local level. Findings from investigations of foodborne illness outbreaks will help bridge gaps in food safety laws in India. Encouraging temples to register will ensure regulatory compliance in food safety and prevent future outbreaks in such settings.


   Conclusion Top


Improper storage practices might have led to microbial proliferation of the food served. Our finding will help guide the enforcement of food safety policies for community kitchens.

Acknowledgment

We would like to acknowledge Patiala district health officials, including epidemiologists, multipurpose health workers, and accredited social health activist workers, for their support during this investigation.

Financial support and sponsorship

This public health activity was conducted by the India Epidemic Intelligence Service (EIS) program of the National Centre for Disease Control at the request of the Integrated Disease Surveillance Programme, Punjab. 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.



 
   References Top

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Havelaar AH, Kirk MD, Torgerson PR, Gibb HJ, Hald T, Lake RJ, et al. World Health Organization global estimates and regional comparisons of the burden of foodborne disease in 2010. PLoS Med 2015;12:e1001923.  Back to cited text no. 1
    
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Koppel K, Higa F, Godwin S, Gutierrez N, Shalimov R, Cardinal P, et al. Food leftover practices among consumers in selected countries in Europe, South and North America. Food 2016;5;2-14.  Back to cited text no. 9
    
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Food Safety and Standards Authority of India. Safe Food Handling & Hygiene Booklet for Food Handlers. Available from: https://archive.fssai.gov.in/dam/jcr: 189db590-87bd-4c7c-a30e-bd111bf21e58/FSMS_Booklet_English_31_10_2017.pdf. [Last accessed on 2019 Oct 10].  Back to cited text no. 10
    
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Jones TF, Imhoff B, Samuel M, Mshar P, McCombs KG, Hawkins M, et al. Limitation of successful investigating and reporting of foodborne outbreaks: An analysis of foodborne disease outbreaks in FoodNet catchment areas, 1998–1999. Clin Infect Dis 2004;38 Suppl 3:S297-302.  Back to cited text no. 13
    


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