Report of the multi-disciplinary committee on the Sudden Convulsions of Unknown Origin in Eluru, West Godavari, Andhra Pradesh 1 CONTENTS 1. INTRODUCTION 2. EMERGENCY RESPONSE AND PREPAREDNESS 3. DAY WISE ACTIVITIES 4. DEMOGRAPHIC ANALYSIS 5. SUMMARY OF BIOLOGICAL INVESTIGATION FINDINGS 6. SUMMARY OF WATER & AIR INVESTIGATION FINDINGS 7. RECOMMENDATIONS 8. CONCLUSION 9. SOURCE OF THE OUTBREAK 10. RECOMMENDATIONS 11. GALLERY 12. REPORTS 2 Members of the Committee as per the GO 1946 GA(SC.I) dept. 10.12.2020 Sl Designation Role Signature 1 Chief Secretary to the government Chairperson 2 Spl Chief Secretary to Government, Agriculture, and Member Cooperation Department 3 Spl Chief Secretary to Government, Animal Member Husbandry, Dairy Development and Fisheries Department 4 Spl Chief Secretary to Government, Environment, Member Forest, Science and Technology Department 5 Spl Chief Secretary to Government, Water Resources Member Department 6 Secretary to Government, Municipal Administration Member and Urban Development Department. 7 Commissioner, Health & Family Welfare Member 8 District Magistrate, West Godavari, Eluru Member 9 Dr. Mukesh Tripathi, Director & CEO of AIIMS(Mangalagiri) Member 10 Dr.Ahmadullah Shariff, HOD Clinical ecotoxicology, AIIMS(Delhi) Member 11 Dr.Rakesh K Mishra, Director CCMB Member 12 Dr.Chandrasekar, Director IICT Member 13 Dr. J JBabu, Scientist NIN Member 14 Dr.Jamshed Nair, Associate Professor, Dept of Member Emergency Medicine, AIIMS (New Delhi) 15 Dr.Sanket Kulkarni, Deputy Director NCDC (Delhi) Member 16 Dr.Avinash, Scientist D, ICMR - NIV (Pune) Member 17 Dr.Asish K Satapathy, National Professional Officer, Member NPSP WHO, South Region, Bangalore 18 Dr. B Chandrasekhar Reddy, Neuro physician, Govt. Member of AP 19 Dr.Malathi, Neurophysician, Siddartha Medical Member College 20 Dr. Mohan, Medical Superintendent, DH Eluru Member 21 Principal Secretary to Govt., HM&FW Dept., Member- Convenor 3 INTRODUCTION On 5th December 2020 afternoon, number of cases were reported at District Hospital, Eluru with symptoms of convulsions and loss of consciousness who had no previous history of seizures or other neurological conditions, fever, headache, vomiting, diarrhoea, head injury or trauma. After 5pm large numbers of cases were reported with similar symptoms. The district medical and health department was alerted immediately after receiving the information from the district hospital. Critical observations by the district medical and health experts by the end of first day Convulsions of unknown etiology were reported with sudden onset affecting all age groups with no previous history of illness. The disease is mild in nature, non-communicable lasting for 15-30 minutes. Single episode of epileptic seizures were observed and only about 6-7 percent of cases were identified with recurrent episodes. It was identified that on 4th December few cases were reported at District Hospital with similar symptoms. Population effected were with-in Eluru Municipality. 1-2 members from the same family and few houses in the same locality were affected. Cases reported were not age-specific. Based on the distribution of reported cases within a short duration of time, the source of contamination was suspected to be common drinking water, milk of same packaging, cereals or pulses from a common distribution point, and vegetables of the same produce, i.e., distributed from the same market. Patients generally did not remember anything since the onset of drowsiness. A few cases sustained injuries subsequent to falls and seizures like tongue bites, head and limb injuries. Clinical findings were consistent and had a similar pattern in majority of cases. In most of the subjects there was a sudden onset of drowsiness, followed by seizures of mostly generalized tonic - clonic type followed by fall and loss of consciousness for 3-30 minutes. Mental confusion was presented in most cases and very few cases had nausea and vomiting episodes during or after the seizures. Pupillary reactions were sluggish in a small proportion of patients. Characteristically recovery from the episode was quick and complete and no residual neurological symptoms were reported. No patient was comatose. A sudden onset on 4th December with a steep raise and peaking was observed from 5th December to 7th December. Subsequent fall in number of cases was observed on 8th December and there was a gradual decline. From 13th December no further cases were reported. Therefore, it was indicative that the outbreak was a common source single exposure outbreak. In the absence of fever, the possibility of infectious origin was unlikely and toxicity of unknown origin was the primary suspected cause. 4 The Government involved various departments like Municipal Administration, Zilla Parishad, District Malaria Department, District Public Health Laboratory, and Animal Husbandry for Outbreak Emergency Response and Preparedness planning. All Outbreak Emergency Response and Preparedness activities were implemented with immediate effect on 05.12.2020 in the view of prevention and control for early identification and case management. Day wise activities were planned and Active Surveillance system was established for ensuring quality and emergency care management. Paramedical teams were deployed to conduct house to house survey. Day wise super sanitation drive was planned. Ambulance services (108) were mapped to multiple areas covering Eluru constituency for shifting of patients in view of emergencies. Elaborate arrangements were made to ensure quality medical care in all village and ward secretariats, UPHCs and PHCs in Eluru, District Hospital- Eluru, ASRAM Hospital, Andhra Hospitals and Chaitra Hospital were all covered. The Hon’ble Deputy Chief Minister and Hon’ble Minister of Health and Family Welfare A.P, Principal secretary Health, Commissioner of Health and Family Welfare A.P, District Collector and Magistrate; W.G Dist, Joint Collector VSWS & Development; W.G Dist, Director of Health and Family Welfare A.P and State Medical and Health team, State Surveillance Unit, District Medical and Health Officer and team, Medical Superintendent and District coordinator for Health Services and team, District Surveillance Unit, District Municipal and Mandal Administration and other district and state teams came into force for the prevention and control of the outbreak. 5 EMERGENCY RESPONSE AND PREPAREDNESS In all 62 wards and 22 village secretariats in Eluru constituency, active surveillance was conducted.24/7 Paramedical teams were deployed to conduct house to house survey. Super sanitation activities like removal of old debris and stilt from drains, Fogging and Spraying, Chlorination tests, Leakage identification and correction, removal of old pipes passing through culverts, disconnection of hand bores which are connected to municipal supply head water works was done. Chlorination was done in all the affected and unaffected areas of the Municipal Corporation. Specialists, duty doctors and other paramedical staff were deployed to strengthen the Medical and Health services at District Hospital Eluru and ASRAM hospital Eluru as below: NO. DOCTORS SPECIALITY WISE GENERAL NAME OF THE DUTY MICROBIOLOGIST NURSES FNOs MNOs HOSPITAL GENERAL PEDIATRICIAN GYNAECOLOGIST DOCTORS MEDICINE GGH ELURU 6 6 0 27 1 62 62 62 ASRAM 3 3 0 6 1 18 12 12 Since, the etiology of the outbreak was not known; all major and renowned agencies in the country were reached out by the Government and were actively involved. The following agencies were involved: LIST OF AGENCIES/LABORATORIES/INSTITUTIONS INVOLVED SL NO NAME OF THE AGENCY 1 ALL INDIAN INSTITUTE OF MEDICAL SCIENCE, MANGALAGIRI 2 ALL INDIAN INSTITUTE OF MEDICAL SCIENCE, DELHI 3 INDIAN INSTITUTE OF CHEMICAL TECHNOLOGY, HYDERABAD 4 CENTER FOR CELLULAR & MOLECULAR BIOLOGY, HYDERABAD 5 NATIONAL INSTITUTE OF NUTRITION, HYDERABAD 6 NATIONAL ENVIRONMENTAL ENGINEERING RESEARCH INSTITUTE 7 A.P POLLUTION CONTROL BOARD 8 SIDDHARTHA MEDICAL COLLEGE, VIJAYAWADA 9 NATIONAL INSTITUTION FOR VIROLOGY, PUNE 10 FOOD TESTING LABORATORY, KAKINADA 11 NATIONAL VETERINARY LAB, BHOPAL 12 VENEREAL DISEASE RESEARCH LABORATORY, VIJAYAWADA 13 WHO- NATIONAL PUBLIC HEALTH SURVEILLANCE PROJECT 6 On 10.12.2020 as per the G.O. RT. No. 1946, the government constituted a multi- disciplinary committee with the following members to investigate the source of the infection, to rule-out various causes of the incident and to suggest remedial measures to prevent any occurrence of such events in future in the state. 1 Chief Secretary to the government Chairperson 2 Spl Chief Secretary to Government, Agriculture, and Cooperation Member Department 3 Spl Chief Secretary to Government, Animal Husbandry Dairy Member Development and Fisheries Department 4 Spl Chief Secretary to Government, Environment, Forest, Science and Member Technology Department 5 Spl Chief Secretary to Government, Water Resources Department Member 6 Secretary to Government, Municipal Administration and Urban Member Development Department. 7 Commissioner, Health & Family Welfare Member 8 District Magistrate, West Godavari, Eluru Member 9 Dr.Mukesh Tripathi, Director & CEO of AIIMS (Mangalagiri) Member 10 Dr.Ahmadullah Shariff, HOD Clinical ecotoxicology, AIIMS(Delhi) Member 11 Dr.Rakesh K Mishra, Director CCMB Member 12 Dr.Chandrasekar, Director IICT Member 13 Dr. J JBabu, Scientist NIN Member 14 Dr.Jamshed Nair, Associate Professor, Dept of Emergency Medicine, Member AIIMS (New Delhi) 15 Dr.SanketKulkarni, Deputy Director NCDC (Delhi) Member